|Year : 2022 | Volume
| Issue : 2 | Page : 81-88
Psychological wellness of health-care professionals during the coronavirus disease-2019 pandemic
Lakshmi Ranganathan, Nagarajan Ramakrishnan
Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
|Date of Submission||29-Dec-2021|
|Date of Decision||23-Feb-2022|
|Date of Acceptance||09-Mar-2022|
|Date of Web Publication||27-Apr-2022|
Apollo Hospitals, Chennai - 600 006, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: The outbreak of the coronavirus disease-2019 (COVID-19) has been a major health crisis and is associated with psychological distress, specifically in health-care workers (HCW). Our study aimed to assess psychological wellness and sleep disturbances among HCW during the COVID pandemic and also to determine if the symptoms differed in those who were involved in caring for COVID patients in comparison with those who were not. Methods: This observational, cross-sectional survey was conducted during April–May 2020 at two facilities of a tertiary care hospital in Chennai, India, that provided care for COVID-19 patients. HCWs working in the critical care units and designated COVID units were included. A survey questionnaire comprising three components ‒ demographics, psychological wellness, and sleep ‒ was administered by email to participants. Results: The survey was sent to 230 HCW, and 190 completed it (response rate – 82.6%); the mean age was 29.7 ± 9.7 years; males/females–70 [36.8%]/120 [63.2%]). The overall mean depression score was 16.6 ± 4.4, indicating moderately severe depression. The overall mean anxiety score was 10.1 ± 3.4, indicating moderate anxiety. About 35.3% of the participants got <6 h of sleep, 56.3% reported inadequate sleep, and 52.6% reported disturbed sleep‒wake cycle. “Risk of getting infected” was the most important impacting factor (57.9%), followed by “disturbed work-life balance” (40.5%) and “uncertainty of outcomes” (24.2%). There were no differences in the depression, anxiety scores, or sleep quotients between the COVID treating and nontreating groups. Conclusion: Health-care professionals report high rates of symptoms of depression, anxiety, and sleep disturbances during the COVID-19 pandemic, irrespective of their involvement in caring for infected patients.
Keywords: Anxiety, coronavirus disease-2019, depression, pandemic, psychological wellness, sleep
|How to cite this article:|
Ranganathan L, Ramakrishnan N. Psychological wellness of health-care professionals during the coronavirus disease-2019 pandemic. Apollo Med 2022;19:81-8
| Introduction|| |
Fear and anxiety about a disease can be overwhelming and can cause strong emotions., The outbreak of the coronavirus disease-2019 (COVID-19) has been a major health crisis affecting several countries and is associated with psychological distress and symptoms of mental illness. The COVID-19 global pandemic has so far been responsible for 609,533 deaths worldwide (as on July 20, 2020)., The pandemic specifically has brought more anguish to the health-care workers (HCW), as they are facing an increasing workload and are also at a greater risk of infection. Worries about getting exposed to the infection and safety of self and family are common among medical staff, which could affect their sleep and psychological wellness., Studies have confirmed this and have shown that symptoms of anxiety and depression were common psychological reactions to the COVID pandemic.,,, Understanding the psychological impact of the outbreak among HCW could assist in making interventions to support them.
Our study aimed to assess the psychological wellness and sleep disturbances among HCW during the COVID pandemic and also to determine if the symptoms differed in those who were involved in caring for COVID patients in comparison with those who were not.
| Methods|| |
This was an observational, cross-sectional, hospital-based, two-center survey conducted from April 30, 2020, to May 19, 2020, at two facilities of a tertiary care hospital in Chennai, India, that provided care for COVID-19 patients. Health-care staff from the departments of the critical care unit (CCU), infectious diseases (ID), and designated COVID care wards were included.
A survey questionnaire comprising three components ‒ 14 questions on basic demographics and professional details; 16 questions on psychological wellness to assess the symptoms of depression and anxiety; and 3 questions on sleep ‒ was administered.
Demographic and professional data
Demographic and professional data including age, gender, education, marital status, professional information, and modes of commute to work were collected. Details on whether they were directly involved in the diagnosis and care of patients with suspected or proven COVID-19 infection and factors that impacted them during the pandemic were also recorded.
Psychological wellness scoring scale
The Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Questionnaire (GAD-7) were used to assess the symptoms of depression and anxiety, respectively. The PHQ-9 is a 9-item self-administered tool which is used for the diagnosis of both major depression and subthreshold depression in the general population and also to grade the severity of depressive symptoms. GAD-7 is a 7-item self-report questionnaire designed to assess the symptoms and severity of generalized anxiety. Both the questionnaires are validated,, and are free to use. Three questions on general sleep habits – average sleep hours, sleep adequacy, and normalcy of sleep‒wake cycle (sleeping in the night and awake in the daytime) – were included. The answers were set to a Likert scale and scoring was done based on the scale. Optional space for open-ended remarks was also provided.
