key: cord-340535-78bpvtuf
authors: Elbay, Rümeysa Yeni; Kurtulmuş, Ayşe; Arpacıoğlu, Selim; Karadere, Emrah
title: Depression, Anxiety, Stress Levels of Physicians and Associated Factors In Covid-19 Pandemics
date: 2020-05-27
journal: Psychiatry Res
DOI: 10.1016/j.psychres.2020.113130
sha: 
doc_id: 340535
cord_uid: 78bpvtuf

AIM: To investigate anxiety, stress, and depression levels of physicians during the Covid-19 outbreak and explored associated factors in both clinical and general site. METHODS: An online survey is conducted to asses psychological responses of healthcare workers and related factors during Covid-19 outbreak. It is consisted of three subsections covering the following areas: 1) sociodemographic data 2) information on individuals` working condition 3) Depression Anxiety and Stress Scale-21 (DAS-21). RESULTS: Of all 442 participants, 286 (64.7%) had symptoms of depression, 224 (51.6%) anxiety, and 182 (41.2%) stress. Being female, young, and single, having less work experience, working in frontline were associated with higher scores, whereas having a child was associated with lower scores in each subscale. Factors found to be associated with higher DAS-21 total scores in frontline workers were as follows: increased weekly working hours, increased number of Covid-19 patients cared for, lower level of support from peers and supervisors, lower logistic support, and lower feelings of competence during Covid-19 related tasks. CONCLUSIONS: Our findings highlight the factors which need to be taken into consideration to protect the mental wellbeing of doctors while fighting with a disaster that has major impacts on society worldwide.

Since December 2019, the world is facing a new contagious disease, Covid-19. It is first described in Wuhan, China and has spread globally in months. The rapid transmission of the disease and increasing influx of infected cases and associated deaths lead to an enormous panic and anxiety in public. In an early study investigating immediate psychological response during Covid-19 epidemic among general population in China, 53.8% of participants rated the psychological impact of the outbreak as moderate or severe (1) .

Besides psychological aspects of the outbreak on society, healthcare workers (HCWs) are subjected to an additional stress due to engaging directly in the treatment of infected patients and increased risk for contagion, fear of transmission to their families, concerns about health of self and loved ones, feeling stigmatized and rejected and working under extreme pressures. On the other side, the increasing number of cases and disease-related deaths, heavy workload for extended period of time and depletion of personnel protection equipment (PPE) cause emotional and physical burnout over time.

Stress reaction symptoms such as anxiety, depression, somatization and hostility have been reported in about 10% of healthcare workers during and in the aftermath of previous outbreaks (2) . During a recent epidemic SARS, a study from Taiwan investigated stress reactions among hospital staff and reported 5% suffered from an acute stress disorder, 20% felt stigmatized and 9% reported reluctance to work or had considered resignation (3) . In another study investigating long term psychological effects of SARS outbreak on healthcare workers, 23% of staff were found to have moderate or severe depressive symptoms in a 3year follow-up (4) . More recently, during Covid-19 pandemic, the prevalence of depression, anxiety and stress-related symptoms were found to be 50.7%, 44.7% and 73.4% respectively, among Chinese healthcare workers (5) . However, the evidence is still scarce and little is known about psychological needs of healthcare workers facing with this global disaster.

Therefore, there is an urgent need for more systematic research to understand the psychological effects of Covid-19 outbreak on healthcare workers and related risk and protective factors.

Based on this perspective, here, we aimed to investigate anxiety, stress and depression levels of physicians during Covid-19 outbreak and explored associated factors in both clinical and general site. We hoped, our study would provide a better understanding of psychological needs of our colleagues during this disaster and strengthen preparations in safeguarding their mental wellbeing.

A cross-sectional survey was designed to assess psychological responses of healthcare workers and related factors during Covid-19 outbreak. We used an online survey to minimize face to face interactions and to facilitate participation of healthcare workers who work extensively during this emergency period. A convenience sample of physicians were contacted to participate in this study. The survey was shared on various social network groups from different specialities. All respondents provided an informed consent at the beginning of the survey with a yes-no question confirming their willingness to participate in the study. Data was collected between March 10, 2020 and March 15, 2020.

