Prevalence of mental health disorders among health-care providers of COVID-19 positive and suspected cases.

Background: Health-care providers (HCP) engaged in demanding work like being involved in the care of COVID-19 positive and suspected cases are likely to have a lot of stress, anxiety, depression, and other mental health issues. It will be noteworthy to have an idea about the magnitude of the mental health problems in them to formulate effective intervention strategies for their well-being. Aims and
Objectives: The aim of this study is to determine whether frontline HCP engaged in the treatment and care of COVID-19 positive and suspect cases experienced increased mental health problems. Methodology: Two hundred and fifty-one frontline HCPs engaged in COVID-19 duty and 97 nonfrontline (controls) HCP were assessed and compared using tools like General Health Questionnaire 12, Hamilton Anxiety Rating Scale, and Hamilton Depression Rating Scale. Appropriate statistical tools such as analysis of variance and Chi-square were used.
Results: Frontline HCP who were directly involved in COVID-19 duty had a higher proportion (28.3%) of psychological morbidities as compared to 19.6% among controls; HCP-frontline had significantly 2.17 times chances of having psychological distress compared to HCP controls. Among, HCP-frontline 13.1% had clinical depression, whereas in the HCP control, this was 6.2%. Further, 20.3% of HCP frontline and 10.3% of HCP control had clinical anxiety, and the difference between the two groups was statistically significant (P = 0.0011).
Conclusion: Frontline HCPs working in demanding work such as COVID-19 patient care are susceptible to psychological distress, anxiety, and depression which warrant urgent attention. Copyright:

By the end of September 2020, almost all the countries of the world were affected by COVID-19 pandemic and India emerged as the country with the second highest number of confirmed COVID cases.[1] Suddenly, our health-care providers (HCPs) were overwhelmed. Especially the “front-line” (HCPs) involved in duty related to COVID often faces a high risk of infection and increased workload. The HCPs have to deal with stress, fatigue, and psychological issues such as anxiety and insomnia, along with personal issues and added stigma. It is also well-known that acute stress in disasters could have a long-lasting effect on the overall well-being, especially poor psychological outcome in patients.[23] Hence, the mental health problems of HCPs in COVID-19 epidemic do need an urgent attention.

Experiences of survivors in previous pandemics have been well documented in the literature.[456] Various studies exploring the psychological outcomes among health-care workers have revealed that burnout, psychological stress, and posttraumatic stress disorder were higher and felt isolated.[45] It was also reported that health-care frontline workers had to face social discrimination, ostracization, and stigma due to working in health units which dealt with pandemic cases.[6]

A recent review article seems to suggest that HCPs do have increased stress, anxiety, depression, and sleep problems.[7] This review included only six articles in the final analysis, of which one is from India. However, the Indian study is a qualitative one and it was mainly carried out with the purpose to find out the “perceived motivation influencing morale” in the HCPs.[78] Other Indian studies also tried to focus on mental health impact in HCPs, but these were online and questionnaire based and did not include nonmedical HCPs.[910]

It is of paramount importance that the mental health well-being of the HCPs is taken care of. However, we in India are yet to have a true picture of the magnitude of mental health issues in the HCPs who are working to combat this pandemic. As such it will be worthwhile to have a look into the mental health issues of this class of population so that effective mental health intervention can be chalked out. The present study was conceived to determine whether frontline HCPs engaged in the treatment and care of COVID-19 cases experience increased mental health problems.

METHODOLOGY

The National Mental Health Survey 2015–2016 reported that about 10% of the population had common mental disorder which also included substance use disorder.[11] Considering an assumed prevalence of psychological consequences among contacts of COVID-19, as 20% a total of 245 participants were required with 5% absolute precision. For this study, 251 participants were enrolled consecutively from a list which was prepared. Furthermore, a sample of 97 controls who were not involved in patient care of COVID-19 confirmed and suspected cases was also taken. The study was carried out in a tertiary care hospital which also had COVID care facility.

Tools used

Sociodemographic datasheet

General Health Questionnaire-12 (GHQ-12) English and Hindi version[1213]

Hamilton Anxiety Rating Scale (HARS)[14]

Hamilton Depression Rating Scale (HDRS).[15]

Procedure

Informed consent was obtained from each participant (hard copy or soft-copy if the person was on duty/quarantine) after providing complete description of the study.

