Various factors such as work pressure, long working hours, night calls, and fatigue increase occupation-related stress. Few studies have identified the stress-promoting factors and highlighted the need to reduce it. Anesthesiologists and emergency physicians are the frontline professionals who have been involved in patient care in emergency departments, operation theater, and intensive care units (ICUs) during the COVID-19 pandemic. The increasing number of COVID-19 cases, depletion of personal protection equipment (PPE), widespread media coverage, lack of specific drugs, and feeling of being inadequately supported may all contribute to mental burden and stress. The psychological effects of these factors may manifest as various psychiatric diseases such as depression, anxiety disorders, substance abuse, suicide, and posttraumatic stress disorder. The present study attempted to assess the effects of the COVID-19 pandemic on mental health of front-line health-care workers (HCWs) using standardized self-reported questionnaires to report subsyndromal depression, anxiety, and stress.
MATERIALS AND METHODS
The present cross-sectional study was conducted on 237 HCWs of either sex aged between 28 and 65 years involved in the care of suspected or diagnosed COVID-19 patients across the country from June 2020 to September 2020. The study was initiated after Institutional Ethics Clearance and CTRI registration (CTRI/2020/05/025344/date-May 25, 2020). An online form was distributed to the participants to obtain their consent.
An exponential snowball sampling was performed to recruit the participants in an unbiased sampling environment for the study. Considering the error margin as 10% and the response rate at 20%, the questionnaire was distributed to 250 prospective participants. Multiple attempts were made to collect maximum responses. The identity of the respondents was masked during the data analysis.
Study variables and instruments
The questionnaire (available at https://docs.google.com/forms/d/1Jpi1WXKVOmxD-XerSSjUzeaebb8dbRGvBuyFTmIW2ZQ/edit) circulated by the investigators basically comprised two parts. The first part comprised a set of 18 general questions related to age, sex, marital status, living condition (i.e., whether staying with family), prophylaxis status, training in handling patients with COVID-19, duration of posting in the corona ward or ICU, and sleep pattern. The second part comprised stress assessment using the Depression Anxiety Stress Scale 21 (DASS-21). DASS-21 is a questionnaire that comprises 21 items and is a self-report instrument designed to measure three related negative emotional states, namely depression, anxiety, and tension or stress. Each of the emotional component has a set of 7 questions, which are rated from 0 to 3. The combined score of each item is the total DASS-21 score.
The data were retrieved from the response sheet. The statistical analysis was performed using SPSS software version 26 IBM Statistical Package for Social Sciences ver. 26 (SPSS Inc., Chicago, IL, United States). Descriptive statistics were determined in the study, and categorical variables were expressed as frequency and percentage.
The sociodemographic data, exposure to COVID-19 patients, types of procedures performed, and drug prophylaxis data are given in Table 1. Of the total, 25% of participants were dissatisfied with their sleep patterns during the pandemic. The frequency and percentage of DASS-21 items are depicted in Table 2.
The grading of the severity of the three components is presented in Table 3. The DASS-21 exhibited more frequent depression than anxiety or stress. Severe depression and stress were observed in <10% of cases, whereas severe anxiety was observed only in 14% of respondents.
Anxiety and mental illnesses among people have increased during the COVID-19 pandemic. The present study evaluated depression, anxiety, and stress in health-care professionals working in different parts of India during the COVID-19 pandemic.
A half of the total participants were aged more than 35 years, and a slight male preponderance was noted in the studied population (male: female = 53:47). In addition, 70% of the participants were married. This finding is concurrent with that of Jain et al., who studied the psychological impact among anesthesiologists. However, most participants in this study were resident doctors, whereas most participants in the present study were consultants. In addition, a high adjusted odds ratio (OR) (0.42) for anxiety was observed among the females in the study. These results are concurrent with that of Li et al., who observed that females are more susceptible to depression (OR, 1.62; 95% Confidence Interval CI, 1.12–2.12; P = 0.035). Pappa et al. performed a meta-analysis of 13 studies. Of these 13 studies, 5 studies had used the self-rating anxiety scale, 4 studies had used the Generalized Anxiety Disorder-7 (GAD-7) scale, whereas the other studies had used different scales. Tan et al. used the DASS, which was also used as a measuring tool in the present study. The DASS is a comprehensive and relevant tool because it also evaluates the stress prevalence.
