key: cord-262428-erlmyzwn
authors: CABARKAPA, Sonja; Nadjidai, Sarah E.; Murgier, Jerome; Ng, Chee H.
title: The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: A rapid systematic review
date: 2020-09-17
journal: Brain Behav Immun Health
DOI: 10.1016/j.bbih.2020.100144
sha: 
doc_id: 262428
cord_uid: erlmyzwn

BACKGROUND: As the world is battling the COVID-19 pandemic, frontline health care workers (HCWs) are among the most vulnerable groups at risk of mental health problems. The many risks to the wellbeing of HCWs are not well understood. Of the literature, there is a paucity of information around how to best prevent psychological distress, and what steps are needed to mitigate harm to HCWs’ wellbeing. METHODS: A systematic review using PRISMA methodology was used to investigate the psychological impact on HCWs facing epidemics or pandemics, using three electronic databases (PubMed, MEDLINE and CINAHL), dating back to 2002 until the 21st of August 2020. The search strategy included terms for HCWs (e.g., nurse and doctor), mental health (e.g., wellbeing and psychological), and viral outbreaks (e.g., epidemic and pandemic). Only studies with greater than 100 frontline HCWs (i.e. doctors or nurses in close proximity to infected patients) were included. RESULTS: A total of 55 studies were included, with 53 using quantitative methodology and 2 were qualitative. 50 of the quantitative studies used validated measurement tools while 5 used novel questionnaires. The studies were conducted across various countries and included people with SARS (13 studies), Ebola (1), MERS (3) and COVID-19 (38). Findings suggest that the psychological implications to HCWs are variable with several studies demonstrating an increased risk of acquiring a trauma or stress-related disorders, depression and anxiety. Fear of the unknown or becoming infected were at the forefront of the mental challenges faced. Being a nurse and being female appeared to confer greater risk. In past epidemics, the perceived stigma from family members and society heightened negative implications; predominantly stress and isolation. Coping strategies varied amongst the contrasting sociocultural settings and appeared to differ amongst doctors, nurses and other HCWs. Implemented changes, and suggestions for prevention in the future consistently highlighted the need for greater psychosocial support and clearer dissemination of disease-related information. CONCLUSION: This review can inform current and future research priorities in the maintenance of wellbeing amongst frontline HCWs. Change needs to start at the level of policy-makers to offer an enhanced variety of supports to HCWs who play a critical role during largescale disease outbreaks. Psychological implications are largely negative and require greater attention to be mitigated, potentially through the involvement of psychologists, raised awareness and better education. The current knowledge of therapeutic interventions suggests they could be beneficial but more long-term follow-up is needed.

Large-scale disease epidemics pose various challenges to individuals of all ages and cultures but the emotional stress experienced by frontline health care workers (HCWs) is severe, and can be enduring. 1-3 The 2019 novel coronavirus (COVID-19) which emerged in Wuhan, China, led to a pandemic unlike any other in the last century. The subsequent demand placed on HCWs is difficult to encompass in its entirety. Even less is known about the implications for their mental health and well-being. Evidence from studies during COVID-19 and similar past epidemics can help inform this, and how best to address it.

A pandemic is the worldwide spread of a new disease, otherwise known as an epidemic that has spread over several countries or continents. 4 high global death toll, with thousands of HCWs becoming infected. 5 The fast changing response to this novel virus was likely to have had a profound effect on the wellbeing of hospital employees working on the front-line. Furthermore, the rapid transmission rate of COVID-19 led to unparalleled tasks that HCWs may not have been adequately equipped to deal with, from both a professional and psychological viewpoint.

Dealing with a severe global health disaster is an uncharted journey into the unknown at various levels. Government bodies make plans using other countries' data to project infection rates. The high degree of uncertainty associated to novel pathogens further J o u r n a l P r e -p r o o f contributes to the communal anxiety held, and makes for an overall negative experience for most. However, the challenge encountered can also result in positive changes, as individuals harness their coping skills, work together in teams, and the change instrumented by leaders can strengthen nations' preparedness against future disasters.