The HCPs were consecutively approached for interview, taking numbers proportionate to size representing the four groups of HPWs, namely doctors, staff nurses, and other staffs which included laboratory personnel, ward attendants, “safai karmcharis” or sanitization workers, and medical social workers. To begin with, all the participants who had consented to participate in study were assessed on GHQ-12 and the sociodemographic details were documented. In order to avoid personal contact of research staff with HCPs, a hard copy of the GHQ-12 and sociodemographic data collection sheet was delivered at the screening OPD, COVID-19 isolation ward, and COVID-19 suspected cases ward. The HCPs were asked to fill up the GHQ-12 and sociodemographic datasheet and send it back on E-mail/WhatsApp of the principal investigator. Keeping in mind that some staff may also be on post duty quarantine, Internet-based invitation link to the GHQ-12 as well as sociodemographic datasheet was sent through E-mail or WhatsApp, and the reply was collected. The participants were also guided over phone by the investigators whenever required. For participants who did not respond to first request, two reminders were sent at an interval of 3 days and when someone failed to respond even after two reminders, he/she was dropped from the study.

For some of the staff who may not have smart phones, hard copies of GHQ-12 and sociodemographic data sheet were sent and the doctor or nurse posted along with were requested to assist them. In very few instances, where the HCP could not be contacted personally due to post home duty quarantine, telephonic/video call interview (recorded) was conducted and responses were marked accordingly.

After the primary data collection and evaluation, HCPs with GHQ-12 scores more than 2 were administered HARS and HDRS by the research staff. To compare the mental health disorders among the frontline HCPs with those who were not involved in delivery of care to COVID-19 suspected or confirmed cases, a sample of 97 such HCPs as controls were also recruited. Like the frontline HCPs, data were also collected from this group in a similar manner; initially sociodemographic and GHQ-12 was recorded and then those who had GHQ-12 score more than 2 were further administered HARS and HDRS. The control group had proportionate numbers of doctors, nurses, and ancillary staff.

HCPs (both frontline and controls) who were found to have anxiety and/or depression on HARS and HDRS as well as all who have GHQ-12 score more than 2 were asked to seek help from psychiatry telemedicine and helpline services provided 24 × 7 by the department of psychiatry, Government Medical College and Hospital, Chandigarh. Data were collected over a period of 3 months, from May 2020 to July 2020.

Ethics statement

The study was approved by the Institutional Ethics Committee of Government Medical College and Hospital, Chandigarh.

Statistical analysis

Data were entered in Microsoft Excel spreadsheet and analyzed using SYSTAT software version 13.2 for Windows (San Jose, CA: Inpixon Inc.). Study findings were presented as frequencies, means (with standard deviation), and proportions. The Chi-square test was employed to see the association between the qualitative variables. For quantitative data, Student's t-test and analysis of variance was applied for two and more than two groups which were normally distributed. Binary logistic regression analysis (enter method) was performed to see the strength of association in terms of odds ratio and 95% confidence interval. P < 0.05 was considered statistically significant.

RESULTS

A total of 348 participants including 97 controls were interviewed, and their sociodemographic details along with information regarding psychological morbidity were collected. The mean age was 32.11 (9.43) and 33.18 (8.28) years among HCP-frontline and controls (HCP-control), respectively. Females constituted 43.8% and 54.6% among HCP frontline and HCP controls, respectively. Doctors comprised the highest proportion in both HCP frontline and HCP control group. 33.1% of the HCP-frontline and 14.4% of the HCP-controls also reported that they had previous experience of working in facilities such as quarantine and isolation ward. 96.9% and 86.1% participants came from the urban background among HCP frontline and HCP controls. Sociodemographic details are given in Table 1.

Table 1

Sociodemographic details of study participants

Variables	Categories	HCP-frontline, n (%)	HCP-controls, n (%)
Age (years)	21-35	174 (69.3)	64 (66.0)
	36-50	66 (26.3)	29 (29.9)
	>50	11 (4.4)	4 (4.1)
Marital status	Single	96 (38.2)	49 (50.5)
	Married	149 (59.4)	46 (47.4)
	Widowed/divorced/separated	6 (2.4)	2 (2.1)
Gender	Male	141 (56.2)	44 (45.4)
	Female	110 (43.8)	53 (54.6)
Profession	Doctor	101 (40.2)	60 (61.9)
	Nurse	35 (13.9)	19 (19.6)
	Other staff	115 (45.8)	18 (18.6)
Duration of work experience (years)	Up to 10	173 (68.9)	74 (76.3)
	>10	78 (31.1)	23 (23.7)

