|Year : 2021 | Volume
| Issue : 1 | Page : 20-27
COVID-19 outbreak: Impact on psychological well-being of the health-care workers of a designated COVID-19 hospital
Vishalkumar Kanaiyalal Patel1, Sunayna Pandey2, Arpit Madhusudanbhai Jani3, Deepak Sachidanand Tiwari4, Falguni Babubhai Patel1, Rajendra Kumar Amritlal Thakrar5
1 Department of Psychiatry, Dr. M. K. Shah Medical College and Research Center, Ahmedabad, Gujarat, India
2 Department of Psychiatry, BJ Medical College and Civil Hospital, Ahmedabad, Gujarat, India
3 Department of Psychiatry, Banas Medical College and Research Institute, Palanpur, Gujarat, India
4 Department of Psychiatry, Dr. M. P. Shah Government Medical College, Jamnagar, Gujarat, India
5 Department of Psychiatry, Smt. B. K. Shah Medical Institute and Research Center, Vadodara, Gujarat, India
|Date of Submission||28-Oct-2020|
|Date of Decision||10-Jan-2021|
|Date of Acceptance||26-Jan-2021|
|Date of Web Publication||30-Jul-2021|
Department of Psychiatry, BJ Medical College and Civil Hospital, Asarwa, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
Context: COVID-19 outbreak has had a huge impact on health-care facilities, and challenges of health-care providers would compromise their physical and mental well-being during this epidemic. Aims: This study aimed to find out stress, anxiety, insomnia, and depression among the health-care workers during COVID-19 outbreak. Settings and Design: This was a 3-month, cross-sectional, observational, single-center study of health-care workers of designated COVID-19 hospital. Subjects and Methods: Study objectives were explained to health-care workers, and written consent was obtained. Participants were approached in their department as per their convenience and requested to fill the pro forma. Depression, Anxiety, and Stress Scale-21 and Insomnia Severity Index were used to detect psychological issues in the form of stress, anxiety, insomnia, and depression. Statistical Analysis: Descriptive statistics and Chi-square test were used for analysis of variables in the study. Results: Overall 27.41% and 29.18% of the health-care workers reported stress and anxiety symptoms, respectively, while 18.78% reported clinically significant insomnia and depression. Among them, being female, married, elderly, presence of medical illness, frontline workers, frequently watching COVID news, and excessive fear of COVID emerged as statistically significant variables associated with stress, anxiety, insomnia, and depression. Conclusions: Health-care workers experienced many mental health issues while performing duties during COVID-19 outbreak. Such issues are alarming and need to be addressed with appropriate health-care policy.
Keywords: Anxiety, COVID-19, depression, health-care workers, insomnia, stress
|How to cite this article:|
Patel VK, Pandey S, Jani AM, Tiwari DS, Patel FB, Amritlal Thakrar RK. COVID-19 outbreak: Impact on psychological well-being of the health-care workers of a designated COVID-19 hospital. J Mental Health Hum Behav 2021;26:20-7
|How to cite this URL:|
Patel VK, Pandey S, Jani AM, Tiwari DS, Patel FB, Amritlal Thakrar RK. COVID-19 outbreak: Impact on psychological well-being of the health-care workers of a designated COVID-19 hospital. J Mental Health Hum Behav [serial online] 2021 [cited 2021 Nov 28];26:20-7. Available from: https://www.jmhhb.org/text.asp?2021/26/1/20/322818
| Introduction|| |
Novel coronavirus disease (COVID-19) was first reported in November 2019 and then transmitted from person to person within Wuhan of China. The WHO has officially declared COVID-19 as a “pandemic” in February 2020, and as a Public Health Emergency of International Concern in March 2020., Globally, many people are experiencing various mental health issues such as anxiety, fear, panic, depression, insomnia, etc., during COVID-19 outbreak. Health-care workers performing duties in hospitals especially frontline workers directly involved in the diagnosis, treatment and care of patients with COVID-19 are more prone to suffer from mental health issues.,
Previous studies have reported high levels of stress, anxiety, depression and insomnia during severe acute respiratory syndrome-2003 outbreak among the health-care workers.,,, Also recent studies reported psychological burden and psychiatric morbidities among the doctors, nurses and other frontline health-care workers during current epidemic.,,
COVID-19 outbreak has increased the burden on the health-care system. While performing duties for patients with COVID-19, health-care workers are facing many challenges such as long working hours and frequent rotation due to paucity of staff, working with full personal protective equipment, shift duty, quarantine after performing duty, fear of transmission of infection to family members, and lack of transportation due to lockdown. Furthermore, uncertainty of novel virus, lack of proper guidelines, unprepared health infrastructure, and fear, prejudice, and stigma toward the health-care workers are additional burden. A recent Indian study in which around 47% of the participants were health-care workers, concluded that two-fifth of the people are experiencing anxiety and depression, due to lockdown and the prevailing COVID-19 pandemic. Another Indian study showed that COVID-19 lockdown was associated with poor sleep quality, shift in sleep cycle to delayed phase sleep–deprivation based on nighttime sleep, and depressive symptoms in a sizable number of population. Thirty-six percent of the participants were health-care workers in this study. A study by Mehra et al. concluded that very seventh health-care worker was suffering from diagnosable mental disorders. Another study suggests that 38% of the health-care workers on COVID-19 duty in Nepal were suffering anxiety and/or depression. A study by Sahoo et al. highlights the presence of anxiety and depressive symptoms, and negative emotional states in a significant proportion of housekeeping attendants and sanitary attendants on COVID-19 duties. All these issues in the current outbreak have exposed them to burnout, insomnia, fear, anxiety, and depression which reduce their work output and also affect the patient's care and treatment.