Ethical approval for the study was granted by the ethical committee of Istanbul Medeniyet University with the number 2020/187.

Sociodemographic data were collected on age, gender, marital status, specialties, number of children, composition of the household, comorbid medical diseases, history of mental disorders, smoking status, alcohol consumption and time spent daily on social media since the outbreak. Participants were also asked whether they have ever diagnosed with Covid-19 so far.

The Depression Anxiety Stress Scale (DASS) 21 is a self-report tool containing 21 items that assess three constructs: Depression, Anxiety, and Stress (6) . Each subscale includes 7 statements. Items consist of statements referring to the previous week, respondents are asked to read these statements and rate the frequency of the negative emotions. Ratings are made on a series of 4-point Likert-type scales from 0 (did not apply to me at all/ never) to 3(applied to me very much/ always). Higher scores indicate more severe emotional distress. The validity and reliability studies of the Turkish version of the DASS-21 were performed by Sarıçam et al in 2018 and it was concluded that the scale was a valid and reliable instrument in the assessment of depression, anxiety, and stress levels. (7).

Data were analysed using SPSS version 25 (SPSS Inc., Chicago, IL). In addition to descriptive statistics, we first conducted univariate analyses to explore the associations between psychiatric symptoms and related factors by using either Student's t-test and ANOVA test or Pearson`s correlation test. Then, we conducted multiple linear regression analyses to identify the unique contribution of relevant predictors on the DAS total and subscale scores, separately. With this purpose, life-time psychiatric history and correlates that showed statistical significance at p-value less than 0.05 in the univariate analyses were included in the regression analysis. As work experience and age were highly correlated variables, we only included age as a covariate in the regression analyses to avoid multicollinearity.

All analyses were two-tailed with alpha set at 0.05.

442 people participated in the study. Characteristics of the participants are presented in Table   1 . The mean age was 36.058.69. There were more females than males in the sample (56.8% vs 43.2%). Table 2 presents the working conditions of doctors who work in the frontline during this pandemic.

18.1% (n:80) of the overall sample were smokers. Of these, 20 reported an increase, whereas 27 reported a decrease in daily cigarette consumption after the outbreak. 100 people (22.6%) were drinking alcohol in the whole sample. Of these, 17 reported an increase, while 34 reported a decrease in alcohol consumption.

We asked participants to rate their social media usage during the outbreak. 3.6% reported reduced social media use and 19.5% reported no change. However, social media usage was increased in 48.2% and was extremely increased in 28.7% of the sample.

Mean DAS-21 total and subscale scores of the sample were presented in Table 1 . Of all participants, 286 (64.7%) had symptoms of depression, 224 (51.6%) anxiety and 182 (41.2%) stress. For depression subscale, 17.6% of the sample were reported mild depressive symptoms, 27.4% were reported moderate, 9.5% were reported severe and 10.2% were reported extremely severe depressive symptoms. For anxiety subscale, 16.3% of the sample were considered to have mild anxiety symptoms, 13.1% were considered to have moderate, 10 .6% were considered to have severe and 11.5% were considered to have extremely severe anxiety symptoms. For stress subscale, 10.2% of the sample were reported mild stress symptoms, 15.6% were reported moderate, 10.4% were reported severe and 5.0% were reported extremely severe anxiety symptoms.

The findings of univariate analysis for psychiatric symptoms in the overall sample were presented in Supplementary Table 1 . Being female, young and single, having less work experience, working in frontline jobs were associated with higher scores, whereas having a child was associated with lower scores in each subscale. Composition of the household was found to be associated with only DAS total and depression subscale scores. Post-hoc analyses revealed that the scores were higher for those who live alone than those living with their spouse and children. Having comorbid medical diseases and having diagnosed with Covid-19

were not found to be associated with psychiatric symptoms. independently associated with each subscale scores, with the only exception is that age was not found to be associated with DAS-anxiety scores (p=.195).