HCP – Health-care providers

Regarding, GHQ-12, scores <3 were considered having no psychological morbidity taking the scoring pattern of 0-0-1-1.[16] Mean scores for HCP-frontline were higher 1.90 (2.07) as compared to HCP-controls, 1.51 (1.98), but it was not statistically significant (P = 0.074). HCPs who were directly involved in COVID-19 duty (HCP-frontline) had a higher proportion (28.3%) of psychological morbidities as compared to 19.6% among controls (HCP-controls). However, this was not statistically significant [Table 2]. Among HCP-frontline, 71 had higher GHQ scores, i.e., more than 2. On univariate analysis, significantly lower age (30.24 ± 6.20 vs. 34.33 ± 8.72 years) was seen among HCP-frontline participants who had higher GHQ score >2 (P ≤ 0.001) as compared to participants who had lower GHQ score ≤2.

Table 2

Comparison psychological distress between health-care providers - frontline and health-care providers - control

	HCP- frontline, n (%)	HCP- control, n (%)
With psychological morbidity (GHQ score >2)	71 (28.3)	19 (19.6)
No psychological morbidity (GHQ score ≤2)	180 (71.7)	78 (80.4)
Total	251	97

Chi-square test, P=0.097. HCP – Health-care providers; GHQ – General health questionnaire

As depicted in Table 3, 42 of the 101 doctors in HCP-frontline (41.5%) and 17 out of 60 doctors in HCP-control (28.3%) had some psychological distress, i.e., GHQ >2. However, this difference was not significant between the two groups. Similarly, there was also no statistically significant difference between the nurses in HCP-frontline (5 out of 35; 14.25%) and HCP-control (2 out of 19; 10.5%). Among the other staff, 20.8% (24 out of 115) in HCP-frontline had psychological distress in comparison to none in the HCP-control group.

Table 3

Psychological distress comparison in health-care providers - frontline and health-care providers - control as per profession

	HCP-frontline, n (%)	HCP-control, n (%)	P
Doctors	42 (41.5)	17 (28.3)	0.093
Nurses	5 (14.2)	2 (10.5)	0.701
Others	24 (20.8)	0	-
Total	71 (28.3)	19 (19.6)	0.097

HCP – Health-care providers

Table 4 shows the multivariate analysis for developing psychological morbidity, as depicted by GHQ score >2. Subjects with age <30 years had higher odds of GHQ >2, as compared to those aged more than 30 years, but it was not statistically significant. HCP working in COVID-19 areas, i.e., HCP-frontline had significantly 2.17 times chance of having GHQ score more than 2 as compared to HCP-controls working in non COVID-19 areas. Doctors and nursing staff had higher odds of GHQ >2 as compared to other staff (lab technician, sanitization workers, etc.,) with odds of 2.73 and 1.14, respectively. Males had lower odds of GHQ >2 as compared to female health workers which was nonsignificant.

Table 4

Logistic regression analysis depicting risk of developing psychological distress (general health questionnaire >2)

Variables	Proportion (%)	aOR	P
HCP
Frontline	27.9	Reference	0.011*
Controls	72.1	2.178 (1.193-3.978)
Gender
Female	46.8	Reference	0.082
Male	53.2	0.638 (0.384-1.059)
Age (years)
>30	50.3	Reference	0.210
≤30	49.7	1.409 (0.825-2.406)
Profession
Other staff	38.2	Reference
Doctors	46.3	2.736 (1.495-5.006)	0.001*
Nursing staff	15.5	1.149 (0.497-2.659)	0.745

aOR – Adjusted odds ratio; HCP – Health-care providers; *P<0.05

Taking a cut-off of >7 for depression on HDRS,[15] 33 out of 251 HCP-frontline cases, i.e., 13.1% had clinical depression, whereas in the HCP-control, this was 6.2% (6/97). Although the proportion of individuals with depression was more in HCP-frontline, the difference between the two groups was not significant (P = 0.065). Again taking a cutoff of >7 for anxiety on HAM A,[17] 20.3% of HCP-frontline (51/151) and 10.3% of HCP-control (10/97) had clinical anxiety, and the difference between the two groups was significant (P = 0.0011).

In Table 5, we can see that among the HCP-frontline group, both HAM-A and HDRS mean scores were least in the nursing staff, followed by the doctors and highest in other staff and this difference among the three professions was also statistically significant.

