BACKGROUND
The novel coronavirus has emerged as a highly infectious and contagious, acute severe respiratory syndrome named SARS-CoV2, emerging from Wuhan, China, and it was declared a “pandemic” by the World Health Organization in March 2020 and a public health emergency of international concern.[ 1 ] Across the globe, the COVID-19 pandemic crisis has greatly resulted in a huge burden on the healthcare delivery system, especially on healthcare workers.[ 2 ] In most countries, the health care system has been stretched past its limits in terms of manpower resources, capacity, training, availability of personal protective equipment, policies, guidelines, and so on while striving toward continued delivery of quality care and battle against the war of COVID-19 infection. The COVID-19 pandemic has intensely reminded the public about the importance and valuable work that healthcare workers (HCWs) do daily in challenging circumstances and has exposed the limitations of healthcare systems around the world.[ 3 ] The existing published research articles across the World have reported that widespread infectious diseases, such as severe acute respiratory syndrome (SARS, 2003), the Middle East Respiratory Syndrome (MERS-Cov, 2012), and the Ebola virus (2013–16), that these major epidemic outbreaks thrown high levels of ongoing mental distress and higher risk of developing posttraumatic stress disorder (PTSD).[ 4 ] Many of the HCWs reported symptoms of isolation, depression, stigmatization, interpersonal difficulties, and extreme stress during the pandemic and experiencing challenges in adapting quickly to changes in patient volume, mounting demands, and clinical roles.[ 5 ]
The ongoing pandemic had resulted in the lockdown or stays at home for 1.3 billion people in India. The Government of India ordered a nationwide lockdown for 21 days from March 24, 2020.[ 6 ] The pandemic coupled with the lockdown made a deep impact on the socio-economic fabric as well as the mental health conditions of the people.[ 7 ] The existing studies in India have reported that the HCWs are facing enormous pressure due to direct care to COVID-positive patients and high-risk procedures, high workload, shortage of staff, frequent rotation, long working hours, caseload, lack of supplies of drugs, inadequate supportive oxygen, lack of mechanical ventilator, shortage of beds.[ 8 ] Apart from this, the media-hyped ‘corona phobia’ and lack of contact/away from family members further results in a high risk of developing psychological morbidity such as anxiety, frustration, depression, and insomnia, amidst the COVID-19 pandemic.[ 9 ] Instead of superficial or temporary appraisal and reward, we need to invest in and accelerate protective and preventive measures to reduce the burden on healthcare workers on a more permanent basis. This should also involve leveraging existing evidence-based interventions for alleviating psychological distress in public health emergencies.[ 10 ] Hence urgent attention is required to identify mental morbidity and to plan appropriately to grapple with mental health issues through comprehensive, continuing and persistent efforts for HCWs in India is the need of the hour. Accordingly, there is a need to develop a plan to assess all the HCWs for psychiatric morbidity and provide them with psychological support.[ 11 ] Across India, there have been multiple individual studies conducted to address the issues of the mental health of healthcare workers during the COVID-19 pandemic. However, there is a wide variation in the prevalence rates across studies due to the differences in measuring instruments with different cut-off scores.
Objective
Hence, the present study aimed to estimate the pooled prevalence of psychological morbidity among healthcare workers during the early phase of the COVID 19 pandemic in India.
METHODS
This systematic review is reported following the PRISMA checklist[ 12 ] and the protocol was registered in the PROSPERO (CRD42021281963). We searched the following electronic bibliographic databases: PubMed, ScienceDirect, and Wiley online library.
Search strategy
The following keywords were used in various combinations as per databases: “Prevalence,” “anxiety,” “depression,” “stress ,” “COVID-19,” “Health Care Workers,” and “India.” In addition, fifty pages of Google scholar and archives of related Indian journals were reviewed to maximize the inclusion of available studies. The cross-references of the identified studies were explored for additional studies. Two researchers independently carried out internet searches and selected potentially relevant articles from the search outputs by reading the study titles and abstracts. A list of possible articles was generated based on the eligibility criteria. Additionally, one investigator independently appraised the full texts of appropriated records to reach a common consensus regarding the inclusion and exclusion of individual studies. An example of a search string used in PubMed is described in Supplementary Material 1.
