key: cord-0894936-nq7i7efc authors: Ashoor, Mona Mohammedsaleh; Almulhem, Noorah Jamal; AlMubarak, Zaid Abdulrahman; Alrahim, Ahmed Abdulrahman; Alshammari, Saad Mohammed; Alzahrani, Fahad Saleh; Alhayek, Ali Radi; Alardhi, Abdullah title: The psychological impact of the COVID‐19 pandemic on otolaryngologists: Should we be concerned? date: 2021-04-02 journal: Laryngoscope Investig Otolaryngol DOI: 10.1002/lio2.556 sha: 7faf53a6a7d79d98b70067fd091803b36b315e2b doc_id: 894936 cord_uid: nq7i7efc OBJECTIVE: Physicians on the frontline of the COVID‐19 pandemic are at increased risk of contracting the disease. Otolaryngologists are amongst the high‐risk practitioners, as they are in close proximity to patient's upper airway, which may induce their psychological stress. METHODS: A cross‐sectional survey study, conducted among otolaryngologists in Saudi Arabia from June 11 to June 22. Survey consisted of sociodemographic questionnaire, Coronavirus Anxiety Scale (CAS), Obsession with COVID‐19 Scale (OCS) and Patient Health Questionnaire‐9 (PHQ‐9). Available otolaryngologists with no history of mental health problems were included. A P‐value lower than .05 was considered statistically significant. RESULTS: The study included 129 participants; 63.6% men and 36.4% women. 81.4% of participants were living with family, 57.4% living with either a child or an elderly family member. Nearly 7.8% of participants had dysfunctional COVID‐19 anxiety and 75.2% had COVID‐19‐related depression symptoms ranging from minimal to severe. Obsession and dysfunctional thinking regarding COVID‐19 were found in 26.4% of participants. Single otolaryngologists had significantly higher CAS (P = .025), OCS (P = .048), and PHQ‐9 (P < .001) scores. Participants who lived with children or elderly individuals had significantly higher OCS scores (P = .005). When comparing job ranks, residents had significantly higher scores for the CAS (P = .016) and PHQ‐9 (P < .001). CONCLUSION: COVID‐19 has a considerable psychological impact on otolaryngologists. Specifically, the young and single who have less social support. This indicates the importance of psychological support to this group. Additional thorough studies should explore the psychological impact of COVID‐19 in this field as it may carry devastating long‐term consequences if left unattended. LEVEL OF EVIDENCE: Level 4. deaths, and thousands of cases in hospitals, the World Health Organization (WHO) declared a pandemic. 3 Health care workers (HCWs) are on the frontline, managing patients. Therefore, HCWs are more at risk of contracting the disease than the general population. Many physicians and HCWs have been infected while caring for COVID-19 patients. In some countries, HCWs accounted for 29% of all infected patients and 12.3% of hospitalized COVID-19 patients. 4, 5 Additionally, the infection rate among HCWs is as high as 10%. 6 This high infection rate can lead to psychological strain, which affects the cognitive functioning, and clinical decision making of HCWs. 7, 8 During the MERS-CoV outbreak in Saudi Arabia, 40% of cases were HCWs. 9 Consequently, medical institutions initiated interventions to foster proper prevention and control measures to provide a safe environment. Due to high viral load in nasal and oropharyngeal mucosa, potential aerosol-generating procedures (eg, endoscopy, tracheostomy, and upper airway surgery) place otolaryngologists at higher risk of contracting the disease, particularly in procedures performed without proper personal protective equipment (PPE). 10 Consequently, otolaryngologists may experience significant anxiety, which may affect their ability to care for patients. Similar adverse effects were reported among HCWs exposed to the severe acute respiratory syndrome (SARS) during the outbreak of 2002-2003; they experienced significant psychological stress due to quarantine, and refused to provide medical care to their patients. 11 Our hypothesis is that COVID-19 pandemic has a psychological impact on Otolaryngologists in Saudi Arabia. Therefore, the aim of our study is to assess the psychological impact of COVID-19 on otolaryngology practitioners in Saudi Arabia; this may help establish a support system for the affected physicians. Three validated English questionnaires were used in this study: the Coronavirus Anxiety Scale (CAS), 12 the Obsession with COVID-19 Scale (OCS), 13 and the Patient Health Questionnaire-9 (PHQ-9). 14 1. The Coronavirus Anxiety Scale (CAS) is a 5-item self-report mental health scale measuring dysfunctional anxiety associated with the coronavirus crisis. Each item of the CAS is rated on a 5-point scale. A total score ≥ 9 indicates probable dysfunctional coronavirusrelated anxiety. Elevated scores on a particular item or a high total scale score (≥9) may indicate problematic symptoms for the individual that might warrant further assessment and/or treatment. 