Across the globe, some published studies have reported significant mental health issues among health-care workers during COVID-19 pandemic.,,,,,,, With this background, to add the research findings during current outbreak, this study aimed to evaluate the impact of novel coronavirus disease epidemic on mental health of health-care workers of designated COVID-19 hospital.
| Subjects and Methods|| |
This was a 3-month, cross-sectional, observational, and single-center study of health-care workers. It was conducted from April 2020 to June 2020 to find the impact of COVID-19 epidemic on mental health. This study was conducted in a tertiary care multispecialty hospital attached to a medical college. This multispecialty hospital had a staff of 410 health-care workers. Memorandum of understanding was signed for isolation facility containing 400 beds for the patients with COVID-19 between Municipal Corporation and this multispecialty hospital. During April to June 2020, average 50–150 patients with COVID-19 were present every day in the ward/high dependency unit/intensive care unit of hospital and 200–400 new cases of COVID-19 emerged every day in the city. Health-care workers of the hospital were screened for psychological well-being. As per study protocol, participants were explained the objectives, and their written informed consent was obtained.
A total of 410 health-care workers of the hospital were recruited as study participants. Health-care workers included doctors, nursing staff, technicians, pharmacists, receptionists, attendants, and cleaning staff of the hospital, among those who were directly involved in the diagnosis, treatment, and care of the patients with COVID-19 called as “frontline health workers.” As per COVID-19 guideline, duties of the doctors and other staffs were distributed and rotated for the patients with COVID-19 and other patients of the hospital. Doctors and nurses considered as “medical health workers” and rest of others as “nonmedical health workers.” Participants using substance (tobacco, alcohol, cannabis, etc.) daily, reported symptoms of depression, anxiety, distress, and insomnia before March 2020, not on regular duty, and those who refuse to participate were excluded. The study was approved by the institutional ethics committee.
Semi-structured pro forma
It included demographic details and other questions such as performing duties as frontline worker, watching and listening of COVID-19 news in a day (never/occasionally/half the time/most of time/all the time), excessive fear of contracting COVID-19 infection and fear of death (never/occasionally/half the time/most of time/all the time), presence of medical problems (diabetes, hypertension, heart disease, and any other), presence of symptoms of depression, anxiety, and insomnia before March 2020, and regular daily substance (tobacco, alcohol, cannabis, etc.) use since the last 12 months.
Modified BG Prasad socioeconomic classification
Updated version (2020) was used to know the socioeconomic status of the participants.
Insomnia Severity Index
It has seven questions and each question rated with five-point Likert scale. Total score is 28, where 'zero to seven' is no clinically significant insomnia, 8–14 is sub-threshold insomnia, 15–21 is clinical insomnia (moderate severity), and 22–28 is clinical insomnia (severe). The survey tool was made available in local language using translation and back translation with the help of language expert. The test–retest reliability for Insomnia Severity Index (ISI) (Intra-class correlation coefficient, ICC2, 1 − 0.84) was excellent; internal consistency for the ISI (Cronbach's α – 0.84) was excellent.