Table 5

Hamilton Anxiety Rating Scale and Hamilton Depression Scale mean scores among health-care providers - frontline as per their profession

Health personnel	HCPs
	HARS score	HDRS score
Doctors	9.24±3.62	7.55±3.78
Nursing staff	5.83±3.06	4.33±3.32
Other staff	9.91±3.15	7.83±2.42
P	0.040	0.074

HCP – Health-care providers; HARS – Hamilton Anxiety Rating Scale; HDRS – Hamilton Depression Scale

Among the controls, anxiety and depression scores were higher among nursing staff as compared to doctors. Mean anxiety scores were 6.87 ± 3.87 and 9.75 ± 5.25 among doctors and nursing staff, whereas mean depression scores were 5.27 ± 3.19 and 8.50 ± 4.43, respectively. The comparison of scores among HCP-frontline and HCP-control revealed a significant difference between doctors for HAM-A and HDRS (P = 0.042 and 0.037).

DISCUSSION

Studies trying to explore the mental health issues in the HCPs are very few, more so from India. In India, such studies were either qualitative[8] or online based and involved only doctors and nurses.[910] Another study did involve HCP comprising of doctors, nurses, and allied health-care workers, but it was strictly a self-administered questionnaire-based study and also included other employees such as administrators, and clerical staff who are not directly involved in duties related to COVID-19 care.[18] There are no studies as yet, which compared the mental health problems in those HCP who were involved directly in treatment, care, and sanitization of COVID-19-positive/suspect patients with those HCPs who were not at all involved in COVID-19-related duty. Moreover, in addition to doctors and nurses, we also need to include other HCPs such as laboratory technicians, sanitization workers, and attendants to have a more complete picture on mental health issues confronting the HCPs. Our study took these important issues in to consideration, and thus, we hope that through this study we will be able to provide valuable information, especially in the Indian context.

The two groups, HCP-frontline and HCP-controls, were comparable with respect to sociodemographic variables such as age, gender, marital status, and duration of work-experience. With progression of time, more HCPs were employed in COVID-19 care duties with lesser number available as control; hence, the disparity in terms of profession. Overall prevalence of psychological morbidity among HCP was 25.86% (90/348), with higher proportion among ‘frontline’ HCPs (28.3%).

On univariate analysis, no statistically significant difference was observed between the two groups with regard to psychological distress, as measured by GHQ-12 scores. This means that both the two groups were equally affected. A study where staff working with Ebola patients were compared with those who were not involved in care of such patients reported similar findings.[4] However, a study in China, comprising of nurses and doctors who were involved in COVID-19 care duty or otherwise reported that frontline HCP were more likely to have psychological problems such as anxiety, depression, insomnia, and stress compared to the non-frontline HCPs.[19]

Adjusting for age, gender, and profession, revealed higher chances (OR-2.17) of developing psychological issues among frontline HCPs. This was in line with the study by Lai et al. where the frontline HCPs had a higher risk of having unfavorable mental health outcome in comparison to the second line HCPs (who were not directly involved in COVID-19 care).[20] Furthermore, subjects with age <30 years and females had higher chances of developing psychological distress. Vulnerability of female gender was also reported by an Indian study.[10] Study findings from Lai et al. also revealed higher odds for frontline worker (OR-1.52) and female (OR-1.94).[20] In our study, doctors and nursing staff had higher odds, as compared to other staff, thus implying that they were more vulnerable to have psychological distress. This is quite understandable, as doctors and nurses are well aware that risk of exposure is very high while working with COVID-19 positive/suspect patients which add on to their stress. In fact, HCPs do have increased stress in setups like ICU; one Indian study[21] revealing that as much as 67% had some amount of stress while another Indian study[22] reported that as much as half of the study population working in ICU set-up had some stress. Similarly, stress was also reported by those involved in COVID-19-related duty and more than 80% in a study population had moderate to severe stress.[10] Although our study specifically did not look into the stress of HCPs, it did look into the presence of psychological distress, which, although not quite high, was also not less nevertheless and indirectly showed that substantial proportion of the study sample of the front-line HCPs may have had stress which could have led to psychological distress, as reflected by the GHQ12 score of more than 2 in 28.3% of the sample. This figure is much higher than the prevalence of common mental disorder as per NMHS[11] and it is quite concerning because, GHQ-12 can actually give a true picture of psychiatric morbidity, especially that of common mental illness.[13]