Inclusion and exclusion criteria for article selection
All studies were conducted in the Indian setting that estimated the psychological morbidities such as anxiety, depression, and stress of health workers during the COVID-19 pandemic and was published in the English language. We aimed to evaluate the psychological morbidities of healthcare workers during the early phase of the pandemic and therefore, included studies conducted from the onset of the COVID-19 pandemic until 25 September 2021. Studies that evaluated the psychological distress related to COVID-19 among the general population of India were excluded. Studies with inadequate data on outcome measures such as depression, anxiety, stress , and insomnia were also excluded.
Data extraction, quality assessment, data synthesis
The data from the studies were extracted into a data extraction form with the following study characteristics and relevant data, namely author (year and period of conducting the study), study design, sample size, age, and survey tools. The main outcomes assessed were the prevalence of anxiety, depression, and stress among healthcare workers. The methodological quality of included studies was assessed by two independent reviewers employing the “JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data.”[ 13 ] This checklist contains nine criteria with a total quality score ranging from 1 to 9 and there is no specified cut-off for the classification of studies for risk of bias. Therefore, we arbitrarily classified JBI scores as having a high (0–3), moderate (4–6), and low (7–9) risk of bias. The score of the included studies was not considered for the study selection criterion. Discrepancies in the quality scoring of two reviewers were addressed by a third reviewer. Open meta-analyst software was used to perform this meta-analysis. Open Meta-Analyst is a free, open-source program for performing meta-analysis research studies that include methods for performing multivariate meta-analysis and network meta-analysis in addition to all standard fixed and random effects methods (Available from http://www.cebm.brown.edu/openmeta/ [ 14 ] The magnitude of statistical heterogeneity among the selected studies was measured by using Cochran’s Q test and the I-square statistics. DerSimonian and Laird method was applied to calculate the pooled prevalence. The funnel plot and Egger’s regression tests were used to assess potential publication bias.
RESULTS
The initial search across different electronic databases yielded 1740 citations. After screening the full text of 86 studies, 51 were excluded due to the following reasons; studies with inadequate data as per outcome measures (n = 4), samples as general populations (n = 43), and review articles (n = 4). Finally, a total of 35 full-text studies meeting the inclusion and exclusion criteria were included [Figure 1 ]. The included studies in the current review had conducted from March to July 2020. Table 1 shows the characteristics of eligible studies. Thirty-five studies conducted in various parts of the country were included in the systematic review.[ 15–49 ] Out of the thirty-five studies, five studies did not specifically mention the prevalence of any of the outcome measures such as depression, anxiety, stress , and insomnia therefore not included in the meta-analysis.[ 32 , 39 , 43 , 44 , 49 ] The prevalence rate of anxiety is reported in twenty studies[ 15–17 , 19 , 20 , 23 , 27 , 29 , 31 , 33–36 , 40–42 , 45–48 ] whereas twenty-one and twenty-two studies reported the prevalence rate of depression[ 15–17 , 19 , 20 , 23 , 25 , 27 , 29 , 31 , 33 , 35 , 37 , 38 , 40–42 , 45–48 ] and stress [ 15 , 16 , 18 , 19 , 21–24 , 26 , 28–31 , 33 , 37 , 38 , 40 , 41 , 45–48 ] respectively. There are six studies available with accurate data on the prevalence of insomnia.[ 28 , 31 , 33 , 34 , 41 , 45 ] The online mode of the survey was carried out in many studies except for five studies that employed a hospital-based paper-pencil approach to recruiting the potential subjects. Doctors, nurses, and paramedical staffs were the study population in the majority of the studies. However, the population of interest in some studies was orthopedic surgeons (n = 2), ophthalmologists/ophthalmology trainees (n = 2), dental practitioners (n = 1), and dermatologists (n = 2). Depression, Anxiety, and Stress Scale-21 (DASS-21), Generalized anxiety disorder (GAD-7), Patient health questionnaire (PHQ-9), and Perceived stress scale (PSS) were the most commonly used scales for estimating the depression, anxiety, and stress of health care workers in this setting.