Depression, Anxiety, and Stress Scale-21 items
It is a set of three self-report scales designed to measure the emotional states of depression, anxiety, and stress. Each of the three Depression, Anxiety, and Stress Scale-21 (DASS-21) contains 7 items. Each item rated with four-point Likert scale. Scores for depression, anxiety, and stress are calculated by summing the scores for the relevant items and interpreted as normal to extremely severe. It was made available in Gujarati language using translated and back translated with the help of language expert. The Cronbach's alpha for stress (English = 0.71; Hindi = 0.63), depression (English = 0.76; Hindi = 0.70), and anxiety (English = 0.73; Hindi = 0.74) was adequate.,
We visited each outpatient department, ward, and department to approach the health-care workers as per their convenience. For those health care workers who were on regular non-COVID work in the hospital, written informed consent was taken in person while for those who were doing COVID duty or were in quarantine, Google docs (including consent) was provided to them. We explained the study objectives and requested them to fill the semi-structured pro forma that included demographic details and questions related to COVID-19 outbreak, Modified BG Prasad socioeconomic classification, DASS-21, and ISI. We have collected all the pro forma after few days from the participants.
All data were collected, tabulated, and analyzed using statistical software Statistical Package for Social Sciences version 20. (Chicago, Illinois, USA). Descriptive statistics and Chi-square test were used for analysis of variables. P < 0.05 was considered statistically significant.
| Results|| |
Out of 410 participants, 394 health-care workers were included for the analysis of the data. The rest of 16 participants were excluded because three were on maternity leave, 6 participants did not complete their pro forma, 4 had history of depression and anxiety disorder before March 2020, and 3 had history of regular substance use for the past 12 months.
The mean age of the health-care workers was 34.63 ± 11.54. Among them, 90.9% were adults and 9.1% were old-age (60 years and above) participants, 57.4% were females and 42.6% were males, 66% were married and 34% were single/separated/divorced/widow, 58.6% were living in joint family and 41.4% were living in nuclear family, 71.3% belonged to urban domicile and 28.7% belonged to rural domicile, 66% belonged to upper middle/upper class, 15% belonged to middle and 19% belonged to lower/lower middle, 66.5% were medical health workers (doctors and nurses) and 33.5% were nonmedical health workers, and 41.4% were frontline health-care workers those who were directly involved in the care and treatment of patients with COVID-19.
Stress, anxiety, and depression in health-care workers
Overall, 27.41%, 29.18%, and 22.08% of the health-care workers reported stress, anxiety, and depression, respectively, using DASS-21.
Seventy-two and six-tenths percent of female health-care workers reported moderate, 47.17% reported severe anxiety, and 55.92% had no/mild anxiety. Female health-care workers reported higher anxiety compared to male health-care workers. Out of 9.1% (n = 36) of old-age participants, more than 50% reported moderate-to-severe grade of stress, anxiety, and depression. Nearly one-third of married participants reported moderate-to-severe grade of stress and anxiety and one-fourth reported moderate-to-severe grade of depression. More than one-third of participants with frontline work reported moderate-to-severe grade of stress and anxiety and one-fourth have reported moderate-to-severe grade of depression.
Nearly 50% of the participants reported moderate-to-severe grade of stress and anxiety, and more than one-third who reported moderate-to-severe grade of depression were watching COVID-19 news for half of the time in a day. Around two-third of the participants reported moderate-to-severe grade of stress and anxiety, and half of the participants with moderate to severe grade of depression were watching COVID 19 news for most of the time in a day. More than 50% of the participants who reported moderate-to-severe grade of stress and anxiety had fear of contracting COVID infection and death, and more than one-third who reported moderate-to-severe grade of depression had fear of contracting COVID infection and death for the half of the time during COVID outbreak. Nearly 85% of the participants who reported moderate-to-severe grade of stress and anxiety had fear of contracting COVID infection and death, and more than three-fourth who reported moderate-to-severe grade of depression had fear of contracting COVID infection and death for most of the time during COVID outbreak. More than one-third of the participants with medical comorbidity reported moderate-to-severe grade of stress, anxiety, and depression.
Distribution of gender, age, marital status, frontline worker, watching COVID news, fear of COVID, and medical illness was statistically significant with stress, anxiety, and depression [Table 1], [Table 2], [Table 3].
|Table 1: Distribution of sociodemographic and other variables with stress|
Click here to view
|Table 2: Distribution of sociodemographic and other variables with anxiety|
Click here to view
|Table 3: Distribution of sociodemographic and other variables with depression|
Click here to view
Insomnia in health-care workers
Eighteen and eight-tenths percent of participants had clinically significant insomnia using ISI.