Associations with DAS-21 total and subscale scores in frontline workers were presented in were independently associated with DAS-anxiety and stress scores. In addition, higher total number of Covid-19 patients cared for was also associated with higher DAS-stress scores independently (p=.045).

The first confirmed case of Covid-19 outbreak has been reported in Turkey on March 11, 2020 . As in the rest of the world, a rapid transformation and adaptation process started in the healthcare system and immediate steps were taken in our country, as well. We found that being married and having a child were associated with lower DAS total and subscale scores, whereas being younger and women, having less professional experience and working in the frontline were associated with higher scores in the whole sample. In addition, those living with their spouse and children had lower scale scores than those living alone.

Regression analysis showed that being a woman, being young, having a history of psychiatric disorders and working in the frontline were independent predictors for worse mental health outcome in almost all subscales. Similar to our findings, Lai et al indicated that women and frontline workers had a greater risk for developing adverse psychiatric outcomes during Covid-19 outbreak in China (5) . In another study investigating the psychological impact of SARS outbreak on hospital employees, younger participants and those worked in high risk locations, such as SARS wards, were more likely to have high PTSD symptoms (12) . Being single was found to increase the odds of having a high level of depressive symptoms in hospital staff, 3 years after the SARS outbreak (4). These factors were found to be independently associated with either total scale score or subscale scores after regression analysis. Our another finding is the excessive workload is associated with psychological symptoms. For this reason, it should be aimed to ensure appropriate working hours, reasonable rest periods and rotating shifts for workers. Logistic support seems to be another 

To the best of our knowledge, this is the first study in Turkey investigating psychological impact of COVID-19 outbreak on healthcare workers. However, we recognize several limitations to our investigation. First of all, the study is limited by its cross-sectional nature and lacks longitudinal follow-up. Data collection phase of the study was completed within 6 days. Given the time sensitivity across this emergency situation, we aimed to explore psychological symptoms of physicians and related factors, so that findings of this study would identify immediate needs of doctors and provide a guidance for implementing relevant intervention policies in the early period to protect their mental wellbeing during this struggle.

Furthermore, the voluntary nature of the survey might have led to a selection bias and the respondents may not represent well the entire population. Lastly, in order to reach as many participants as possible during this emergency time and to minimize face to face interviews, we used a self-report questionnaire to assess psychological symptoms which did not rely upon diagnostic assessment by mental health professionals. In this study, we only investigated depression, anxiety and stress levels of physicians. However, further studies incorporating social support and PTSD assesment in healthcare workers would undoubtly contribute to the litareture. Notwithstanding the above limitations, findings of this study provide valuable information on early psychological effects of Covid-19 in physicians from different specialties across the country. Most importantly, our findings will assist health authorities worldwide in implementing relevant measures to minimize the psychological effects of the largest pandemic of our time on HCWs.

Providing mental wellbeing of healthcare workers is crucial for ensuring the sustainability of healthcare services during our struggle with Covid-19. Our findings show that women, young and less experienced people and particularly those working in the frontline positions are in the risk group and should be followed closely. Our study further indicated that the excessive workload (increased total number of patients cared for and increased weekly working hours, working in both daytime and night-shifts), lower logistic support, lower support from peers and supervisors and lower feelings of occupational competence during covid-19 related tasks cause a more emotional impact in physicians who work in the frontline. 1 50.38 (114.02) Support from peers 2 2.35 (0.61) Support from supervisors 2 2.14 (0.70) Logistic support 3 2.45 (1.07) Occupational competence 4 3.18 (1.10) 1 Ns varies because of the missing data 2 As measured by a Likert scale. Possible scores range from 0 to 3, with higher scores indicating better support. 3 As measured by a Likert scale. Possible scores range from 0 to 5, with higher scores indicating better support. 4 As measured by a Likert scale. Possible scores range from 0 to 5, with higher scores indicating better competence. 

Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China

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

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

Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories

The psychometric properties of Turkish version of Depression Anxiety Stress Scale-21 (DASS-21) in health control and clinical samples

The mental health of hospital workers dealing with severe acute respiratory syndrome

The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital

Stress and psychological distress among SARS survivors 1 year after the outbreak

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

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