3. The Patient Health Questionnaire-9 (PHQ-9) is a 9-item selfadministered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which is a valid tool for measuring the severity of depression. Each of the 9 DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) items is rated in a 4-point scale. A PHQ-9 score ≥ 10 has a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively. Data were captured using numbers for all qualitative variables while the mean, SD, and median (min-max) were used to summarize all quantitative variables. Comparisons between CAS, OCS, and PHQ-9 scores and socio-demographic characteristics were calculated using the Mann-Whitney U test or the Kruskal-Wallis test. Normality, statistical interactions, and collinearity (ie, the variance inflation factor) were assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. A P-value <.05 was considered statistically significant. Correlation procedures determined the linear agreement of the CAS, OCS, and PHQ-9. All data analyses were carried out using Statistical Packages for Software Sciences (SPSS) version 21 Armonk, New York, IBM Corporation. The study was distributed among 262 participants. Around 132 participants fully answered the questionnaire, with response rate of 50.3%. We excluded three candidates who had been diagnosed with depression in the past. We included 129 otolaryngologists in the study. The T A B L E 2 Statistical association between CAS, OCS and PHQ-9 in relation to sociodemographic characteristics of otolaryngologists (n = 129) Factor CAS OCS PHQ-9 Total score (14) Total score (15) Total score (27) Mean ± SD Mean ± SD Mean ± SD Table 1 . When measuring the association between the CAS, OCS, and PHQ-9 scores in relation to participants' sociodemographic charac- When comparing between consultants, residents, and specialists/fellows, we found that residents had significantly higher CAS (F = 2.543; P = .016) and PHQ-9 scores (F = 9.841; P < .001). Additionally, participants who had been quarantined had significantly higher CAS (t = 2.912; P = .022) and PHQ-9 scores (t = 3.439; P = .001) (see Table 2 ). The correlation between the CAS and OCS score was positively and highly statistically significant (r = .538; P < .001), suggesting that when the CAS increases the OCS will also likely increase (see Figure 1A ). The Correlation between the CAS and PHQ-9 was positively and highly statistically significant (r = .648; P < .001), indicating that as the CAS increases the PHQ-9 will also increase (see Figure 1B ). There was a positive and highly statistically significant correlation between OCS and PHQ-9 scores (r = .568; P < .001), which suggests that when the OCS score increases the PHQ-9 score will also likely increase (see Figure 1C ). While calculating post hoc analysis using Bonferroni test of CAS score, we found no statistical significant difference when comparing age group in years (P > .05) and similar findings were observed when calculating post hoc analysis of CAS score in job title (P > .05) (see Table 3 ). However, while calculating post hoc analysis using Bonferroni test of OCS score, we found significant difference between age group 25-35 years and age group >45 years and vice versa (P = .015) and similar findings were observed between age group 36-45 years and age group >45 years and vice versa (P = .013) (see Table 4 ). Factor CAS OCS PHQ-9 Total score (14) Total score (15) Total score (27) Mean ± SD Mean ± SD Mean ± SD Finally, while calculating post hoc analysis of PHQ-9, using Bonferroni test, there was a significant difference between age group 25-35 years and age group >45 years and vice versa (P < .001). We also detected a significant difference between age group 36-45 years and age group >45 years and vice versa (P = .005). Furthermore, there was a significant difference found between resident and specialist/ F I G U R E 1 A, Correlation between CAS and OCS scores. The correlation between the CAS and OCS score was positively and highly statistically significant (r = .538; P < .001) suggesting that when the CAS increases the OCS will also likely increase. B, Correlation between the CAS and PHQ-9, which was positively and highly statistically significant (r = .648; P < .001), indicating that as the CAS increases the PHQ-9 will also increase. C, There was a positive and highly statistically significant correlation between OCS and PHQ-9 scores (r = .568; P < .001), which suggests that when the OCS score increases the PHQ-9 score will also likely increase fellow and vice versa (P = .007) while the comparison between resident and consultant and vice versa were also statistically significant (P < .001) (see Table 5 ). However, when considering that the pandemic is ongoing, the psychological impact still needs further research, as it is expected to evolve over time. In a systematic meta-analysis of 13 cross-sectional studies involving 33 062 HCWs, many reported significant anxiety and depression (23.2% and 22.8% respectively) during the COVID-19 pandemic. 