More than half of the old-age participants reported moderate-to-severe clinical insomnia. Nearly one-fourth of the married health-care workers reported moderate-to-severe clinical insomnia. Twenty-five percent of the frontline health-care workers reported moderate-to-severe clinical insomnia. One-third of the participants watching COVID news for half of the time in a day had moderate-to-severe clinical insomnia. More than two-third of the participants watching COVID news for most of the time in a day had moderate-to-severe clinical insomnia.
More than one-third of the participants with moderate-to-severe grade of insomnia had fear of contracting COVID infection and death for the half of the time during COVID outbreak. More than two-third of the participants with moderate-to-severe grade of insomnia had fear of contracting COVID infection and death for the most of the time during COVID outbreak. More than one-third of the participants with medical illness had moderate-to-severe grade of insomnia.
Distribution of age, marital status, frontline work, watching COVID news, fear of COVID, and medical illness with insomnia severity was statistically significant [Table 4].
|Table 4: Distribution of sociodemographic and other variables with insomnia|
Click here to view
| Discussion|| |
Health-care workers reported 27.41% and 29.18% of stress and anxiety symptoms, respectively, while 18.78% reported clinically significant insomnia and depression. An Indian study found 39.5%, 33%, and 35% prevalence of stress, anxiety, and depressive symptoms in doctors during COVID-19 outbreak. Such a high prevalence of mental health problems in health-care providers during COVID-19 is alarming. Another study among the health-care workers found 14.5%, 8.9%, and 6.6% prevalence of anxiety, depression, and stress, respectively, during this epidemic. A study by Mehra et al. found anxiety disorder and depressive disorder to be present in 15.9% and 13.6%, respectively, among health-care workers. One study in Nepal found that the prevalence of anxiety disorder and depression among health-care workers was 37.3% and 8%, respectively. Variations in the rates of mental health issues among the health-care workers may be due to differences of the amount of care of the patients with COVID-19, duty hours, level of preparedness, protective measures, paucity of staff, etc.
Female health-care workers reported high anxiety compared to male participants. This finding corroborates with the Zhang et al. and Lai et al., who studied the mental health problems in health-care workers during COVID-19 epidemic in China., Another study from Italy also reported similar findings during novel coronavirus disease outbreak. This may be due to increase in responsibilities of home during COVID-19 or as anxiety disorders are more common in females.
Old-age participants (60 years and above) had significant stress, anxiety, depression, and insomnia compared to younger ones. This may be due to presence of medical comorbidity and news reported that the mortality due to COVID-19 is higher in old age compared to adults.,
High rates of symptoms of stress, anxiety, insomnia, and depression reported by married participants compared to single. This finding is in line with study from China during novel coronavirus outbreak. This may be attributed to days of staying away from children and family while performing duties in isolation ward and quarantine place, home responsibilities, and fear of transmission of infection to loved ones among the married health-care workers.
Frontline health-care workers had significantly high level of stress, anxiety, depression, and insomnia compared to participants with low risk of contact with COVID-19 patients in hospital. This finding corroborates with the Chatterjee et al, health care providers involved in high risk procedures during COVID 19 outbreak had significant stress, anxiety, and depression. Studies from China and Italy also found high rates of symptoms of distress, anxiety, insomnia, and depression among the frontline health-care providers during this outbreak.,,
Participants watching COVID-19 news for more time and its fear for more occasions had reported high level of stress, anxiety, depression, and insomnia. News about coronavirus-positive patients and death toll may trigger the fear, anxiety, and panic attack among the health-care workers.
Health-care workers with medical illness had more stress anxiety, insomnia, and depression during COVID-19 outbreak. A recently published Indian study found that the presence of more medical comorbidities in doctors was significantly associated with the depression. This finding corroborates with the study from China during COVID-19 epidemic among the health-care workers. This may be attributed to the more severe infection, and death due to novel coronavirus disease is common in patients with medical comorbidities.
| Conclusions|| |
Health-care workers reported high prevalence rate of stress, anxiety, insomnia, and depression during COVID-19 outbreak. Among them, being female, married, old age (60 years and above), presence of medical illness, frontline workers, frequently watching COVID news, and excessive fear of COVID were significant variables associated with mental health issues. Training of using personal protective equipment and treating COVID patients, avoiding long duty hours, periodic screening of health workers for psychological well-being, etc., are certain specific measures to improve mental health issues of the health-care providers. Health-care workers should be provided with psychological support, counseling, and treatment by mental health experts for their psychological well-being.
