key: cord-325643-nszsf0nu
authors: Tan, Benjamin Y.Q.; Chew, Nicholas W.S.; Lee, Grace K.H.; Jing, Mingxue; Goh, Yihui; Yeo, Leonard L.L.; Zhang, Ka; Chin, Howe-Keat; Ahmad, Aftab; Khan, Faheem Ahmed; Shanmugam, Ganesh Napolean; Chan, Bernard P.L.; Sunny, Sibi; Chandra, Bharatendu; Ong, Jonathan J.Y.; Paliwal, Prakash R.; Wong, Lily Y.H.; Sagayanathan, Renarebecca; Chen, Jin Tao; Ying Ng, Alison Ying; Teoh, Hock Luen; Ho, Cyrus S.; Ho, Roger C.; Sharma, Vijay K.
title: Psychological Impact of the COVID-19 Pandemic on Health Care Workers in Singapore
date: 2020-04-06
journal: Ann Intern Med
DOI: 10.7326/m20-1083
sha: 
doc_id: 325643
cord_uid: nszsf0nu

nan

Of 500 invited health care workers, 470 (94%) participated in the study; baseline characteristics are shown in Table  1 . Sixty-eight (14.5%) participants screened positive for anxiety, 42 (8.9%) for depression, 31 (6.6%) for stress, and 36 (7.7%) for clinical concern of PTSD. The prevalence of anxiety was higher among nonmedical health care workers than medical personnel (20.7% versus 10.8%; adjusted prevalence ratio, 1.85 [95% CI, 1.15 to 2.99]; P = 0.011), after adjustment for age, sex, ethnicity, marital status, survey completion date, and presence of comorbid conditions. Similarly, higher mean DASS-21 anxiety and stress subscale scores and higher IES-R total and subscale scores were observed in nonmedical health care workers ( Table 2) .

Discussion: Overall mean DASS-21 and IES-R scores among health care workers were lower than those in the published literature from previous disease outbreaks, such as the severe acute respiratory syndrome (SARS). A previous study in Singapore found higher IES scores among physicians and nurses during the SARS outbreak, and an almost 3 times higher prevalence of PTSD, than those in our study (4) . This could be attributed to increased mental preparedness and stringent infection control measures after Singapore's SARS experience.

Of note, nonmedical health care workers had higher prevalence of anxiety even after adjustment for possible confounders. Our findings are consistent with those of a recent COVID-19 study demonstrating that frontline nurses had significantly lower vicarious traumatization scores than non-frontline nurses and the general public (5) . Reasons for this may include reduced accessibility to formal psychological support, less first-hand medical information on the outbreak, less intensive training on personal protective equipment and infection control measures.

As the pandemic continues, important clinical and policy strategies are needed to support health care workers. Our study identified a vulnerable group susceptible to psychological distress. Educational interventions should target nonmedical health care workers to ensure understanding and use of infectious control measures. Psychological support could include counseling services and development of support systems among colleagues.

Our study has limitations. First, data obtained from selfreported questionnaires were not verified with medical records. Second, the study did not assess socioeconomic status, which may be helpful in evaluating associations of outcomes and tailoring specific interventions. Finally, the study was performed early in the outbreak and only in Singapore, which may limit the generalizability of the findings. Follow-up studies could help assess for progression or even a potential rebound effect of psychological manifestations once the imminent threat of COVID-19 subsides.

In conclusion, our study highlights that nonmedical health care personnel are at highest risk for psychological distress during the COVID-19 outbreak. Early psychological interventions targeting this vulnerable group may be beneficial. DASS-21 = Depression, Anxiety, and Stress Scales; IES-R = Impact of Events Scale-Revised; PTSD = posttraumatic stress disorder. * The DASS-21 is a 21-item system that provides independent measures of depression, stress, and anxiety with recommended severity thresholds. Cutoff scores >9, >7, and >14 indicate a positive screen for depression, anxiety, and stress respectively. The IES-R is a 22-item self-report instrument that measures the subjective distress caused by traumatic events. It has 3 subscales (intrusion, avoidance, and hyperarousal), which are closely affiliated with PTSD symptoms. A total IES-R cutoff score of 24 is used to classify PTSD as a clinical concern. † Adjusted for age, sex, ethnicity, marital status, presence of comorbid conditions, and survey completion date. The adjusted prevalence ratio was derived from logistic regression models by calculating marginally adjusted prevalence for each group. The 95% CIs were derived by using the delta method. The adjusted mean difference was obtained by using linear regression.

Updates on COVID-19 (coronavirus disease 2019) local situation. Ministry of Health

Manual for the Depression Anxiety Stress Scales

Psychometric properties of the impact of event scale -revised

Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore

Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control