|Ahead of print
|Impact of pandemic on the mental health of doctors working in a district COVID-19 hospital
Therissa Benerji1, Sarath Bodepudi2, Srikanth Lella2, Madhavi Kodali3
1 Post-Graduate, Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Krishna, Andhra Pradesh, India
2 Assistant Professor, Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Krishna, Andhra Pradesh, India
3 Professor, Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Krishna, Andhra Pradesh, India
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|Date of Submission||19-Jan-2021|
|Date of Acceptance||24-Mar-2021|
|Date of Web Publication||31-Aug-2021|
Background: COVID-19 pandemic can significantly affect the mental health of doctors as they stand in the front line of this crisis. The psychiatric consequences, in part, can be due to the stress the doctors are subjected to due to their close involvement in the treatment of infected patients. Some of the other reasons are related to the fear of transmission to their families and concerns about the health of self and family, stigmatization, and rejection.
Aims: To assess the levels of depression, anxiety, and stress among doctors working in district COVID hospital, note the possible association of life events with the mental health of the doctors during the current situation and address the coping styles they have sought to endure the current crisis.
Materials and Methods: An online survey is conducted to assess the psychological responses of doctors during the COVID-19 outbreak. It consisted of four subsections covering (1) sociodemographic data and information on individuals' working conditions, (2) Depression Anxiety and Stress Scale-21, (3) presumptive stressful life events scale, (4) Brief-COPE.
Statistical Analysis Used: Statistical analysis was done using SPSS version 25.
Results: Of the 353 participants, 80 had symptoms of depression, 151 anxiety, and 74 stress. Significant levels of depression were found among doctors involved in the direct care of patients with COVID-19 compared to those not involved in direct care. Undesirable events were found to be greater in number than desirable events. Concerning coping strategies, we found the more frequent use of adaptive coping strategies compared with maladaptive coping strategies among respondents.
Conclusion: COVID-19 pandemic has a sizeable psychological impact on the mental health of doctors involved in direct and indirect care of patients with COVID-19.
Keywords: COVID-19, doctors, mental health
|How to cite this URL:|
Benerji T, Bodepudi S, Lella S, Kodali M. Impact of pandemic on the mental health of doctors working in a district COVID-19 hospital. Arch Ment Health [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.amhonline.org/preprintarticle.asp?id=325050
| Introduction|| |
A novel coronavirus (nCoV) was isolated in January 2020 by Chinese scientists from patients with atypical pneumonia in Wuhan, China, which was the center of the outbreak of pneumonia of unknown cause. Wang et al. reported that the 2019-nCoV being very contagious is spreading fast with an increasing number of infected patients nationwide in China. Owing to the global spread of the disease (nearly 143 countries) and alarming levels of severity, WHO characterized the COVID situation as a pandemic.
The mode of spread of this nCoV was observed to be person-to-person transmission, especially when not maintaining protection while working at a close distance or having intimate contact with infected persons.,
Medical workers were under enormous pressure due to the high risk of infection, inadequate protection from contamination, overwork, and isolation while working in hospitals dealing with the pandemic leading to mental health problems such as stress, anxiety, depressive symptoms, insomnia, and fear. In the postquarantine period, healthcare workers were psychologically more affected, felt stigmatized, and reported a greater loss of income. Furthermore, healthcare workers, including doctors, were subjected to stigma in the neighborhood, harassment from landlords, violence at the workplace, social isolation, and discrimination.
The unprecedented scenario of the COVID-19 pandemic has made the healthcare professionals across the world to work under extreme pressures and take difficult decisions, which caused some to experience moral injury or mental health problems. Thus, the COVID-19 pandemic is found to affect the physical health and the mental health of frontline workers, which may have a devastating effect on the health care system.
Hence, there is a need to understand the psychological effects of the COVID-19 outbreak on doctors and the related risk and protective factors to address the psychological needs and strengthen preparations to safeguard the mental wellbeing of doctors in this global pandemic.
Based on this perspective, this study was conducted on doctors providing direct and indirect care for patients with COVID-19. In addition, it included those closely involved in the care of other patients during the current pandemic (teleconsultation services). Here, we aimed to understand the emotional experiences and explore depression, anxiety, stress, and coping among this population.
This research is undertaken with the primary objective of studying the impact of the COVID-19 pandemic on the mental health of doctors working in a district COVID hospital by assessing their levels of depression, anxiety, and stress; also to address the coping styles they have sought to endure the current crisis.
| Materials and Methods|| |
A cross-sectional study was conducted by the department of psychiatry of a tertiary care center designated as district COVID-19 hospital. The questionnaire was designed to assess the impact of the COVID-19 pandemic on the mental health of doctors providing direct care for patients with COVID-19 and also those involved in teleconsultation services. The study was undertaken following approval from the Institutional Ethics Committee. We used an online survey to minimize one-on-one encounters and facilitate the participation of health care workers working extensively for long hours during the current crisis. A convenience sample of doctors was contacted to participate in this study. The survey was sent as a WEBSMS and also shared on various social network groups of different specialties. All the respondents provided informed consent at the beginning of the survey with a yes-no question. Data were collected between Jul 3, 2020, and Jul 30, 2020.