Limitations and future recommendations
This was a cross-sectional and single-center study, so results cannot be generalized. Depression, anxiety, and insomnia detected with DASS and ISI scales needed further clinical evaluation for the confirmation of diagnosis. Large scale studies involving multiple designated COVID-19 centers, and follow up studies will be required to estimate the causal association of COVID-19 outbreak and mental health issues among the health care providers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chan JF, Yuan S, Kok KH, To KW, Chu H, Yang J, et al.
A familial cluster of pneumonia associated with the 2019 novel corona virus indicating person-to-person transmission: A study of a family cluster. Lancet 2020;395:514-23.
Eurosurveillance Editorial Team. Note from the editors: World Health Organization declares novel coronavirus (2019-nCoV) sixth public health emergency of international concern. Euro Surveill 2020;25:200131e.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al.
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
Grover S, Dua D, Sahoo S, Mehra A, Nehra R, Chakrabarti S. Why all COVID-19 hospitals should have mental health professionals: The importance of mental health in a worldwide crisis! Asian J Psychiatr 2020;51:102147.
Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al.
The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168:1245-51.
Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv 2004;55:1055-7.
Lee AM, Wong JG, McAlonan GM, Cheung V, Cheung C, Sham PC, et al.
Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry 2007;52:233-40.
Chua SE, Cheung V, Cheung C, McAlonan GM, Wong JW, Cheung EP, et al.
Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers. Can J Psychiatry 2004;49:391-3.
Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, et al.
Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun 2020;87:11-7.
Chatterjee SS, Bhattacharyya R, Bhattacharyya S, Gupta S, Das S, Banerjee BB. Attitude, practice, behavior, and mental health impact of COVID-19 on doctors. Indian J Psychiatry 2020;62:257-65. [Full text]
Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al.
Psychological impact of COVID-19 lockdown: An online survey from India. Indian J Psychiatry 2020;62:354-62. [Full text]
Gupta R, Grover S, Basu A, Krishnan V, Tripathi A, Subramanyam A, et al.
Changes in sleep pattern and sleep quality during COVID-19 lockdown. Indian J Psychiatry 2020;62:370-8. [Full text]
Mehra A, Sahoo S, Nehra R, Verma M, Grover S. Psychological issues faced by the healthcare workers during the COVID-19 pandemic. J Postgrad Med Edu Res 2020;54:88-93.
Gupta AK, Mehra A, Niraula A, Kafle K, Deo SP, Singh B, et al.
Prevalence of anxiety and depression among the healthcare workers in Nepal during the COVID-19 pandemic. Asian J Psychiatr 2020;54:102260.
Sahoo S, Singh G, Bhogal RP, Mehra A, Aggarwal AK, Goel K, et al.
Psychosocial issues among the “faceless corona warriors”: The hospital housekeeping staff and sanitary workers on COVID-19 duty: An exploratory survey from a tertiary healthcare center from North India. J Postgraduate Med Educ Res 2020;54:94-9.
Mathiyalagen P, Davis P, Sarasveni M. Updated BG prasad socio-economic classification: The 2020 update. Indian J Pediatr 2021;88:76-7.
Veqar Z, Hussain ME. Validity and reliability of insomnia severity index and its correlation with Pittsburgh sleep quality index in poor sleepers among Indian university students. Int J Adolesc Med Health 2017;32.
Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales (DASS). Psychology Foundation Monograph. New South Wales, Australia: University of New South Wales; 1995.
Henry JD, Crawford JR. The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample. Br J Clin Psychol 2005;44:227-39.
Tan BY, Chew NW, Lee GK, Jing M, Goh Y, Yeo LL, et al.
Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med 2020;173:1-3.
Zhang WR, Wang K, Yin L, Zhao WF, Xue Q, Peng M, et al.
Mental health and psychosocial problems of medical health workers during the COVID-19 Epidemic in China. Psychother Psychosom 2020;89:1-9.
Rossi R, Socci V, Pacitti F, Di Lorenzo G, Di Marco A, Siracusano A, et al.
Mental health outcomes among frontline and second-line health care workers during the coronavirus disease 2019 (COVID-19) pandemic in Italy. JAMA Netw Open 2020;3:e2010185.
[Table 1], [Table 2], [Table 3], [Table 4]