|Year : 2021 | Volume
| Issue : 3 | Page : 166-173
Anxiety, depression, and stress risk among medical staff during COVID-19 pandemic: a single-center experience
Mohamed R Soltan1, Shaimaa S Soliman2, Mariam E Dawoud1
1 Department of Psychiatry, Faculty of Medicine, Fayoum University, Fayoum, Egypt
2 Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||10-Apr-2021|
|Date of Decision||20-May-2021|
|Date of Acceptance||09-Jun-2021|
|Date of Web Publication||28-Sep-2021|
MD Mariam E Dawoud
Department of Psychiatry, Faculty of Medicine, Fayoum University, PO Box 63514, , Fayoum, 63514
Source of Support: None, Conflict of Interest: None
Background The widespread pandemic of coronavirus disease 2019 (COVID-19) virus has caused major psychological effects, especially among health care workers who are exposed to high viral load. The aim was to investigate the psychological effects of COVID-19 on health care workers and factors affecting them. The study was carried out with an online questionnaire distributed through Google Forms for medical staff at Faculty of Medicine, Fayoum University, Egypt. The questionnaire included sociodemographic questions; validated psychometric tools for the assessment of depression, anxiety, and stress (Depression Anxiety Stress Scales-21); and the Impact of Event Stress Scale-Revised (IES-R).
Results The total number of the participants was 115 respondents. IES-R showed that 28.7% had high posttraumatic stress disorder. By Depression-Anxiety-Stress Scale, 13% had severe, 26.1% had extremely severe depression, 10.4% had severe, and 13.9% had extremely severe anxiety, and stress level was severe in 16.5% and very severe in 13.9%. The factor ‘work-years less than 5 years’ was significantly associated with the presence of stress. Personal psychiatric history of anxiety was significantly associated with abnormal IES and depression.
Conclusions During the COVID-19 outbreak, medical health workers had psychosocial problems and risk factors for developing them. They were in need of attention and recovery programs.
Keywords: anxiety, COVID-19 pandemic, depression, medical staff, stress
|How to cite this article:|
Soltan MR, Soliman SS, Dawoud ME. Anxiety, depression, and stress risk among medical staff during COVID-19 pandemic: a single-center experience. Egypt J Psychiatr 2021;42:166-73
|How to cite this URL:|
Soltan MR, Soliman SS, Dawoud ME. Anxiety, depression, and stress risk among medical staff during COVID-19 pandemic: a single-center experience. Egypt J Psychiatr [serial online] 2021 [cited 2022 May 16];42:166-73. Available from: http://new.ejpsy.eg.net/text.asp?2021/42/3/166/326849
| Background|| |
The coronavirus disease 2019 (COVID-19) pandemic is increasing rapidly. The WHO reported 5 819 962 confirmed cases worldwide on May, 2020, whereas in Egypt, 22 082 confirmed cases were reported and 879 deaths have been seen till May 2020. On March 24, 2021, there have been 124 535 520 confirmed cases of COVID-19, including 2 738 876 deaths worldwide, and in Egypt, 197 350 confirmed cases of COVID-19 with 11 720 deaths (World Health Organization Internet, 2020, 2021; https://covid19.who.int/).
Health care professionals are facing the critical and threatened situation of this growing pandemic and are subjected to considerable distress of the rapidly increasing number of cases and deaths, depletion of personal protection equipment, conflictual media news, lack of certain treatment protocol, and feelings of being inadequately appreciated, which may all contribute to the mental burden of these health care workers. So, they are prone to psychological distress and other mental health symptoms (Lai et al., 2020).
Previous studies have been done to assess the psychological effect of epidemics or pandemics, such as psychological stress of health care professionals in response to Ebola epidemic (Lehmann et al., 2015) and psychological impact of the pandemic (H1N1) 2009 on general hospital workers in Kobe (Matsuishi et al., 2012). The current and the previous reports of negative psychological effect of epidemics and pandemics (Kakunje, 2011) reflect the need for psychological resilience intervention.
| Aim|| |
The aim of the present study was to investigate the subjective distress as a psychological effect of the pandemic of COVID-19 on Fayoum University medical staff and to investigate how it is affected by age, sex, and other different variables as a step for warranting the clinical attention to the need for psychological resilience intervention measures.
| Patients and methods|| |
This study was proposed for approval at the Faculty of Medicine, Fayoum University Research Ethics Committee. Online Google Form was prepared to be filled by the participants. Detailed informed consent was included in the beginning of the form explaining the aim of the study and the used tools, in which respondents’ approval was mandatory before form completion.