21 COVID-19 has severely affected the well-being of HCWs. In Hong Kong, medical and nursing staff were found vulnerable to burnout, anxiety, and mental exhaustion. 22 In Germany, doctors reported high levels of anxiety and depressive symptoms. 23 Most studies on the psychological impact of COVID-19 on HCWs have addressed high-risk and low-risk areas of health care. Thus, it is difficult to standardize these results for all HCWs. As the present study focused on one specialty, its results are expected to have greater accuracy on the concerned group. Our study was conducted from 11 to 22 June 2020, during the peak of COVID-19 pandemic in Saudi Arabia, with cases reaching up to 4700 per day and death cases during the same period reaching above 400. During this time, lockdown was still ongoing as well as strict precautions being taken. 24 T A B L E 4 Post hoc analysis for the OCS score China, in which social support reduced anxiety and stress and improved self-efficacy. 31 Social support can help medical staff reduce their anxiety, as friends and family provide social and emotional support. 32 Additionally, social interactions reduce negative emotions and can improve mood. 33 Thus, it is important to provide psychological support to HCWs during health crises. Our study suggests that health institutions must focus on having a good psychological support and intervention system for their single staff who have less social support at home. Moreover, OCS scores of otolaryngologists living with young children or elderly family members were significantly higher than scores of those living alone (P-value .005). Although their anxiety and depression level may be lower due to the social support they receive at home, they are nevertheless concerned for their vulnerable family members and may fear infecting them more than infecting themselves. 5 Furthermore, the statistical significance of the linear correlation between the three scoring systems applied in this study was high (CAS, OCS, and PHQ-9); the correlation demonstrates having a positive scale might predict involvement of other psychological aspects. Therefore, the otolaryngologist might need to be screened for other psychological disorders as well if one of these scales are positive. Our study highlights the importance of providing otolaryngologists with psychological and emotional support and interventions by specialized personnel during health crises. Specifically, the most vulnerable otolaryngologists which include the single or unmarried, young, and those living with vulnerable family members at home. It has been found that evidence-based education and training of HCWs on readiness for a pandemic improves the experience, skills, and mental well-being of HCWs during the pandemic. 34 This study has a few limitations. First, we used a cross-sectional electronic-based questionnaire; it would have been preferable to conduct face-to-face interviews rather than a self-reporting survey, but due to the health crisis, face-to-face interviews were not possible. Second, the self-reported levels of psychological impact in the form of anxiety, depression, and obsession may not be as accurate as those derived from an assessment performed by a mental health professional. Third, due to the ongoing changes in post-traumatic mental health, continuous long-term mental state follow-ups would be preferable. Forth, a larger sample size is needed to confirm our conclusions. Finally, our data is collected from a single country, therefore an international multicenter study would be suggested in the future to compare between otolaryngologists in different countries. COVID-19 has had a significant psychological impact on otolaryngologists. Particularly the single and younger group. Additional, thorough mental health studies should be done in the field of otolaryngology, as the effects of the pandemic may carry devastating long-term consequences if left unattended. 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The authors have no financial conflicts of interest to disclose. https://orcid.org/0000-0003-1386-971X BIBLIOGRAPHY