Based on the questionnaires used, depression scores were interpreted as follows: 1–9: mild depression, 10–14: moderate depression, 15–19: moderately severe depression, and 20–27: severe depression. Anxiety scores were interpreted as follows: 1–9: minimal/mild anxiety, 10–14: moderate anxiety, and 15–21: severe anxiety.
The questionnaire was sent by email to the doctors, nurses, physician assistants, and respiratory therapists working in the CCU, ID, and designated COVID units. One reminder email was sent to all of them after a week. A statement declaring that the participation is voluntary and that consent was implied by filling out and returning the survey was mentioned in the questionnaire. The questionnaires were completed anonymously by the participants. The Institutional Ethics Committee approved the study.
Data for all the parameters were coded and analyzed with the statistical software SPSS 20.0 (IBM Corp., Armonk, N.Y., USA). Individual items of the responses were coded based on the scale provided and summary scores were calculated for both depression and anxiety. The mean, standard deviation, frequency tables, and proportions were computed to describe the answers for each questionnaire. Categorical variables were reported as percentages and continuous variables as mean and standard deviation. For the comparison of groups and proportions, Pearson's correlation analysis, t-test, and Chi-square tests were applied and linear regression analysis was used to test for the association between variables. P < 0.05 was considered to be statistically significant.
| Results|| |
At the time when the study started, 906 had tested positive in Chennai, with a rise to 7672 positive cases in 3 weeks. During this study period, a total of 242 patients were admitted to the CCU and COVID care wards.
The questionnaire was sent to 230 HCW, of whom 190 completed the survey ([response rate 82.6%; the mean age was 29.7 ± 9.7 years; males/females – 70 [36.8%]/120 [63.2%]). The demographic data of the participants are shown in [Table 1].
The overall mean depression score of all the participants was 16.6 ± 4.4, indicating symptoms of moderately severe depression. When categorized based on the scores, 6 (3.2%) of the participants were mildly depressed, 62 (32.6%) were moderately depressed, 79 (41.6%) were moderately severe depression, and 43 (22.6%) were severely depressed [Table 2] and [Figure 1]a.
Further analysis showed that nurses had more symptoms of depression than doctors and other health-care staff (P = 0.02). Age was negatively associated with the severity of depression (R = −0.24, P < 0.05). Those who were single were more depressed than married participants (P = 0.01). Being the only earning member of the family and having other health issues had a significant effect on depression (P < 0.05). Those who found it difficult to commute to the workplace exhibited more symptoms of depression (P < 0.001); however, the effect of distance between home and workplace or the mode of transport was not significant [Table 3].
The overall mean anxiety score was 10.1 ± 3.4, indicating symptoms of moderate anxiety. Categorizing based on the scores, 92 (48.4%) were minimally/mildly anxious, 81 (42.6%) were moderately anxious, and 17 (8.9%) were severely anxious [Table 2] and [Figure 1]b.
Age was negatively associated with the severity of anxiety (r = −0.18, P < 0.001). Being the only earning member of the family, having other health issues, and having difficulty in commuting to the hospital were significantly associated with anxiety (P < 0.001). Profession, gender, marital status, and having children below 18 years did not have an effect on anxiety [Table 3].
Hundred and eleven (58.4%) participants got 6–8 h of sleep, 67 (35.3%) got < 6 h of sleep, and 12 (6.3%) slept more than 8 h. About 56.3% of the participants felt that they did not get adequate sleep and 52.6% felt that their sleep‒wake cycle was disturbed [Table 2].
Those who slept < 6 h were noted to be more depressed (P < 0.001). However, no such association was found in anxiety. Those who felt that their sleep hours were inadequate and that their sleep‒wake cycle was disturbed reported both high depression and anxiety scores [Table 3].
The results of the linear regression analysis revealed that age (B = −0.112, P < 0.05), prior health issues (B = −1.826, P < 0.05), difficulties to commute (B = −1.500, P < 0.05), and disturbed sleep‒wake cycle (B = −1.782, P < 0.05) were significantly associated with the symptoms of depression. Being the only earning member of the family (B = −0.941, P < 0.05), prior health issues (B = −2.647, P < 0.001), and difficulties to commute (B = −1.776, P < 0.001) were significantly associated with symptoms of anxiety [Table 4].
Analysis of the responses to “impacting factors during the pandemic” showed that “risk of getting infected” was the most important factor (57.9%), followed by “disturbed work-life balance” (40.5%) and “uncertainty of outcomes” (24.2%) [Figure 2]. The top five concerns that were mentioned in the free text open remarks column were (a) more respect and empathy needed for HCW, (b) need for improved support systems, (c) lack of awareness among the public, (d) work pressure, and (e) lack of motivation.