The study was a cross-sectional one. The target population was medical staff doctors of Faculty of Medicine, Fayoum University (academic and clinical specialties). Psychological effect of this group was assessed using online Google Form containing demographic data and structured questionnaire. This online form was available on the official WhatsApp group of the faculty through the period from May 2020 till June 2020 in which the form can be filled once. The questionnaire was anonymous to ensure the confidentiality and reliability of the data. Finally, all valid completed questionnaires were included in the final analysis.
All doctors were invited to fill the form despite their specialty. Sociodemographic data, including age, sex, marital status, work years, scientific grades, and type of their work whether academic, clinical or both, were obtained. Moreover, history of previous road accident, history of psychiatric disorders, and family history of psychiatric disorders were included.
The psychological effect of COVID-19 was assessed, especially anxiety, depression, and stress, using the following psychometric tools.
The Depression Anxiety Stress Scale-21 (DASS-21) (Lovibond and Lovibond, 1995) is a psychometric tool that contains 21 quantitative questions on to dimensionally assess depression, anxiety, and depression subscales perceived by the participants over the past week. Each question was graded from 0 to 3, in which 0 = did not apply to me at all, whereas 3 = applied to me very much or most of the time. Each subscale is calculated by summation of scores.
Impact of Event Stress Scale-Revised (IES-R) (Weiss, 2007) is a self-report questionnaire containing 22 questions that measure the stress experienced after exposure to a traumatic event over the past week. Each question denotes the difficulty experienced from 0 to 4, in which 0=not at all, whereas 4=extremely. Respondents were asked to denote their response to COVID-19 as a stressful life event. Intrusion, avoidance, and hyperarousal subscales’ scores can be calculated separately. Then, total score of posttraumatic stress disorder (PTSD) can be calculated.
An IBM compatible personal computer with SPSS statistical package, version 23, was used to analyze data (SPSS Inc., 2015. International Business Machines Corporation SPSS statistics for Windows; SPSS Inc., Armonk, New York, USA). The variables were expressed in number, percentage, mean, and SD. Association between qualitative variables was assessed using χ2 test. Fisher’s exact test was used in the case that any of the expected cells were less than five. A logistic regression was performed to ascertain the effects of possible risk factors on depression, anxiety, and other outcomes. Two-sided P value less than 0.05 was considered statistically significant.
| Results|| |
The study included 115 valid responses. Overall, 53.9% were females, 40.9% were in the age group of 31–40 years, 71.3% were married, 79.1% had work-years more than 5 years, 53.9% had MD/PhD degree, 51.2% worked in both clinical and academia, 76.5% did not have any previous road accidents, 64.3% did not have any personal history of psychiatric illness, and 78.3% did not have any family history of psychiatric illness. [Table 1] shows other details of the participants’ characteristics.
The mean total IES-R scale of the participants was 30.73±13.23. This showed mean hyperarousal of 9.79±4.97, mean avoidance of 9.45±5.44 and mean intrusion of 11.48±7.36. The results of the Depression Anxiety Stress Scale were as follows: the mean depression was 18.97±12.59, the mean anxiety was 9.96±9.25, and the mean stress was 19.20±12.13 ([Table 2]).
Among the participants, 27.0% had no impact by the IES-R, 35.7% had clinical concern, 8.7% had probable PTSD, and 28.7% had high PTSD enough to suppress immunity. The depression was not present in 27.8% but 4.3% had mild, 38.7% had moderate, 13% had severe, and 26.1% had extremely severe depression. Normal level of anxiety was present in 44.3%, but 6.1% had mild, 25.2% had moderate, 10.4% had severe, and 13.9% had extremely severe anxiety. Stress level was normal in 28.7%, mild in 27.8%, moderate in 13.0%, severe in 16.5%, and very severe in 13.9% ([Table 3],[Table 4],[Table 5]).
|Table 3 Prevalence of Impact of Event Stress Scale disorders, depression, anxiety, and stress among the studied groups (N=115)|
Click here to view
The age groups were not significantly associated with the presence of any abnormal IES or anxiety; however, the age group 20–30 years was significantly higher among participants with depression and stress (P=0.001 and 0.028, respectively). Sex and marital status were not associated with the presence of any psychological abnormality among the studied group. The factor ‘work-years less than 5 years’ was significantly associated with the presence of stress (P=0.002). Diploma/master was significantly associated with abnormal IES, depression, and anxiety (P=0.003, P<0.001, and P=0.013, respectively), with participants with MD/PhD having significantly lower stress level (P=0.031). Previous road accidents was significantly lower among participants with depression (P=0.042). Personal psychiatric history of anxiety was significantly associated with abnormal IES and depression (P=0.001 and 0.026), but family history of anxiety was significantly associated with abnormal stress (P=0.028). This is detailed in [Table 6].
| Discussion|| |
Medical health professionals constitute a highly vulnerable group to stress because of the nature and the requirement of their job, especially the demand to be on the front line in dealing with infectious diseases. The risk doubled when there is shortage of infection control measures and increased burden of work hours. This study was held among doctors only and found that they had high scores among stress, anxiety, and depression scales.
