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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
An online cross-sectional survey of depression, anxiety, and stress among resident doctors working at a COVID-19 tertiary care center in India


1 Junior Resident, Department of Psychiatry, Gandhi Medical College, Secunderabad, Telangana, India
2 Associate Professor, Department of Psychiatry, Gandhi Medical College, Secunderabad, Telangana, India
3 Assistant Professor, Department of Psychiatry, ESIC Medical College Hospital, Hyderabad, Telangana, India
4 Assistant Professor, Department of Psychiatry, Gandhi Medical College, Secunderabad, Telangana, India
5 Professor and HOD, Department of Psychiatry, Gandhi Medical College, Secunderabad, Telangana, India

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Date of Submission29-Dec-2020
Date of Acceptance02-Apr-2021
Date of Web Publication31-Aug-2021
 

  Abstract 


Background: Health-care workers around the world are extending support to contain the COVID-19 pandemic. This unprecedented situation has put the health-care system under tremendous pressure. One of the underrepresented and under addressed area is that of psychological stress experienced by doctors in this time of crisis.
Aim: The aim of the study was to evaluate for the symptoms of depression, anxiety, and stress among resident doctors working at a COVID-19 tertiary care center and the factors associated with their mental health status.
Materials and Methods: An online cross-sectional survey of resident doctors was conducted over a 10-day period from June 1 to 10, 2020, through e-mail using a 2-part questionnaire – 1st part included information about sociodemographic profile and factors affecting the mental status and the 2nd included questions from the Depression, Anxiety, Stress Scale-21 (DASS-21). The scoring cutoffs for the presence of depression, anxiety, and stress symptoms were >9, 7, and 14, respectively. The responses were analyzed using SPSS version 22.0 (IBM) with P value as significant below 0.05 and all tests were two tailed.
Results: Four hundred and thirty six out of 620 residents completed the survey yielding a response rate of 70.3%. A considerable proportion had symptoms of depression 132 (30.3%), anxiety 179 (41.1%), and stress 102 (23.4%). Females, first-line workers, those with a past history, and family history of mental illness had statistically significant higher scores on all three subscales of DASS-21. The number of working hours showed a significant positive correlation with symptoms of anxiety (r = 0.138, P = 0.004) and stress (r = 0.108, P = 0.024).
Conclusion: One-third of respondents reported experiencing negative emotional states currently, indicating pandemic's psychological impact on frontline health workers. There is a need for mental health interventions targeting frontline health workers who are a crucial workforce in lower middle economy like India and promote their overall mental well-being.

Keywords: COVID-19, frontline workers, mental health, resident doctors


How to cite this URL:
Sriperambudoori V, Pingali S, Tondehal NR, Joopaka AK, Molanguru U. An online cross-sectional survey of depression, anxiety, and stress among resident doctors working at a COVID-19 tertiary care center in India. Arch Ment Health [Epub ahead of print] [cited 2021 Dec 7]. Available from: https://www.amhonline.org/preprintarticle.asp?id=325051





  Introduction Top


A cluster of cases of pneumonia of unknown cause were reported in Wuhan, China, at the end of December 2019.[1] On January 9, 2020, it was reported that the outbreak was caused by a novel coronavirus. The number of confirmed cases continued to rise in China and soon started to be reported in other countries as well.[2] Human-to-human transmission was recorded in China,[3] and on January 30, 2020, the WHO declared the outbreak as Public Health emergency of international concern and on March 11, 2020, as a pandemic.[4]

Health-care workers who are the forefront of any pandemic have suffered from adverse psychological impact as reported by studies done on them during the severe acute respiratory syndrome (SARS) pandemic.[5] They reported fear of infection to self and those around them, uncertainty, reluctance to continue working, and high levels of negative emotional states of depression, anxiety, and stress.[5],[6] Studies done on health-care workers from China during the COVID-19 pandemic have also reported high level of psychological distress.[6]

The first COVID-19-positive case in India was reported on January 30, 2020 and has spread across widely since then. On March 30, 2020, the central government in collaboration with NIMHANS launched a national helpline to provide psychosocial support and counseling.[7] However, mental health interventions specifically targeting health-care workers (HCWs) are relatively scarce.

