key: cord-327232-oavox35v authors: da Silva, Flaviane Cristine Troglio; Neto, Modesto Leite Rolim title: Psychological effects caused by the COVID-19 pandemic in health professionals: A systematic review with meta-analysis date: 2020-08-06 journal: Prog Neuropsychopharmacol Biol Psychiatry DOI: 10.1016/j.pnpbp.2020.110062 sha: doc_id: 327232 cord_uid: oavox35v BACKGROUND: Psychological suffering by health professionals may be associated with the uncertainty of a safe workplace. Front-line professionals exposed and involved in the diagnosis and treatment of COVID-19 patients are more susceptible. METHOD: This review was conducted based on papers that were published at MEDLINE, BMJ, PsycINFO, and LILACS, the according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA). RESULTS: Health professionals had a higher level of anxiety (13.0 vs. 8.5%, p < 0.01, OR = 1.6152; 95%CI 1.3283 to 1.9641; p < 0.0001) and depression 12.2 vs. 9.5%; p = 0.04; OR = 1.3246; 95%CI 1.0930 to 1.6053; p = 0.0042), besides somatizations and insomnia compared to professionals from other areas. CONCLUSION: Health professionals, regardless of their age, showed significant levels of mental disorders. We observed a prevalence of anxiety and depression. Insomnia was a risk factor for both. Uncertain conditions in healthcare reflect on behavioral changes and disfavor the mental health of people working to save lives. The new coronavirus (COVID-19) has quickly spread from Wuhan, China, to the world (Ahmed et al., 2020; Lunn et al., 2020) . Since the virus was first identified until the moment this study was carried out, there have been more than 3.450,000 confirmed cases spread around the globe (Corona Virus Diagnostipedia, 2020). Thus, health professionals face higher work demand and risks to their physical and mental integrity, and the virus was able to cause large psychological impacts at a short period of time (Whang et al., 2020) . The lack of an effective treatment is still one of the greatest challenges for professionals who work to heal patients and fear the disease. This fear usually favors the development of anxiety, insomnia, depression, frustrations, and hysteria (Shiguemura et al., 2020; Lu et al., 2020; Liu et al., 2020) . During the COVID-19 pandemic, health professionals have been showing some psychosocial problems, as well as higher risk factors for developing them (Zhang et al., 2020a) . Reasons for the psychological suffering of health professionals may be associated with the uncertainty of a safe workplace, irritability, insomnia, sadness, demoralization (Guangming, 2020; Theorell, 2012) and little time to rest, in addition to exhaustion due to the increasingly higher number of cases (Ryall, 2020) . There are many reports in literature showing that front-line professionals exposed and involved in the diagnosis and treatment of COVID-19 patients are more susceptible compared to people who are not dealing directly with these patients (Lu et al., 2020) .Thus, the following question J o u r n a l P r e -p r o o f was raised: What are the main impacts of the COVID-19 pandemic on the mental health of health professionals? People working in health services against COVID-19 show significant mental health burnout and, therefore, present a high prevalence of mental disorders during the COVID-19 pandemic. This study aimed at analyzing the main psychological effects caused by the COVID-19 pandemic in health professionals. This review was conducted by means of a systematized search in April and May 2020 based on papers that were published and are available at MEDLINE, BMJ, PsycINFO, and LILACS. The review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes -PRISMA (Moher et al., 2009 ). The research and selection of studies were organized using the Population The following search terms were applied: "Covid-19" AND "Mental Health"; "COVID-19" AND "Health Workers" in titles and/or abstracts. Once studies were identified, the references were initially screened by applying the search criteria in the databases, using the following filters: studies performed since the beginning of the COVID-19 pandemic (December of 2019). Once papers were filtered, their titles and abstracts were read in order to identify documents that mentioned the proposed theme of the review. The final step of screening (eligibility) for paper inclusion included two independent researchers reading the full papers. If there was disagreement on the inclusion of a specific paper, an additional reviewer was consulted for a final decision (once). The studies concluded this review process and in the event the researchers' decision was included, they would be assigned a table with the following extracted information: Author and Year, Sample, Country, Collection Instrument (Questionnaire) and main conclusion in the order they were found in the databases. The funnel plot was used to test publication bias. In the presence of asymmetry, there may be bias and disagreements in the systematic review results (Figure 1 ). This happens due to the short period for developing primary studies and also reflects on the scarcity of evidence available until now. Journal Pre-proof We have included health professionals from the areas of knowledge (e.g. physicians, nurses, among others) part of a hospital context. The only variable in our study was the time during the COVID-19 pandemic. Professionals' mental health should be assessed using two previously validated questionnaires. Hence, the research instruments should provide data on the prevalence of mental disorders in the population studied. The main analyzed variables were anxiety, depression, insomnia, distress, and fear. Some observational studies of our sample divided the anxiety and depression levels into three levels: mild, moderate, and severe. Subjects with moderate and severe levels were gathered in only one group to categorize the presence and absence of anxiety symptoms during the COVID-19 pandemic. The chosen references included observational studies with a cross-sectional outline. Description of the selected papers by author and year, location, sample, instrument, and main conclusions is shown in Table 1 . During the outbreak period, the levels of depression and anxiety shown by surgical teams were significantly higher compared to surgical teams during the nonoutbreak period (OR=1.8491; 95%CI 0.5117 to 6.6813; p=0.3483 and OR=7.8750; 95%CI 2.9432 to 21.0710; p<0.000). Data from item 3 of Figure 2 show that healthcare teams had higher levels of anxiety compared to administrative teams (OR=1. Data used to calculate item 5 in Figure 2 were extracted from an observational study of insomnia. Health professionals with insomnia were more prone to develop anxiety and depression