An Indian study involving only doctors and nurses in COVID care reported the prevalence of depressive symptoms and anxiety symptoms to be 11.4% and 17.7%, respectively, among them.[10] In another study, the prevalence of depression and anxiety was found to be 12.4% and 17.1%, respectively, in the health-care workers from India.[18] In our study, 13.1% of the frontline HCPs had clinical depression and 20.3% had anxiety, mostly mild. Thus, our findings are somewhat in concordance with this study, although this later study also included staff like clerks and administrators. However, in an Indian study, where information was gathered online from doctors only, the prevalence of anxiety and depression in them was 39.5% and 34.9%, respectively, and was thus, higher than ours.[9] Similarly, a study from China, involving doctors and nurses, reported much higher prevalence of depression and anxiety.[20]

In addition, in our study, the HCP-frontline and HCP-control group had similar levels of depression (data not shown in results). This finding is interesting and contrary to the study by Lin et al.[19] and Lai et al.[20] where significant difference was seen between the frontline and second line/nonfrontline HCPs. The reason for the contrary finding in our study could be the possibility of interplay of intrinsic sociocultural factors,[23] a prior sense of anticipation of the required roles due to the pandemic resulting in some degree of acceptance of the situation and hence lesser prevalence of depression,[24] better knowledge about the illness than the Chinese population, leading to better adaptation in the working environment, etc.

The HCP frontline group had significantly higher prevalence of anxiety than the HCP control group. This finding is in line with the study by Lin et al.[19] and Lai et al.[20] This is understandable, because being directly involved in the care of COVID-19-positive/suspect patients is bound to be demanding, with the fear of getting infected or even dying looming high in the minds of the frontline HCP.[7]

A review reported that nurses had higher levels of anxiety and depression in comparison to doctors and that single doctors were more vulnerable than married nurses toward developing mental health problems.[7] Another study found that nonmedical health care personnel had higher levels of anxiety, depression, stress, and PTSD in comparison to the medical health personnel.[25] Our study too found that the category of other staff, which mostly comprised of non-medical staff had higher levels of anxiety and depression, in comparison to the medical HCPs. Indeed, the job stress level can vary if it does not match with the capabilities[26] which is more likely to be there in the nonmedical health staff, who were probably not well trained to deal with highly contagious disease like COVID-19.

In our study, doctors in COVID-19 care duty had significantly higher proportion of anxiety and depression in comparison to the doctors who had other duties, but such differences were not seen among the nursing staff. This could be because doctors posted in COVID-19 care duty were a heterogeneous group (MBBS, postgraduate trainees, and consultants from different specialties), thus having difference in the level of skills while managing COVID-19 positive/suspect cases. In addition, the numbers of doctors in COVID care duty were less in comparison to the nurses and their turn came more frequently; till the time of writing this report, the doctors had been posted about two to four times in COVID-19 care duty, in comparison to nurses who have done it once or twice. All these factors could have resulted in higher proportion of anxiety and depression in the frontline doctors. Moreover, working in high risk area like COVID-19 care has its own ramifications and it is likely to be similar to working in emergency department, ICUs, infectious ward, etc., where there are increased chances of having mental health problems.[7]

Our study fulfilled its aims and objectives and was able to shed light on whether frontline HCPs have higher proportion of mental health problems. Overall, the frontline HCPs do have increased level of psychological distress. Our study found that HCPs caring for COVID-19 positive/suspect cases were more at risk to develop psychiatric morbidity. The nonmedical HCPs working in frontline was found to have higher levels of anxiety and depression symptoms than the doctors or the nurses. Often while carrying out research of this kind, this category of HCPs are left out when in the given situation they too have an equally important role to play like the medical HCPs while providing care for the COVID-19 positive/suspect patients. Thus, any intervention that plans to alleviate mental health problems of the HCPs should also take into account this precious category of staff otherwise the delivery of health care will be jeopardized.

Limitations

There were a few shortcomings in our study. We also collected some of the data through online mode, especially while administering the GHQ-12 and a few of the interviews for the assessment of anxiety and depression were done through video call as some of the respondents were in quarantine and thus could not be approached in person. Variable such as level of education and socioeconomic status of HCPs which could have had some confounding effect were not taken into account in our study. Also being a study from a single hospital setting, our study finding may not be generalizable.

CONCLUSION

To the best of the author's knowledge, this is the first comprehensive interview based, comparative study (frontline HCPs vs. controls) focusing on the prevalence of mental health problems in the HCPs. It included both the medical and nonmedical staff, who are actively involved in the treatment and care of COVID-positive/suspect patients and reveals that all categories of HCPs, have psychological distress. Many of these HCPs have high level of anxiety and depression which warrants appropriate intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.