In terms of mental health impact of epidemics, HCWs represent a particularly vulnerable group due to the high risk of infection, increased work stress and fear of spreading to their families. 6 During the recent Ebola outbreak, an unprecedented number of HCWs were infected 7, 8 and survivors of infectious diseases have higher rates of post-traumatic stress disorder (PTSD). 9 Recommendations around the use of psychological first aid (PFA) have been made by global authorities. 10 However, the efficacy of this strategy is not well studied and barriers to its application exist. 11, 12 The many risks to the wellbeing of HCWs are not well understood. Post-SARS, there has been some research into this area but little is known about the psychological impact during infectious disease outbreaks. 13 Detrimental outcomes such as burnout, traumatic stress, anxiety, and depressive symptoms have been reported even after an outbreak, suggesting long-term implications. 3 Given the likely increased rate of psychological problems amongst HCWs, these factors must be addressed.

In the context of the COVID-19 pandemic, this timely review is both relevant and urgent.

It is imperative that those working at the frontline with infected patients or in afflicted J o u r n a l P r e -p r o o f regions have the necessary strategies and resources to endure various challenges.

There is a lack of systematic reviews published specifically on the mental health implications experienced by frontline HCWs during an epidemic. Of the literature, there

is also a paucity of information around how to best prevent psychological distress, and what steps are needed to mitigate harm to HCWs' wellbeing. The purpose of this review is to explore the main findings from the literature examining the psychological impact on HCWs in times of severe epidemics, and to identify strategies to address this.

We performed a systematic literature review to identify all international research related to epidemics and pandemics. Specifically, we aimed to identify original research pertaining to severe viral outbreaks, from 2002 to the 21 st of August 2020. To obtain relevant articles, we systematically searched PubMed, MEDLINE and CINAHL. The following search terms were used: 'health worker', 'health care worker', 'medical', 'doctor', 'nursing', 'nurse', 'allied health', 'pandemic', 'outbreak', 'mental health', 'mental illness', 'psychiatric', 'psychological', 'coping', 'psychosocial', 'COVID-19', 'coronavirus', 'SARS', 'MERS' and 'Ebola'. The references of identified articles were also manually searched for additional studies meeting study criteria.

The studies included in this review had to be original research (i.e. commentaries, editorials and reviews were excluded), be published in peer-reviewed journals, be written in English, include frontline HCWs as study participants, and include factors associated with their mental health or psychological wellbeing. As the clear majority of papers used self-reported measures, to ensure inclusion of high quality and adequately powered research, studies needed to include at least 100 frontline HCWs. HCWs J o u r n a l P r e -p r o o f needed to be working in close proximity with infected patients. The initial search yielded 2,876 papers, of which 55 included relevant data and were included in this review. The screening process is depicted in Figure 1 .

One reviewer (SN) examined the titles and abstracts initially to yield the preliminary publications for inclusion (120). Two reviewers (SC and SN) examined the full text studies independently with identical study selection criteria and removed the articles (65) that did not fulfil inclusion criteria. A third reviewer (CN) examined studies that required further consideration. 