Previous studies and predictors stated that sources of adverse psychological impact among health care workers may include feelings of uncertainty and vagueness of COVID-19 nature and concerns about being infected and transmitting infections to family members. Other work-related factors to consider are financial worries, lengthy shifts, lack of rest, frequent exposure, and witnessing deaths while being isolated for long periods (World Health Organization Internet, 2020a).
Moreover, the uncertainty about the definite treatment protocols or the availability of vaccines with a guarantee of protection added increased possibility of adverse psychological effect to this group (World Health Organization Internet, 2020b). In addition, social media reports may be related to aggravation of distress as reported by Gao et al. (2020). Furthermore, in Egypt, there is daily news about increased numbers of infection among medical staff, with rising numbers of deaths among them.
This study revealed that the study group had higher levels of stress, anxiety, and depression, which may warrant clinical significance, and this is also reported by another cross-sectional survey in Egypt held by Ain Shams medical institute among health care workers (healthy doctors, nurses, and nonspecialized nurses) in 20 different hospitals, including fever hospitals, in which 77.3, 79.3, and 83.1% of all the participants reported symptoms of anxiety, depression, and stress, respectively. However, our study included physicians only who work at Fayoum University hospitals (Elkholy et al., 2020).
Arafa et al. (2021) found that among Egyptian and Saudi Arabian health care workers, 69% had depression, 58.9% had anxiety, 55.9% had stress, and 37.3% had inadequate sleeping (<6 h/day). In line with our findings, a cross-sectional study reported a high prevalence of depression (50.4%) and anxiety (44.6%) among 1257 Chinese health care workers on the frontlines during the COVID-19 pandemic (Lai et al., 2020). Another study conducted on 134 health care workers from China put the prevalence of anxiety at 20.1% (Du et al., 2020).
Our results were lesser than the result of a study by Wagdy et al. (2021) in which symptoms of anxiety were reported in 93.3%, whereas depression symptoms were reported among 72.7% of 300 ophthalmologists in Egypt. This high prevalence may reflect that distress of the pandemic affects not only the front-line health care workers but also other specialties that are not in direct contact with COVID cases.
The result of our study showed higher scores than a study held by Zhang et al. (2020) in China, which addressed psychosocial problems of 2182 Chinese health workers during the COVID-19 epidemic, in which anxiety was found to be 13.0% in medical health care workers versus 8.5% in nonmedical health care workers, and depression was seen in 12.2% in medical health care workers versus 9.5% in nonmedical health care workers. This may reflect the risky condition in Egypt as at the time of this study, there was massive shortage of the infection control measures despite the efforts of Ministry of Health to facilitate them.
The metaanalysis of 115 articles by de Pablo et al. (2020) revealed that 62.5% health care worker exposed to MERS/SARS/COVID-19 reported general health concerns, 43.7% fear, 37.9% insomnia, 37.8% psychological distress, 34.4% burnout, 29.0% anxiety features, 26.3% depressive symptoms, 20.7%, PTSD features, 16.1% somatization, and 14.0% stigmatization feelings. Another metaanalysis by Luo et al. (2020) containing 62 studies with 162 639 participants from 17 countries revealed that pooled prevalence of anxiety and depression was 33% (95% confidence interval: 28–38%) and 28% (23–32%), respectively.
The previously mentioned studies reflect only a small part of the published literature concerned with the psychological effect of COVID-19 among health care workers, with the majority of them showing clinically significant results regarding the adverse psychological effect of COVID-19. So, psychological supportive intervention should be designed and introduced to this highly vulnerable group. In Italy, Chirico et al. (2021) suggested that supportive psychological intervention plan is mandatory and should be framed within the occupational health surveillance program to overcome the burden of workplace stress.
Regarding the relation between different studied variables and the risk of negative psychological effect among health care workers, the multivariate logistic regression analyses of a study by Zhang et al. (2020) revealed that four variables were independently associated with anxiety risk among medical health workers: being female, living in rural areas, being at risk of contact with COVID-19 patients in hospitals, and having organic diseases. However, according to the depression tools, being female and having organic diseases were selected as independent factors among medical health workers.
According to a study held in Egypt by Sehsah et al. (2021) who studied psychological distress on 714 physicians, it was revealed that the result of bivariate analysis of sociodemographic and occupational factors showed that physicians with severe psychological distress were more likely to be females, younger (<40 years), currently unmarried, not having children, have a chronic illness, with only MBBCh degree, currently working in Egypt, and with short (<15 years) work duration.