Figure 1: Process of search and selection of studies
Table 1: Characteristics of the studies of the psychological morbidity among health care workers during COVID-19 pandemic in India
Epidemiology of the psychological morbidity
The pooled estimates of depression, anxiety, stress , and insomnia among Indian healthcare workers during the COVID-19 pandemic are 20.1% (95% CI: 15.6 to 24.6%; n = 21 studies), 25.0% (95% CI: 18.4 to 31.6%; n = 20 studies), 36% (95% CI: 23.7 to 48.2%; n = 22 studies) respectively [Figures 2 -4 ]. Approximately 18.9% (95% CI: 9.9 to 28.0%) of the health workers experienced insomnia during the pandemic period. The quality assessment of the studies (n = 35) is summarized in Table 2 . Most of the included studies were found to have a moderate risk of bias (n = 18) and there were thirteen studies with a high risk of bias. The mean score was 4.6 (SD-1.6, Median -5) and approximately half of the studies were having a score range of 1-4 (n = 17). We used the DerSimonian and Laird method of random-effects models to calculate the pooled estimates of psychological morbidity and there was significant heterogeneity in the outcome measures (Depression- I2 = 97.5%, Q = 824.26, P < 0.001, Tau Squared = 0.01; Anxiety- I2 = 98.42%, Q = 1203.69, P < 0.001, Tau Squared = 0.02; Stress - I2 = 99.63%, Q = 5752.78, P < 0.001, Tau Squared = 0.08; Insomnia- I2 = 95.8%, Q = 121.37, P < 0.001, Tau Squared = 0.01).
Figure 2: Prevalence of Depression among health care workers during COVID-19 pandemic in India
Figure 3: Prevalence of Anxiety among health care workers during COVID 19 pandemic in India
Figure 4: Prevalence of stress among health care workers during COVID 19 pandemic in India
Table 2: Quality Assessment Criteria - Joanna Briggs Institute critical appraisal tool for prevalence studies
Subgroup and sensitivity analyses
Subgroup analysis was performed based on the screening instrument of outcome measures and methodological quality assessment [Table 3 ]. Subgroup analyses of the magnitude of depression, anxiety, and depression demonstrated a statistically significant difference in the prevalence rates between the subgroups (p < 0.001). The pooled prevalence of depression based on DASS-21 was 22.3% (12.7%–31.9%) whereas it was 15.3% (11.7%–19.0%) for studies that used PHQ-9. The pooled estimates of anxiety were significantly lower based on GAD-7 measurements as compared to those with DASS-21 [16.9% (13.5%–20.2%) Vs 28.1% (15.4%–40.8%)]. The prevalence rate of stress varied greatly in which studies based on DASS-21 scales had a significantly lower prevalence (22.5%; 95% CI: 12.1%–33.0%) than studies other than DASS-21 scales (43.3%; 95% CI: 27.8%–58.7%). A possible explanation for this wide variation in the overall prevalence of stress might be due to the difference in cut-off points as per screening instruments such as PSS-10. Subgroup analyses based on the methodological quality revealed that low-quality studies (score < 3/9) showed higher prevalence in depression (23.1% Vs 19.1%) anxiety (31.0% Vs 23.5%) and stress (37.9% Vs 34.6%) as compared to those with good-quality studies (score > 3/9). The association was statistically significant (p < 0.01). Sensitivity analysis was performed to identify the effect of individual studies on the estimated pooled prevalence of outcome measures using the random effect model. There was no significant impact of any particular study on the overall pooled effect of anxiety, depression, and stress among healthcare workers in this setting. A reasonable symmetry of the funnel plot in all the outcome measures revealed no publication bias [Supplementary Material 2.1-2.3].
Table 3: The prevalence of psychological morbidity using random effect model by subgroup analyses
DISCUSSION
The present meta-analysis provides a summary of the prevalence of COVID -19 related psychological morbidities from 35 surveys conducted in the Indian setting. The findings open an area of discussion on the evidence-based comprehensive understanding of the mental morbidity of the Health care workers during COVID-19 in India. Furthermore, the individual studies are separately analyzed based on different screening measurements to provide a scientific conscience of the quality of evidence. According to the current meta-analysis, the pooled estimates of depression, anxiety, stress , and insomnia among Indian healthcare workers during the COVID-19 pandemic are 20.1%, 25.0%, 36%, and 18.9%, respectively. The exclusion of any specific study did not affect the overall prevalence of any of the above-said outcome measures. However, our findings need to be taken with some caution. First, the results are purely based on studies conducted in various regions of India at different time intervals. The studies included in the current meta-analysis had conducted from March to July 2020. The first wave of COVID-19 in India started in March 2020 with a peak in September 2020.[ 50 ] Therefore, the current findings reflect the mental health of healthcare workers during the early stages of the first wave of COVID-19 in India. A systematic review of studies conducted across the globe from December 2019 to April 2020 reported 12.1%–55.89% of depression, 24%–67.55% of anxiety, and 29.8%–62.9% of stress among healthcare workers.[ 51 ] There was a well-controlled infection rate during the first wave of COVID-19 in India. This might be the reason for a modest magnitude of COVID-19-related psychological distress among healthcare workers in India as compared to that outside of India.