The studies were conducted across various countries and included people with SARS (13 studies), Ebola (1), MERS (3) and COVID-19 (38) . Of the 55 articles, 53 were quantitative and 2 were qualitative. Details of the characteristics are listed in Table 1 . Of the quantitative studies, fifty studies 1-3, 14-58 incorporated validated questionnaires or measurement tools, while five 59-63 used novel questionnaires. All the studies included in this review assessed the psychological impact of severe epidemics on HCWs. The most common psychiatric disorders diagnosed were posttrauma stress syndrome (PTSS), depression and anxiety, as assessed in 32 studies. 16, 17, 20, 25-30, 35-43, 45-56, 58, 59 In the COVID-19 pandemic, somatisation was reported frequently 36, 49, 51 with 42.7% (2,005 of 4,692) of frontline nurses identifying somatic symptoms 51 , particularly headache, throat pain and lethargy, which were significantly associated with psychological outcomes. 55 Sleep disorders including insomnia were also frequently identified. 38, 39, 41, 47, 55, 56 Female nurses with close contact to COVID-19 patients appeared to have the highest mental health risks 45 , 44, 52 However, it is important to note that most studies included predominantly female participants, especially nurses, with only one study suggesting higher stress levels amongst males. 46 Specifically, being female conferred greater risks for depression, anxiety and higher levels of stress 36, 45, [52] [53] [54] 57 Suicidal ideation was identified amongst 6.5% (306 of 4,692) of HCWs with lower self-perceived health status listed as an additional risk factor. 36, 51 At the early stages of the COVID-19 pandemic, a Wuhan study 28 found that 34.4% (342 of 994) of medical and nursing staff had mild mental health disturbances while 6.2% (62) had severe disturbances, while in another study 24 of 1,521 Chinese HCWs 14.1% had psychological abnormalities. In the Hubei province, 12.5% (64 of 512) of medical staff had anxiety, being more severe in those with direct contact with infected patients. 27 Two-weeks after Wuhan went into lockdown, the proportion of female HCWs with depression, anxiety and acute stress symptoms were respectively 14.2% (621 of 4,369), 25.2% (1101) and 31.6% (1382). 34 One study J o u r n a l P r e -p r o o f found a moderate degree of burnout amongst 2,014 HCWs across two hospitals in Wuhan, with high levels of fear reported. 50 Approximately 20% (127 of 661) of HCWs had PTSD two months after the SARS outbreak in Singapore. 20 While 5% (17 of 338) of staff members at a hospital in East Taiwan met criteria for an Acute Stress Disorder (ASD) during the SARS pandemic. 59 Similarly, HCWs and other staff with direct contact or exposure to Ebola patients, had a range of psychological symptoms, such as obsession-compulsion, interpersonal sensitivity, depression and paranoid ideation. 16 During the 3-year period following their exposure to the 2003 SARS outbreak, around 10% (55 of 549) of Beijing hospital employees had a high degree of post-traumatic stress symptoms which were strongly associated with exposure to SARS, quarantine and a relative or friend acquiring SARS. 17 A study 18 of 1,800 HCWs assessed the psychological impact in the initial stages of the MERS outbreak and one month later. Those who performed MERS-related tasks reported greater distress and more intrusive phenomena. They also had the greatest risk for PTSD symptoms one-month later, and interestingly, this risk was increased even after home quarantine. Home quarantined HCWs had poorer sleep and a heightened degree of numbness than those who were not quarantined.

In terms of impact on different health professionals, a recent study 29 comparing medical HCWs (927) to non-medical HCWs (1,255) demonstrated significantly higher levels of insomnia, anxiety, depression, somatization, and obsessive-compulsive symptoms in medical HCWs. A Spanish study 26 also found that HCWs (613) had higher symptoms of acute stress than compared with non-HCWs (164). Similarly, anxiety and insomnia were J o u r n a l P r e -p r o o f significantly higher in frontline HCWs compared to non-frontline HCWs. 39, 47, 56 Eight studies compared doctors and nurses 1, 2, 15, 22, 46, 48, 60, 62 . Four of these studies focused on SARS and found that nurses experienced greater levels of stress. Of these, one study 2 reported higher distress for nurses and those with direct contact with infected patients. In two quantitative studies 1, 60 from Hong Kong, overall distress level for nurses was significantly higher than for other HCWs with the exception of doctors, and nurses also experienced higher levels of stress and psychological morbidity compared with other professionals. Interestingly, one study 62 of 1,470 nurses, showed that nurses in moderate-risk areas appeared to have more stress symptoms than those working in high-risk areas, but the reasons for this remain unclear. Alternate findings were depicted in two studies 20, 46 where doctors and single nurses were found to be at higher risk compared to nurses and those who were married, and doctors had more stress and anxiety compared to nurses. Further, 27% of participants (177 of 660) had psychiatric symptoms, with the doctors being 1.6 times more likely to experience psychiatric symptoms than nurses, and 20% (127 of 651) had PTSD. In contrast, a study 15 comparing 127 HCWs impacted by SARS, found no significant difference in feelings of stress between the physicians, nurses and other HCWs. An Italian study 25 