Resident doctors (interns, postgraduates, and senior residents) posted on frontline duty in this pandemic spend long-working hours in direct contact with the patients. They are therefore at an increased risk of developing psychological problems. Our study intends to assess depression, anxiety, and stress among resident doctors and the various factors associated with it. Before the initiation of this study (before June 2020), there were no studies in literature available about the psychological impact of COVID-19 on resident doctors in India. This can serve as an important evidence for the need to promote mental health well-being and develop direct interventions targeting frontline health workers who are crucial in providing care to those who are infected.


  Materials and Methods Top


The study was an online cross-sectional survey of resident doctors at a COVID-19 nodal center serving a 35 million population. Resident doctors for the purpose of this study included interns, postgraduates, and senior residents. Contact details of all concerned resident doctors were obtained from the hospital administration after due permission, and questionnaire was e-mailed to them. The number of responses was restricted to one per person to prevent overlapping of data. The questionnaire included the consent form at the beginning, and confidentiality of information was assured. This was followed by a two-part questionnaire – the first part was a semi-structured pro forma designed to capture the sociodemographic data and the factors associated with mental health status as determined by previous studies,[8] and the second part consisted of the Depression, Anxiety, and Stress Scale-21 (DASS-21), a scale that captured the dimensions of depression, anxiety, and stress in the respondent.[9] It took about 10 min to complete. The target sample size of participants was determined using the formula N = Zα2 P (1 − P)/d2.

Taking the frequency of psychological problems to be 35% in HCWs based on previous studies, 5% margin of error, 95% confidence interval, and 20% nonresponse rate, a total of at least 420 sample was aimed for.[10] The data so obtained were analyzed. Approval from the institutional ethics committee was obtained before the initiation of the study.

It was conducted over a period of 10 days from June 1 to 10, 2020.

Inclusion criteria

Residents willing to give informed consent were included in the study.

Exclusion criteria

Undergraduate students, faculty, medical officers, and doctors not currently posted at Gandhi hospital were excluded from the study.

Tools used

Semi-structured pro forma

It included sociodemographic details such as age, gender, marital status, education, occupation, and type of family. It included questions like whether the respondent was a first-line worker, past and family history of mental illness, number of work hours spent in COVID duties, medical comorbidities, and willingness to seek mental health help. Those who were involved in the direct care of COVID patients/posted in COVID wards/handling test samples were designated as first-line workers and others who provided indirect care at the same hospital were designated as second-line workers.

Depression, Anxiety, and Stress Scale-21

The DASS-21 is a set of three self-report scales (7 items per scale) designed to assess core symptoms of negative emotional states of depression, anxiety, and stress. It is based on a dimensional conception of psychological disorder.[9] Ratings are made on a series of 4-point Likert-type scales from 0 (did not apply to me at all) to 3 (applied to me very much) based on their experience in the past 1 week. Higher scores reflect more severe emotional distress.

The scores on each subscale of DASS-21 fell into five categories – normal, mild, moderate, severe, and extremely severe. In this study, severe and extremely severe are grouped together. The scoring cutoffs for the presence of depression, anxiety, and stress symptoms were >9, 7, and 14, respectively.

It has high internal consistency (Cronbach's alpha scores >0.7). The DASS scale has shorter version and longer version (comprising of 21 and 42 items, respectively). The final score is multiplied by two to obtain the final score in DASS-21.[11]

Statistical analysis

Data analysis was performed using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. P value was considered significant below 0.05, and all tests were two tailed. As the scores of depression, anxiety, and stress followed a nonnormal distribution, the values are represented as medians with interquartile range. Nonparametric (Mann–Whitney U-test and Kruskal–Wallis) tests were applied to compare the core symptoms of depression, anxiety, and stress between two or more groups.


  Results Top


The questionnaire was sent to 620 residents, out of which 436 respondents completed the survey (response rate was 70.3%). The sociodemographic characteristics of the nonrespondents were similar to the respondents.