Sociodemographic details included age, gender, relationship status, and nature of services in COVID-19 hospital. The Depression Anxiety Stress Scale 21 (DASS 21) was applied for measuring depression, anxiety, and stress, presumptive stressful life events scale (PSLES) to note the possible association of life events with the mental health of the doctors during the current situation and Brief-COPE to assess the varying coping strategies used by doctors in response to stress.
The DASS 21 is a self-report tool containing 21 items that assess three constructs: Depression, Anxiety, and Stress. Each subscale includes seven 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.
PSLES was constructed by combining the Social Readjustment Rating Schedule and an open-ended questionnaire. It consists of 51 life events relevant to the Indian population. Scale items are classified into desirable or undesirable/ambiguous and personal or impersonal events. It was applied to assess the number and score of SLEs during the patient's past 1 year of life.
The Brief-COPE is a 28-item self-report questionnaire developed as a short version of the original 60-item COPE scale. It was designed to assess individuals'' varying coping strategies in response to stress. It comprises 14 subscales, each of which evaluates the degree to which a respondent utilizes a specific coping strategy. These scales include active coping, planning, positive reframing, acceptance, humor, religion, emotional support, instrumental support, self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame. Each of the 14 subscales comprises two items; total scores on each scale range from 2 (minimum) to 8 (maximum). Respondents rate items on a 4 point Likert scale, ranging from 1 (I haven't been doing this at all) to 4 (I've been doing this a lot). Higher scores indicate increased use of that specific coping strategy.
Statistical analysis was done using Statistical package for social sciences (SPSS), version 25.0, released in 2017 by (IBM corp, Armonk, New York, United States of America). The association between nature of services rendered in the COVID-19 hospital and the severity of depression, anxiety, and stress was assessed using Chi-square test. The association of life events with the severity of depression, anxiety, and stress was assessed using ANOVA. A P < 0.05 has been taken as statistically significant.
| Results|| |
The total sample consisted of 353 respondents, of which 310 (87.8%) were involved in the direct care of patients with COVID-19, and 43 (12.2%) were involved in teleconsultation services. Most of them were between 20 and 30 years of age (n = 246, 69.7%). Of the total sample, 131 (37.1%) were male, and 222 (62.9%) were female.
Participant characteristics are summarized in [Table 1].
Results of the depression, anxiety, and stress scale
Of the total sample, 80 (22.6%) had symptoms of depression, 151 (42.7%) anxiety, and 74 (20.9%) stress. On the depression subscale, 51 (14.4%) reported mild and 29 (8.2%) moderate depressive symptoms. On the anxiety subscale, 55 (15.5%) reported mild, 77 (21.8%) moderate, and 19 (5.3%) severe anxiety symptoms. On the stress subscale, 28 (7.9%) reported mild symptoms of stress, 39 (11.0%) moderate, and 7 (1.9%) reported severe symptoms of stress, as summarized in [Table 2]. The stress experienced was found to make a significant contribution to depressive symptoms (P = 0.04). The nature of services rendered in COVID-19 hospital seemed to play a role with regards to the severity of depression and anxiety in the respondents. Direct care of patients with COVID-19 has been found to be significantly associated with the severity of depression and anxiety (P < 0.05), as shown in [Table 3].
|Table 2: Severity of depression, anxiety and stress according to depression anxiety and stress scale-21|
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|Table 3: Association of the nature of services with severity of depression, anxiety and stress|
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Symptoms of depression, anxiety, and stress all together were present in 74 (20.9%) of the total sample.
Results of the presumptive stressful life events scale
The average number of life events, as summarized in [Table 4], experienced by a respondent was 5 (±1) within the last 1 year. Undesirable events were found to be greater in number (2) than desirable events (<1). The total accumulated stress score among the individuals was around 205.24 points, with undesirable events adding up to a greater average of 91.71 points.
|Table 4: Descriptive statistics of life events experienced by the doctors|
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The association of life events with the severity of depression, anxiety, and stress was assessed using ANOVA, and the results are shown in [Table 5].
|Table 5: Association of stressful life events with severity of depression, anxiety and stress|
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Neither the severity of depression nor anxiety or stress was found to have a correlation with the number of life events experienced and stress accumulated during the past 1 year (P > 0.05). The most common events experienced within the last year were changes in social activities, eating habits, and sleeping patterns.
Results of the brief-COPE questionnaire
Among the adaptive (approach) coping strategies, the most frequently employed ones were accepting reality (45.9%), making fun of the situation (36%), finding comfort in religion or spiritual beliefs, praying or meditating (26.1%), followed by seeking informational support (24.6%) and getting emotional support from others (18.4%) as shown in [Table 6]. Of the maladaptive (avoidant) coping strategies, self-distraction by, for instance, watching TV (22%), turning to work, or other activities (36.3%) was the most often used, followed by ventilating out unpleasant feelings (10.5%).
|Table 6: Adaptive and maladaptive coping strategies as per Brief-COPE inventory|
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| Discussion|| |
This cross-sectional survey enrolled 353 respondents and revealed the presence of mental health symptoms among doctors treating patients with COVID-19 in our center.