HCWs during the COVID-19 pandemic, showed that general practitioners were more likely to have PTSS than other HCWs, while nurses and health care assistants were more likely to exhibit severe insomnia. Similarly, another Chinese study 63 found that nurses (234) working in the frontline against COVID-19 experienced significantly greater levels of vicarious traumatisation when compared to non-frontline nurses (292). This theme was replicated with findings to suggest that frontline HCWs in close contact with J o u r n a l P r e -p r o o f infected patients were 1.4 times more likely to feel fear and twice more likely to suffer anxiety and depression when compared to non-clinical staff. 32 In a study 22 of 1,257 HCW's during the COVID-19 outbreak, high rates of depression, anxiety and insomnia were reported with over 70% reporting psychological distress. A survey 23 of Chinese HCWs during the COVID-19 outbreak found that 36.1% (564 of 1,563) had symptoms of insomnia. A comparison of HCWs in Wuhan, the epicentre of the COVID-19 outbreak, compared to those in a different province found that staff in Wuhan had higher rates of insomnia and stress responses. 31 One study 19 compared HCWs with healthy controls and found that HCWs were not more stressed than controls 

The publications included in this review were predominantly focused on the stressors arising during an outbreak, however, six articles 1, 3, 15, 17, 18, 65 focused either entirely on J o u r n a l P r e -p r o o f the period following the outbreak, or in part, had follow-up. Two 1, 3 articles examined predictors and one study 65 considered the stressors before care was given.

Predictors of the incidence of new-onset episodes of psychiatric disorders after the SARS outbreak included; a past history of psychiatric illness, years of health care experience (inversely associated) and the perception of adequate training and support.

New episodes of psychiatric disorders occurred among 5% (7 of 139) of HCWs. 3 A greater degree of psychiatric morbidity was identified amongst nurses and younger HCWs. 1 Taiwanese nurses found that the pre-care stage contributed to fear, as all (200) reported having difficulties keeping up with daily changing knowledge and skills and being anxious about their safety and of their families, clients, and colleagues. 65

Participants across seventeen studies 1, 2, 16, 17, 19, 21, 30, 50, 53, 59-62, 64, 65 reported fear as the prominent stressor. Particularly, fear of the unknown, becoming infected and threats to their own mortality. The vulnerability of colleagues and family member were also a major cause of concern as reported in an Italian study 25 , being exposed to contagion was associated with symptoms of depression, while having a colleague hospitalised or placed in quarantine was associated with PTSS, whereas, a colleague dying was associated to depression and insomnia.

A major theme was anxiety, especially across most of the COVID-19 studies 22, 24-27, 29, 30, 32, 36-43, 45-56 . In a Chinese study 27 the most important factor in HCWs with high anxiety was being suspected of having COVID-19 infection when compared to those who were not suspected of infection. Of 10,511 HCWs in Singapore, 76% perceived an increased J o u r n a l P r e -p r o o f risk of becoming infected, 56% reported work stress and 53% had increased workloads.

Doctors, nurses and staff in daily contact with SARS patients, and staff from SARSaffected institutions expressed significantly higher levels of anxiety than other HCWs. 21 In 466 questionnaires 60 experienced psychological distress. Similarly, a survey 61 of 117 HCWs after the MERS outbreak found that safety fears for themselves and others were a major concern, with worries that they would transmit the disease to their families and friends. All nurses (200) responding to a qualitative study 65 expressed that a lack of defensive protection against the disease, and difficulties keeping up with daily changing knowledge/skills contributed to fear. The media was also noted to play a role in amplifying uncertainty. 65 

Ten studies 1, 2, 20, 35, 39, 48, 50, 51, 57, 64 highlighted the importance of social support, with emphasis on the need for increased social support mechanisms 48 and regular contact with families 39 . A lack of family support and social isolation had a negative psychological impact on nurses who chose to isolate away from their families while treating SARS patients. 20 Correspondingly, the lack of social support during the SARS outbreak brought out discrimination from the community as well as distancing behavior from HCWs' own families. 64 A study 2 of 1,557 nurses identified three attitudinal factors J o u r n a l P r e -p r o o f (health fear, social isolation and job stress) mediated the association between contact with SARS patients and psychological stress. The levels of anxiety, stress, and selfefficacy exhibited amongst Chinese HCWs in Wuhan during the COVID-19 pandemic appeared dependent on their degree of social support and quality of sleep. 33 Stigma was a major factor identified across five studies 2, 14, 21, 49, 64 , and during the COVID-19 pandemic, it was associated to a higher risk of depressive symptoms 49 . In a large-scale study 21 of 10,511 HCWs, 49% experienced social stigmatization and 31% ostracism by family members. Analogous findings, amongst nurses (187) during a MERS outbreak in Korea found that stigma contributed negatively to the mental health of nurses through a direct effect but also indirectly via stress. 14 Amongst 338 HCWs findings showed that 20% (66 of 338) felt stigmatized and rejected in their neighborhood because of their hospital work, and 9% (20 of 218) reported reluctance to work or had considered resignation. 59 