Of 436 respondents, majority were female (62.4%) and unmarried (86.5%). Interns formed a majority (62.4%) and belonged to nuclear families (74.3%). First-line workers formed 73.2% of the respondents. Respondents having past and family history of mental illness formed 6.4% and 8.3% of respondents, respectively. Majority (70.2%) were willing to seek mental health support should the need arise [Table 1].
Table 1: The socialdemographic characteristics

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Among the respondents, a considerable proportion had symptoms of depression 132 (30.3%) anxiety 179 (41.1%) and stress 102 (23.4%) [Table 2].
Table 2: Total number of respondents with symptoms of depression, anxiety, and stress represented in numbers and proportion

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Since the distribution of depression, anxiety, and stress scores followed a nonnormal distribution, they are represented as median scores with interquartile range [Table 3].
Table 3: The median Depression, Anxiety, Stress Scale-21 scores

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Only factors significantly associated with depression, anxiety, and stress (P < 0.05) are represented in the table. Being female, first-line worker, with a family history of mental illness was significantly associated with higher scores on depression subscale, whereas higher scores on anxiety and stress subscales were significantly associated with a past history of mental illness along with the above factors [Table 4].
Table 4: Association of depression, anxiety and stress scores with sociodemographic factors

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Association between severity of symptoms across all three subscales and subcategories (e.g: severity of depressive symptoms did not vary significantly across males and females).

Depression, anxiety, and stress were categorized as normal, mild, moderate, and severe/extremely severe. Their severity across subcategories of gender, line of work, family, and past history of mental illness was assessed.

The depression severity did not differ significantly across various subcategories (for example, severity of depressive symptoms did not vary significantly across both males and females). However, those with a past history of mental illness were more severely stressed. Female gender, first-line workers, with past and family history of mental illness reported more severe symptoms of anxiety.

The number of COVID-19 duty hours per month showed a significant positive correlation with the presence of symptoms of anxiety (r = 0.138, P = 0.004) and stress (r = 0.108, P = 0.024) but not for depression [Table 5].
Table 5: Prevalence of symptoms of depression, anxiety, and stress among the respondents over four categories

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  Discussion Top


Of the 620 residents contacted, 436 responded yielding an overall response rate of 70.3%. Depression (30.3%), anxiety (41.1%), and stress (23.4%) were reported by the respondents in this study. A study on health-care workers done during acute SARS outbreak reported psychological symptoms in 89% of the health-care workers.[5]

Indian studies on residents done in pre-COVID-19 era used scales based on categorical approach and often excluded or combined resident doctors with other health personnel (faculty, nurses, and medical students).[12]

A previous Indian study done at a tertiary care center during nonpandemic time on resident doctors using DASS-21 reported the prevalence of depression, anxiety, and stress as 27.27%, 36.58%, and 24.24%, respectively.[13]

Compared to pre-COVID-19 era, the prevalence of depression, anxiety, and stress is higher in the current study. The emotional toll generated may have led to the appearance of new psychiatric symptoms or worsening of already present illness.

COVID-19 virus has a high risk of transmission and infection.[14],[15] Recent studies have showed that health-care workers all over are facing mental health issues in the light of COVID-19 pandemic.[16],[17] As compared to SARS/MERS/H1N1 outbreaks, there has been much wider coverage about the COVID-19 pandemic due to digital advancement which has added onto increased negative reactions to the pandemic.

In our study, participants who were women, first-line workers involved in direct care of COVID-19 patients and those with a past and family history of mental illness reported significantly higher symptoms of depression, anxiety, and stress.

Women were found to have higher prevalence and persistence of depression, anxiety, and stress when compared to men.[18],[19] Gender disparity in any psychological disorder is suggested to have resulted from an interplay between biological, reproductive, and psychosocial factors.[18],[19]

Studies in the initial period of the COVID-19 pandemic reported that frontline line health workers involved in the provision of direct care to COVID-19 patients faced higher physical and psychological challenges in accordance with massive health-care demands in the event of pandemic.[20]

Sources of concern specific to COVID-19 are mainly high transmission rate, risk to self, and close contacts, uncertainty about the course and outcomes, long-term complications, treatment protocol, specific drugs, or vaccines.[21],[22],[23]

Our study also has shown similar findings with fear of infection to self and fear of transmitting the infection to others being the concerns of majority of the residents.