Impact of coronavirus disease-2019 care in psychological wellness
Of the participants, 83 HCW were involved in the direct care of COVID patients and the remaining 107 were not. There were no differences in the depression or anxiety scores or sleep quotients between these two groups [Table 5] and [Figure 3]a, [Figure 3]b, [Figure 3]c. Analyzing the scores further for the effect of gender and profession on COVID care also revealed that there were no differences between the groups.
|Table 5: Comparison of variables between the coronavirus disease treating and nontreating groups|
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|Figure 3: Comparison of coronavirus disease treating and nontreating groups. (a) Comparison of depression scores. (b) Comparison of anxiety scores. (c) Comparison of sleep quotients|
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| Discussion|| |
Our study aimed to assess the psychological wellness and sleep disturbances among HCWs in India during the COVID pandemic. Our study showed that most of the health-care professionals exhibited symptoms of moderately severe depression and moderate anxiety. Earlier studies evaluating the same in other parts of the world have also shown similar results.,,
Most respondents in our study were nurses, as has been in other surveys., Nurses have reported more symptoms of depression and anxiety which is similar to our study results.
A survey done by the All India Ophthalmological Society (AIOS) among 1950 physicians across India during the COVID pandemic has found that 15% of doctors reported symptoms of severe depression. Our study has reported a slightly higher rate of 22.9% severe depression. The AIOS survey reported that 2% exhibited suicidal thoughts three to four times a week; our study also noted similar symptoms among 2.6% of our respondents.
Some studies have shown that being older was associated with higher levels of depression in health-care professionals, whereas others have shown that there were no significant associations between age and anxiety or depression levels. In our study, age was significantly negatively associated with symptoms of depression and anxiety. This could be due to the fact that the increased experience and maturity of thoughts that came with age might have resulted in a more balanced attitude and reduced the chances of anxiety and depression.
Marital status was significantly associated with symptoms of depression, but not with anxiety, in our study. Having children below the age of 18 years was not observed to be a contributory factor. This observation is comparable to the results of prior studies that have shown that both marital status, and the number of children were not associated with depression or anxiety.
The AIOS survey has reported that 37.4% of their respondents were worried about the financial impact of the pandemic. Our study had 23.2% of respondents who had mentioned finance as their primary concern. Furthermore, those who were the primary or only earning members of their family and those who had prior medical problems reported higher scores of both depression and anxiety.
Difficulties in commuting have been reported as an important affliction by several individuals who had to commute to the workplace during the pandemic. An interesting finding of our study was that symptoms of both anxiety and depression were significantly high in those who had difficulties in commuting to the workplace, irrespective of the mode of transport. Similar results were observed in a survey conducted on 1000 employees by the Chartered Institute of Personnel and Development, in which a significant proportion (52%) of participants reported that they were anxious about commuting to work.
Sleep quality is an important indicator of health and is closely associated with psychological well-being. The effect of anxiety and stress on sleep quality has been studied earlier., In our study, 56.3% of respondents reported inadequate sleep and 47.4% reported disturbed sleep‒wake cycle. High work intensity and pressure during this emergency and the need to wear protective clothing and suits throughout the day could have also affected sleep quality, which, in turn, could have affected the mental states.
The rapid-cycle survey conducted by the Society of Critical Care Medicine, specifically with critical care specialists, has shown that clinicians revealed increased stress about COVID and were specifically worried about infecting their loved ones. Previous studies that looked into the factors associated with psychological wellness among HCW during pandemics have identified feelings of vulnerability, loss of control, concerns about the health of self and family, the spread of infection, changes in work pattern, and being isolated as the predominant sources of distress., Respondents in our study had mentioned most of these factors, with the risk of getting infected being the most quoted factor, followed by disturbed work‒life balance and uncertainty of outcomes.
Lai et al., in their study on mental health outcomes among HCW exposed to COVID disease, found that frontline workers experienced more severe levels of depression, anxiety, and insomnia than those who were not involved in direct care. However, in our study, such differences were not evident; participants reported higher levels of symptoms of depression, anxiety, and sleep disturbances, irrespective of whether they were involved in direct care. The rapid-cycle survey also noted that anxiety was high among participants regardless of the suspected or confirmed state of infection of the cases in their CCU. This is likely related to the highly transmissible nature of the disease and the associated high mortality.
Our study provides important insights into the factors that impact the psychological wellness of HCW during this pandemic. The study identifies more vulnerable groups, particularly nurses, younger health-care professionals, and those with prior health issues. The study also identifies “difficulty in commuting” as an important contributory factor.
Our study used anonymized self-reported questionnaires and was done within 3 weeks' period; hence, it warrants unbiased data relevant to the period of the pandemic.
However, our study is limited by the sample size and the fact that it is done at two centers of a tertiary care hospital in the same city. Hence, the findings cannot be generalized or extrapolated to our or other hospitals or regions, where work environment and resources might vary. Furthermore, the prevalence of prior depression and anxiety in participants was unknown. Moreover, although a clinical interview could have added value, administering the questionnaire online was a more feasible option during the pandemic.
| Conclusion|| |
Health-care professionals report high rates of symptoms of depression, anxiety, and sleep disturbances during the COVID-19 pandemic, irrespective of their involvement in direct care for infected patients. Nurses and younger professionals may be more vulnerable, and it would be important to consider support systems to help the health-care professionals during these difficult times.
The authors thank the medical staff who participated in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]