HCWs often found themselves working under high levels of physical and psychological stress 21 , sometimes attributed to work conditions. 29 During the COVID-19 pandemic, long work hours were found to increase stress levels amongst nurses. 30 Similarly, the burden of adhering to strict protective measures seemed to increase distress levels. 23 The heavy protective gear was found to add to the physical difficulties of carrying out procedures. 27 Spanish HCWs who perceived protection as insufficient rated higher levels of depression, anxiety and acute stress than those who perceived it to be adequate. 26 Contrastingly, findings from 10,511 HCWs during the SARS outbreak demonstrated that 96% reported that the personal protective measures implemented J o u r n a l P r e -p r o o f were effective, 93% felt that institutional policies and protocols were clear and 90% felt they were timely. 21 Similar findings were depicted by HCWs who generally declared confidence in infection-control measures. 19 Measures to address the psychological risks to HCWs during epidemics

Thirteen studies 15, 20, 24, 28, 29, 40, 42, 44, 48, 57, 60, 61, 65 considered coping strategies, such as acceptance, resilience, active coping and positive framing. 60 Of 466 HCWs, doctors were significantly more likely than nurses and health care assistants (HCAs) to use planning as a coping strategy, while nurses were more likely than doctors to use behavioural disengagement, and HCAs were more likely than doctors to use selfdistraction. 60 Amongst 657 American HCWs, exercise was the most commonly used coping strategy (59%), and access to an individual therapist with online self-guided counselling (33%) generated the most interest. 42 Support from supervisors and colleagues was found to be a significant negative predictor for psychiatric symptoms and PTSD. 20 Further mental health predictors amongst a group of Chinese emergency HCWs included the tenacity, strength and the availability of support. 24 In a study of 652 HCWs, psychological support and practical support with insurance and compensation matters had a protective effect against stress. 1 In parallel with this, positive feedback emerged when counsellors asked the medical staff to share how they coped with this difficult situation. 64 Several studies 3, 16, 33, 60, 65 identified a need for greater support through collaboration, training and education. This appeared to strengthen teams 16 and have protective effects in reducing HCW stress 19 as simple protective measures were reassuring for HCWs 21 .

Additionally, clear communication was seen to reduce psychiatric symptoms. 20

The duration of follow-up was not specified in most studies and there was a lack of studies on the long term supports for HCWs post-epidemic. While others emphasised the need for prompt and continuous psychiatric interventions in high mortality infectious disease outbreaks. 18, 40, 45, 63 Imminent utilisation of interventions promoting wellbeing for HCWs facing COVID-19 was suggested for frontline workers, females and nurses. 22 Furthermore, it is important that nurses are not stigmatised and policymakers should make efforts to ensure this stress is minimised and also allow them to focus on patient care. 14 Stigma could also be minimised through an integrated administrative and J o u r n a l P r e -p r o o f psychosocial response to challenges that are caused by outbreaks. 59 There is a need for the development of prevention programs for stress related psychiatric disorders. 15 In addition, health authorities should provide proactive psychological support for staff by offering support and training, counselling hotlines and offer reimbursements to staff. 19 Workplace awareness and measures Many recommendations focused on enhanced awareness amongst authorities or hospital administrators of their employees' mental health. 50 

Only two qualitative studies met inclusion criteria and the rest were quantitative studies.

The majority of studies used online survey methodology and self-report measures which have inherent limitations. There was a lack of longitudinal studies and therefore little evidence on the long term psychological sequelae and treatment needs. Further, indepth research considering the pre-and post-outbreak psychological risk factors, the effects of stigma and discrimination or impact on families is lacking. Of note, it was difficult to compare studies due to heterogeneity of design and outcome measures.

Geographic factors may have influenced results due to unique social and cultural contexts amongst the study locations where research was conducted.