Previous studies showed that HCWs working in critical care and infectious wards are at a higher risk of having adverse psychological outcomes.[24],[25],[26],[27] This study also showed similar findings, wherein those frontline workers in direct care of COVID-19 patients or handling their blood samples reported higher symptoms of depression, anxiety, and stress when compared to those not involved in direct care.

The results are consistent with previous findings which showed offspring of parents with mental illness to be at a higher risk of developing psychiatric illnesses themselves.[10] Similarly, those with a past history of psychiatric illness had higher chances for developing subsequent episodes and further deterioration.[10],[18]

Our study subjects were residents' doctors who are posted in the COVID wards for long hours ranging from 8 to 10 h. These long working hours, close proximity to the patients, and the discomfort of wearing the personal protective equipment (PPE) for long periods may have contributed to the positive correlation between the amount of time spent in COVID duties and symptoms of anxiety and stress.

A study by Cai et al. suggested that prolonged working hours and lack of PPE lead to increased stress in medical staff in Hunan. Safety from infection was the main concern as they worried most that they might infect their families with COVID-19.[17]

Age, marriage, educational level, occupation, and type of family were not significantly associated with symptoms of depression, anxiety, and stress. This could be explained by resident doctors having more or less work similarities and most of them choosing to stay on the hospital premises due to longer working hours and the lockdown.

A study done by Liang et al. did not find any statistically significant differences in levels of depression and anxiety between different age groups.[16]

The prevalence of symptoms of depression, anxiety, and stress in this study is comparable to those reported in other recent studies albeit differences.[28] This may have to do with functioning of the hospital itself and a larger sample size. Gandhi hospital was slowly converted in a stepwise manner to the sole COVID-19 tertiary care and nodal center in the state of Telangana.

The 1st COVID-19-positive case admitted in the state was in March 2020. This may have given them time to train the staff, acquire resources, develop appropriate combat strategies, gradual acclimatization, and increased preparedness after the hospital's swine flu experience during 2009–2010. The collectivistic culture prevalent in India might have added to social support and resilience.[29],[30]

Strengths

Before the initiation of this study (prior to June 2020), there were no studies in literature available about the psychological impact of COVID-19 on resident doctors in India. It was conducted during the initial period of the pandemic using adequate sample size. It was done on residents' doctors working at the sole COVID-19 center of a state. It is based on a dimensional approach rather than categorical approach. Psychological status of residents' doctors was assessed without clubbing them with other health-care workers. It serves as an evidence for the need to address mental health of frontline health workers during the pandemic and adds to scientific literature.

Limitations

This was a single hospital-based cross-sectional study with voluntary participation. Temporality of association could not be established. It is unknown if the nonrespondents were too stressed to respond or not stressed at all and did not deem it useful to respond. Online nature of survey may lead to a responder bias. Findings may not be generalized to less affected regions and those with a different functioning of hospitals. It has no longitudinal follow-up.


  Conclusion Top


The study was conducted at the sole nodal center of a state serving a population of 35 million which could reflect the impact of rapidly rising infected cases on health-care system. Our study has specifically focused on the psychological needs of residents' doctors and did not club them with other health-care workers. The situation of the resident doctors is unique in the close proximity of the patient and the long working hours they are exposed to. Depression, anxiety, and stress are reported by at least one-third of the residents. Ways and means to address the mental health needs of the resident doctors and to provide them ongoing mental health support is the need of the hour. Research, from low-resource setting countries such as India, is required to design interventions tailored toward the need of the health-care workers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Srilakshmi Pingali,
Department of Psychiatry, Gandhi Hospital, Musheerabad, Secunderabad - 500 003, Telangana
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMH.AMH_75_20




 
 
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