The metaanalysis results of Luo et al. (2020) showed that the risk factors for higher psychological effect of COVID-19 were being women, among health care workers, and being nurses working in front-line with direct contact with COVID-19-infected patients.
As observed previously and in line with our results, being a female is an obvious risk factor related to high psychological effect of COVID. Moreover, our study found a significant relation between history of psychiatric disorders and family history of psychiatric disorders with stress and depression experience.
| Conclusion|| |
This study supported that medical staff were significantly affected with depression, anxiety, and stress during the period of COVID-19 pandemic.
Past history of anxiety was significantly associated with stress and depression.
Limitation of the study
Psychological assessment was based on an online questionnaire, but face-to-face interview may draw more comprehensive results. Only doctors were included; however, nurses and other front-line workers may have much more significant adverse psychological effects. Only a few variables were studied in this study and were not specific to work-stress-related variables. Maybe a long-term follow-up study for the COVID-19-exposed health care professional is highly needed.
The authors express their deep gratitude to all the participants.
Authors’ contributions: M.R.S. prepared the selected methodology and arranged the Google Form items. M.E.D. prepared the Google Form, analyzed and interpreted the patient data regarding the clinical data and psychometric tools, and was a major contributor in writing the manuscript. S.S.S. was the major contributor in statistical analysis. All authors have read and approved the final manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arafa A, Mohammed Z, Mahmoud O, Elshazley M, Ewis A (2021). Depressed, anxious, and stressed: what have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic?. J Affect Disord 278:365–371.
Chirico F, Nucera G, Magnavita N (2021). Protecting the mental health of healthcare workers during the COVID-19 emergency. Br J Psych Int 18:1.
de Pablo GS, Serrano JV, Catalan A, Arango C, Moreno C, Ferre F et al.
(2020). Impact of coronavirus syndromes on physical and mental health of health care workers: systematic review and meta-analysis. J Affect Disord 275:48–57.
Du J, Dong L, Wang T, Yuan C, Fu R, Zhang L et al.
(2020). Psychological symptoms among frontline healthcare workers during COVID-19 outbreak in Wuhan. Gen Hosp Psychiatry 67:144–145.
Elkholy H, Tawfik F, Ibrahim I, Salah El-Din W, Sabry M, Mohammed S et al.
(2020). Mental health of frontline healthcare workers exposed to COVID-19 in Egypt: a call for action. Int J Soc Psychiatry 24:0020764020960192.
Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S et al.
2020. Mental health problems and social media exposure during COVID-19 outbreak. PLoS ONE 15:e0231924.
Kakunje A (2011). Stress among health care professionals − the need for resiliency. J Health Allied Sci 10:1.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N et al.
(2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 3:e203976–e203976.
Lehmann M, Bruenahl CA, Löwe B, Addo MM, Schmiedel S, Lohse AW, Schramm C (2015). Ebola and psychological stress of health care professionals. Emerg Infect Dis 21:913.
Lovibond SH, Lovibond PF (1995). Manual for the depression anxiety & stress scales. (2ndEd). Sydney: Psychology Foundation.
Luo M, Guo L, Yu M, Wang H (2020). The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public − a systematic review and meta-analysis. Psychiatry Res 291:113190.
Matsuishi K, Kawazoe A, Imai H, Ito A, Mouri K, Kitamura N et al.
(2012). Psychological impact of the pandemic (H1N1) 2009 on general hospital workers in Kobe. Psychiatry Clin Neurosci 66:353–360.
Sehsah R, Gaballah MH, El-Gilany AH, Albadry AA (2021). Psychological distress among Egyptian physicians during COVID-19 pandemic. Int Arch Occup Environ Health 94:1–10.
Wagdy F, El Shebshery H, Kasemy Z, Mokbel T, Abd Elfattah D, Al-hessy AA (2021). Psychological impact of COVID 19 pandemic on practicing Egyptian ophthalmologists. Egypt J Ophthalmol 1:40–54.
Weiss DS (2007). The impact of event scale: revised. In Cross-cultural assessment of psychological trauma and PTSD. Boston, MA: Springer; pp. 219–238.
World Health Organization Internet, (2020, 2021). Coronavirus disease 2019 (COVID-19) situation report 131. World Health Organization.
World Health Organization [Internet], (2020a). Shortage of personal protective equipment endangering health workers worldwide. Geneva: WHO.
Zhang WR, Wang K, Yin L, Zhao WF, Xue Q, Peng M et al.
2020. Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China. Psychother Psychosom 89:242–250.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]