From this review of HCWs, fear of uncertainty or becoming infected in the course of their work were at the forefront of the psychological challenges faced. Providing medical care during a global epidemic generates fear and heightens stress levels, with one large-scale study 1 reporting over 70% identified that becoming infected was most distressing. During the COVID-19 pandemic, HCWs have been exposed to high infection risk, death and dying, moral dilemma in deciding who qualifies for intensive care, and excessive workloads. The entire experience can be traumatising and heighten the risk of mental health conditions in a group that are already at increased risk, for instance HCWs are at higher risk of suicide than the general population. 66 It is likely that the psychological effects of epidemics on HCWs are variable across different contexts with several studies demonstrating an increased risk of acquiring a trauma or stress-J o u r n a l P r e -p r o o f related disorder. The risk to the mental well-being of HCWs are likely to be multi-faceted and more research is needed to elucidate the underlying mechanisms that can potentially be mitigated with appropriate measures. Collection of high quality data is urgently needed, especially for vulnerable groups exposed to a pandemic. 67 Interventions to reduce morbidity and severity of psychological problems in HCWs in the early stage may prevent adverse short-term and long-term implications.

It is important to note that professional recognition and ethics can positively reinforce hard work but the value of these are diminished when they are applied in a punitive way that stereotypes HCWs. The emphasis on their self-sacrifice while providing essential and life-saving services becomes magnified in the midst of an epidemic and often HCWs are portrayed as heroes. This in turn can impose certain expectations on them, to demonstrate personal strength and resilience, both emotionally and professionally.

However, this can also impede their ability to recognise vulnerabilities or share traumatic experiences, similar in some aspects to military personnel. This may inadvertently increase their mental health risks and stigmatising beliefs, thus prevent them from seeking psychological help. 68 As such, HCWs must feel free to express their emotions and share experiences, both positive and negative, even when society portrays them as faceless masked agents, and hails them as heroes. 

Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among frontline healthcare workers. Psychological medicine

Factors associated with the psychological impact of severe

Prevalence of psychiatric disorders among Toronto hospital workers one to two years after the SARS outbreak. Psychiatric services

Emergencies preparedness, response website: World Health Organization

Real estimates of mortality following COVID-19 infection. The Lancet Infectious Diseases

Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. The Lancet Psychiatry

Protecting Health Care Workers From Ebola: Personal Protective Equipment Is Critical but Is Not Enough

Unprecedented number of medical staff infected with Ebola [Online] Geneva: World Health Organization

Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a 4-year follow-up study. General hospital psychiatry

Psychological first aid during Ebola virus disease outbreaks

Workforce development at the local level: the NACCHO perspective

Sustainability of Psychological First Aid Training for the Disaster Response Workforce

Long-term psychiatric morbidities among SARS survivors. General hospital psychiatry

Mental health of nurses working at a government-designated hospital during a MERS-CoV outbreak: a cross-sectional study

Mental Symptoms in Different Health Professionals During the SARS Attack: A Follow-up Study. The Psychiatric quarterly

Prevalence of psychological symptoms among Ebola survivors and healthcare workers during the 2014-2015 Ebola outbreak in Sierra Leone: a crosssectional study

The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk

Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients

Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers

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

Risk Perception and Impact of Severe Acute Respiratory Syndrome (SARS) on Work and Personal Lives of Healthcare Workers in Singapore What Can We Learn? Medical Care

Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease

Survey of Insomnia and Related Social Psychological Factors Among Medical Staff Involved in the

A cross-sectional study on mental health among health care workers during the outbreak of Corona Virus Disease

Mental Health Outcomes Among Frontline and Second-Line Health Care Workers During the Coronavirus Disease 2019 (COVID-19) Pandemic in Italy

Mental health impact of COVID-19 pandemic on Spanish healthcare workers

The prevalence and influencing factors in anxiety in medical workers fighting COVID-19 in China: a cross-sectional survey

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, behavior, and immunity

Mental Health and Psychosocial Problems of Medical Health Workers during the COVID-19 Epidemic in China

Work stress among Chinese nurses to support Wuhan in fighting against COVID-19 epidemic

Prevalence, risk factors, and clinical correlates of insomnia in volunteer and at home medical staff during the COVID-19. Brain, behavior, and immunity