[ 52 ] Second, the subgroup analyses of the outcome measures based on the different standard screening instruments had a significant effect on the pooled prevalence. The earlier studies reported that prevalence rates of COVID-19-related psychological distress among health workers vary greatly due to variations in measuring instruments with different cut-offs.[ 53 ] To address this vivid gap in the evidence, we separately analyzed the outcome measures with uniform cut-off scores as per various screening measurements. DASS-21, GAD-7, and PHQ-9 are the most commonly used scales for estimating depression, anxiety, and stress . According to the eight studies included in the meta-analysis, the anxiety and depression as per DASS-21 scales were 28.1% and 22.3%, respectively. Strikingly, a relatively similar proportion of the above-mentioned outcome measures was observed in studies that used GAD-7 (Anxiety – 16.9%) & PHQ-9 (Depression – 15.3%) scales. Our findings are consistent with the results of a recent meta-analysis with similar study contexts and approaches.[ 54–57 ] Third, the findings of the review are based on a representative number of studies (n = 35) and around 20 studies were considered for meta-analysis to estimate the outcome measures. The estimated pooled prevalence of various outcome measures in this study was low as compared to the findings of the recent meta-analysis of studies conducted among health workers in India which reported a pooled prevalence of 35.4%, 35.3%, and 65.1% for depression, anxiety, and stress , respectively.[ 58 ] It is worth noting that the above-said outcome measures of this study were based on only five to six studies. Moreover, comprehensive empirical data exclusively focusing on the mental health of Indian healthcare workers during COVID-19 is missing in the literature. Therefore, the current meta-analysis with a sufficiently representative sample provides an evidence base for the epidemiology of COVID-19-related psychological morbidities among healthcare workers in the Indian setting.
Certainly, the findings of this study might be an eye-opener for the Government of India to design strategies to protect, preserve and promote (3P’s) the mental health and well-being of healthcare workers on a day-to-day basis. Furthermore, our findings address the mental morbidity of HCWs necessitating appropriate intervention strategies and devising policy guidelines to protect and preserve these vulnerable groups during the pandemic situation. This will help policymakers and health authorities to prioritize and address this important public health aspect while focusing on their efforts to control the pandemic situation. To protect the mental health of HCWs there must be a specialized psychological supportive system is required like close monitoring, tele-counseling, training, etc., An underlying truth is that the health care delivery system would be non-existent without the support of HCWs.[59] The concern of mental health of health care workers (HCWs) still needs further illumination and exploration. With the history of pandemics repeating, identifying mental health morbidity among HCWs during the current pandemic before it fades away is vital to create evidence that can be applicable for steering the future pandemic. Thus, there is a need to identify the mental morbidity of Indian healthcare workers before the memory of the pandemic crisis starts to decline, and bring evidence-based measures and interventions must be put into action.
The major strength of the present meta-analysis is that we have tried to provide a comprehensive review of the overall burden of mental health problems among healthcare workers during the first wave of the COVID-19 pandemic in India. To the best of our knowledge, this is the first meta-analysis evaluating the pooled prevalence of COVID-19-associated psychological impact with a representative sample of healthcare workers recruited from different geographic areas of India. Our study has several limitations. The majority of the data is collected through snowball sampling using different social media online platforms. Due to the limitations associated with the pandemic, several studies were having suboptimal methodological quality posing a high risk of bias in terms of the quality of findings. As expected, high heterogeneity was observed in the outcome measures. Although the outcome measures were separately analyzed based on the standard cut-off of validated assessment tools, the diagnosis was not confirmed in any of the studies. Moreover, there were inadequate data that examines the factors that may influence the prevalence of mental health among healthcare workers due to the restrictions of the pandemic.
CONCLUSION
The current meta-analysis with a sufficiently representative sample identified that the pooled estimates of depression, anxiety, stress , and insomnia among Indian healthcare workers during the COVID-19 pandemic are 20.1%, 25.0%, 36%, and 18.9%, respectively. To address the vivid gap in the prevalence rates of COVID-19-related psychological morbidities in Indian healthcare workers, we separately analyzed the outcome measures with uniform cut-off scores of various screening measurements. Our findings address the mental morbidity of HCWs necessitating appropriate intervention strategies before the memory of the pandemic crisis starts to fade and devising the policy guidelines to protect these frontline groups during the pandemic situation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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