symptoms (OR=13.5517; 95%CI 10.4771 to 17.5285; p<0.0001). Most of them also spent ≥ 5 hours reading information on the COVID-19 outbreak during the week and they have considerable uncertainty about the disease and its effective control. In the study by Kang et al. (2020) , it was not possible to calculate it, because it was a quantitative study in which they used questionnaires, but there was no comparison among study subjects. The randomized effect model was 0.33 (95%CI 0.24 to 0.45; p=0.01) in Figure 4, whereas it was 0.36 (95%CI 0.19 to 0.58; p=0.01) in Figure 5 . Both values are considered low, but statistically significant. Weights were calculated based on the analysis of randomized effect in Figure 6 and resulted in 0.69 (95%CI 0.53 to 0.82; p<0.01) and then in 0.64 (95% CI 0.42 to 0.81; p<0.01), as in Figure 7 . These are quite high scores for the non-development of anxiety and depression; however, we should consider all the reasons for the odds from Figure 2 , the sampling differences, and scarcity of high evidence until now. This study aimed to assess the outcome of the COVID-19 pandemic scenario on the mental health of health professionals. The main results found were: a) Health professionals showed high prevalence of mental disorders; b) During the pandemic, the anxiety and depression scores are significantly higher in the healthcare teams; c) The teams working closer to infected patients showed a higher prevalence of mental disorders. According to comparative analyses in primary studies (Figures 4 and 5) , samples with anxiety and depression may not be clearly present in most of the health professionals at this pandemic situation, but there are great odds of their increase due to this and other pandemics (Liang et al., 2020; Xu et al., 2020; Lu et al., 2020; Zhang et al., 2020a, b) . The levels of depression and anxiety shown by health professionals was significantly higher during the outbreak (Xu et al., 2020) mainly due to stress, insomnia, J o u r n a l P r e -p r o o f fear of the disease and infectiousness (Lu et al., 2020; Zhang et al., 2020b) . Similarly, studies carried out during and after epidemics like 2003 SARS and 2014 Ebola observed changes in behavior induced by these disorders (Shultz et al., 2016) . We found many psychiatric disorders like anxiety, depression, and posttraumatic stress in health professionals during and after pandemics (Blakey et al., 2019; Gardner and Moallef, 2015; Mak et al., 2009) . It is noteworthy that this population especially has a higher chance of evolving to more severe conditions of the disease, considering that the infection caused by a high viral load results in a worse prognosis for SARS- CoV-2 (Liu et al., 2020) . Higher exposure to infected patients favors disease spread (Yu et al., 2020) . In addition, healthcare teams with insomnia are more susceptible to developing the disorders mentioned. In the study performed by Zhang et al. (2020a,b) , 1,563 subjects were assessed using a questionnaire that measured the insomnia score. Among the subjects assessed, the population that showed insomnia (n=564) had a significantly higher prevalence of anxiety and depression in a moderate and severe way. It is noteworthy that the COVID-19 pandemic is a worsening factor that increases the number of insomnia cases among health professionals (Zhang et al., 2020a,b) . Some studies compared the mental disorders suffered by healthcare teams to those suffered by professionals from other areas. Anxiety, fear, and depression were substantially higher in health professionals mainly because they are more exposed to infection, unlike professionals from other areas (Lu et al., 2020). Age was not associated with the development of disorders during the pandemic and this study might be a reminder to not neglect the mental health of health professionals by age. The study may also provide evidence that this is not a strong predictor for psychological disorders in pandemics (Liang et al., 2020). The main limitation of the results of this study was that all the studies included in this paper were carried out in China. Thus, the mental health characteristics cannot be extrapolated to the rest of the world, considering that each country has a different scenario for fighting the COVID-19 pandemic, which can be more favorable or not compared to the one found in China. We strongly recommend that other studies be carried out in other countries in order to clarify the pandemic effects on healthcare teams in each affected region. In addition, we hope to strengthen the discussion on the need for healthcare teams to be followed by other professionals, to avoid worse prognoses on mental health. During the COVID-19 pandemic, health professionals, regardless of their age, showed significant levels of mental disorders, which were higher compared to other periods. In the analyzed studies, we observed a prevalence of anxiety and depression, and insomnia was a risk factor for both FCTS and MLRN designed the review, developed the inclusion criteria, screened titles and abstracts, appraised the quality of included papers, and drafted the manuscript. MLRN and FCTS reviewed the study protocol and inclusion criteria and provided substantial input to the manuscript. MLRN and FCTS reviewed the study protocol. MLRN read and screened articles for inclusion. All authors critically reviewed drafts and approved the final manuscript. Table 1 . Description of the selected papers by author and year, location (country and cities), sample, instrument (questionnaire), and main Preliminary identification of potential vaccine targets for the COVID19 coronavirus (SARS-CoV-2) based on SARS-CoV immunological studies Posttraumatic safety behaviors: Characteristics and associations with symptom severity in two samples Reported cases of corona virus in the world in real time Psychological impact on SARS survivors: Critical review of the English language literature Preferred reporting items forsystematic reviews and meta-analyses: the PRISMA statement Coronavírus: os médicos desmaiam de exaustão à medida que o vírus se espalha pela Coreia do Sul. The Telegraph Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations The role of fear-related behaviors in the 2013-2016 West Africa Ebola virus disease outbreak Avaliando eventos de vida e estressores crônicos em relação à saúde: estressores e saúde no trabalho clínico Psychological stress of medical staffs during outbreak of COVID-19 and adjustment strategy Psychological status of surgical staff during the COVID-19 outbreak SARS-CoV-2 viral load in sputum correlates with risk of COVID-19 progression Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak The authors declare that they have no competing interests.