Psychological status of medical workforce during the COVID-19 pandemic: A cross-sectional study

The Effects of Social Support on Sleep Quality of Medical Staff Treating Patients with Coronavirus Disease 2019 (COVID-19) in January and February 2020 in China

Psychological impact on women health workers involved in COVID-19 outbreak in Wuhan: a cross-sectional study

Tackling the mental health burden of frontline healthcare staff in the COVID-19 pandemic: China's experiences. Psychological medicine

The Psychological Status of 8817 Hospital Workers during COVID-19: a cross-sectional study in Chongqing

Prevalence and Predictors of Stress, anxiety, and Depression among Healthcare Workers Managing COVID-19 Pandemic in India: a Nationwide Observational Study

Effect of COVID-19 Pandemic on Mental Wellbeing of Healthcare Workers in Tertiary Care Hospital

Assessment of Mental Health Factors among Health Professionals Depending on Their Contact with COVID-19 Patients

epidemic on medical staff in different posts in China: A multicenter study

Mental health burden of frontline health professionals treating imported patients with COVID-19 in China during the pandemic

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. General hospital psychiatry

Impact of COVID-19 on the Mental Health of Healthcare Professionals in Pakistan

COVID-19 Psychological Impact in 3109 Healthcare workers in Spain: The PSIMCOV Group

Anxiety and Depression and the Related Factors in Nurses of Guilan University of Medical Sciences Hospitals During COVID-19: A Web-based Cross-Sectional Study

Mental Health Status of Paediatric Medical Workers in China During the COVID-19 Outbreak

The Mental Health Effects of COVID-19 on Health Care Providers in China

The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in COVID-19 services

Psychological distress surveillance and related impact analysis of hospital staff during the COVID-19 epidemic in Chongqing, China

Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A large-scale cross-sectional study

Immediate Psychological Impact on Nurses

Government-Designated Hospital During COVID-19 Outbreak in China: a crosssectional study

Depression, anxiety, stress levels of physicians and associated factors in Covid-19 pandemics

Psychological symptoms among frontline healthcare workers during COVID-19 outbreak in Wuhan. General hospital psychiatry

Mental health of healthcare workers during the COVID-19

A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak

The mental health of frontline and non-frontline medical workers during the coronavirus disease 2019 (COVID-19) outbreak in China: A case-control study

Psychological effects of the COVID-2019 pandemic: Perceived stress and coping strategies among healthcare professionals

Prevalence of depression and its impact on quality of life among frontline nurses in emergency departments during the COVID-19 outbreak

Survey of stress reactions among health care workers involved with the SARS outbreak

The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope

Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak

The impact of work-related risk on nurses during the SARS outbreak in Hong Kong

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

The psychological impact of SARS on health care providers

Dying and caring on the edge: Taiwan's surviving nurses' reflections on taking care of patients with severe acute respiratory syndrome

Suicide among physicians and health-care workers: A systematic review and meta-analysis

Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry

UK military doctors; stigma, mental health and help-seeking: a comparative cohort study

First responders and psychological first aid

Resilience Scale-15. DSM-IV=Diagnostic and Statistical Manual of Mental Disorders

GHQ-28= General Health Questionnaire 28

MERS=Middle East respiratory syndrome

MSPSS=Multidimensional Scale of Perceived Social Support

Primary Care PTSD Screen for DSM-5. PHQ-2= Patient Health Questionnaire-2. PHQ-4=Patient Health Questionnaire-4. PHQ-9=Patient Health Questionnaire. PHQ-15= Patient Health Questionnaire-15

SCID=Structured Clinical Interview for DSM-IV. SCL-90-R=Symptom Checklist-90-Revised. SCL-90= Symptom Checklist-90. SDS=Zung Self-rating Depression Scale

SF-36= Medical Outcomes Study Short Form 36 Survey

☐ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☒The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:The corresponding author is not a recipient of a scholarship. There is no funding associated to this study. Sonja Cabarkapa, Sarah Nadjidai and Jerome Murgier have no conflicts of interest. Chee Ng declares receiving the following over the last 36 months; travel support and honorarium for delivery of talk from both Lundbeck and Pfizer. He has also received travel support and honorarium for consulting service for Janssen.