Lai et al. exhibited a high incidence of depression (50.4%), anxiety (44.6%), insomnia (34%), and psychological distress (71.5%) among the frontline Chinese health-care providers. The COVID-19 pandemic required challenging ethical decisions regarding medical care, leading to severe psychological pressures resulting in anxiety and depression among exposed HCWs. Dutta et al. reported anxiety and depression in 25.5% and 25.9% of Indian HCWs, respectively. In addition, Krishnamoorthy et al. observed anxiety and depression in 25% of HCWs. However, all these studies were conducted on HCWs such as physicians and nurses. The present study exhibited a higher prevalence of depression (54.2%) and anxiety (45.8%) than that reported in other studies. In addition, the severity of anxiety (moderate–severe), we found a higher prevalence of 32.4% versus 6.8%; and severity of depression scores (moderate–severe) was 36.5% in comparison to 16.2% in a study by Pappa et al. Anesthesiologists are exposed to potential nosocomial risks during aerosol-generating procedures such as ventilation, endotracheal intubation, suctioning secretions, and nebulization. Several anesthesiologists worked in ICUs and thus witnessed severe illness and high mortality among patients, which negatively influenced their mental health. Additionally, their long working hours contribute to physical exhaustion due to working under conditions with inadequate PPE. Furthermore, they had to take conflicting decisions regarding their professional and ethical duties, as well as the well-being of themselves and their family. Studies have exhibited that these psychological symptoms are further escalated by isolation and loss of social support. More than half of the responders were married, staying with family, or having parents or kids. Fear of transmitting the infection to loved ones due to a lack of proper isolation during duties prevails among anesthesiologists. Khanal et al. concluded that insufficient isolation precautions were associated with anxiety and depression among HCWs.
Jain et al. conducted a survey among anesthesiologists in India using the GAD-7 scale and exhibited mild anxiety in 75% of the participants, which is higher than that observed in the present study (45.8%). This difference could be due to the preponderance of younger participants in their study (residents vs. junior consultants). Li et al. reported the prevalence rates of 43.1% and 41.6% for anxiety and depression, respectively, among operating room personnel, including anesthesiologists and nurses. Medical staffs who had close contact with COVID-19 patients were more prone to depression (OR, 2.52; 95% CI, 1.81–3.39; P = 0.005) and anxiety (OR, 2.67; 95% CI, 1.92–3.62; P = 0.002) than those without close contact. A study from Italy indicated that first-line HCWs exhibit a higher percentage of moderate–severe anxiety, depression, and stress levels than second-line HCWs. Anesthesiologist work in most critical areas. The severity of stress among frontline HCWs was 33.3%, which is similar to that reported in the present study (36%). Additionally, an inverse relationship was observed between emotion regulation abilities and psychological parameters. This aspect has not been evaluated yet.
Like the GAD-7, the DASS-21 does not evaluate insomnia. Altered sleep patterns were observed in 69% of cases. Jain et al. observed moderate–severe insomnia in 29% of anesthesiologists. The mental health status of at-risk groups must be regularly screened. Dedicated training and the implementation of fundamental guidelines and proper application of PPE for HCWs involved caring COVID-19 patients could help to reduce anxiety. Promoting resilience in support from friends, family, and society towards anesthesiologists could help them alleviate their psychological pressure.
The present study has certain limitations. The study was conducted in June-September 2021 when some of the anesthesiologists were not exposed to critical areas such as COVID ICU and COVID operation theater. A gender subgroup analysis was not conducted. Female anesthesiologists have additional challenges in managing home and kids, particularly in the Indian cultural system. In addition, an online interview was conducted using self-reported DASS-21 questionnaires, where some junior residents might have skipped the survey fearing interpersonal risk in speaking up.
Most HCWs on COVID-19 duty exhibited negative emotional states such as anxiety, depression, stress, and insomnia. Addressing risk factors identified in the present study with targeted interventions and psychosocial support will help them cope better.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors’ appreciation goes to all the participants who took part in this study.
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