Of the total sample, 22.6% scored ≥10 on the depression subscale. This finding of our study is in accordance with earlier studies, which observed that about 25% of the physicians had reported symptoms of depression., Whereas, a nationwide observational study in India found depression in 11.4% of healthcare professionals, wherein 84.3% were doctors. The current study revealed significant levels of depression in doctors involved in the direct care of patients with COVID-19 compared to those not involved in direct care. Similar findings were observed in previous studies.,,
A higher proportion of doctors had symptoms of anxiety (42.7%) in our study, while other studies from India reported 12% to 17% prevalence., However, a study from Iran had observed a significantly higher prevalence of anxiety in doctors as opposed to other occupations. A change in working pattern, poor quality of sleep, lack of family support along with an increased perception of disease risk, a lack of knowledge about COVID-19, and psychological unpreparedness could have led to depression and anxiety in the doctors involved in COVID-19 services.,
In the present study, no significant difference was found in stress levels in doctors involved either in COVID or in non-COVID care. Whereas a study from Oman had found that doctors who cared for COVID-19 patients reported significantly higher levels of stress than those who did not. Extensive work hours, fear of contracting the disease while caring for the people, and transmitting the disease to family and friends were the reasons given for elevated stress.,
Undesirable and desirable life events experienced by a respondent within the last 1 year were also considered in this study to note their possible association with the mental health of the doctors during the current situation. Neither the severity of depression nor anxiety or stress was found to have a correlation with the number of life events experienced and stress accumulated during the past 1 year (P > 0.05). The more common events reported by the respondents were changes in social activities, change in eating habits, and in sleeping patterns, which could be the common phenomena experienced during a pandemic. A study from Iran had pointed out that during pandemic the stressful life events which had an impact on the people were decrease in income, change in communication pattern with family and friends, change in work schedule, health habits, dietary changes, staying at home, change in customs and traditions. However, Epidemic Stressful Events Checklist was used, and stressful events in COVID 19 pandemic were measured with an emphasis on adaptation, threat or harm, demands exceed resources, and interruption of goals.
Concerning coping strategies, we found the more frequent use of adaptive compared with maladaptive coping strategies (78% vs. 18.9%) among respondents, which might explain the relatively moderate stress levels among our study participants. Frequent use of adaptive coping strategies have been previously reported among doctors and may reflect the accumulated experience of adequate coping with work stressors., The adaptive (approach) coping strategies identified to be used were accepting reality, making fun of the situation, finding comfort in religion or spiritual beliefs, and seeking informational support. Of the maladaptive (avoidant) coping strategies, self-distraction by, for instance, watching TV, turning to work, or other activities to take the mind off things was the most often used. Studies have shown that more positive refocusing, altruism, i.e., religious coping boosted the resilience and coping mechanisms among frontline health workers.,, Lower positive attitude, higher social support, and higher avoidance strategies were predicted to be associated with higher levels of distress. Furthermore, avoidance of harmful coping strategies such as substance misuse, constant rumination about COVID-19, or engaging in high-risk behaviors play a crucial role, as these activities are more damaging in the long term.
The COVID-19 pandemic threatens to overburden healthcare systems. It also has a sizeable psychological impact on doctors involved in direct and indirect care of COVID-19 patients. Doctors involved in the diagnosis, treatment, and care are particularly vulnerable to adverse mental health outcomes. Healthcare organizations are recognizing the impact of mental health problems on the quality of healthcare., It might be of help to screen doctors for psychological symptoms as early intervention, if required, can be provided.
This is the first study in our area investigating the psychological impact of the COVID-19 outbreak on doctors. Scales used in our research are well-validated.
This was a preliminary study done in a single center. The study is limited by its cross-sectional nature and lacks longitudinal follow-up. Hence, the generalization of the findings is restricted. Limitations were the moderate response rate, the voluntary nature of the survey, and an absence of legitimacy in the absence of direct interviews. Anonymity may have permitted doctors to feel good in detailing their pressure, yet it forestalled the follow-up of nonresponders and those who required assistance.
| Conclusion|| |
The current study underlined the impact of the COVID-19 pandemic on the mental health of doctors and thereby the healthcare systems. Doctors' mental wellbeing is pivotal for ensuring the sustainability of health care services during our struggle with COVID-19.
- Dr. Krishna Mohan Parvathaneni, Professor and HOD, Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation
- Dr. Satyanarayana Murthy Pusuluri, Principal, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation
- Dr. Narayan Chander, Medical Superintendent, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation
- Mrs. Savithri Bhavaraju. MSc Statistics, Department of Community Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation
- Mr. Hima Kiran, Administrative officer, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Psychiatry, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Krishna, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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