The psychological impact of COVID-19 duty among resident doctors working in a COVID-hospital: A short-term follow-up study : Indian Journal of Psychiatry

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The psychological impact of COVID-19 duty among resident doctors working in a COVID-hospital: A short-term follow-up study

Prakash, Aathira J.; Agarwal, Vivek; Kar, Sujita Kumar; Dalal, P.K.

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Indian Journal of Psychiatry 65(1):p 107-112, January 2023. | DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_159_22
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Abstract

INTRODUCTION

Among the healthcare workers, frontline workers which include the physicians of the treating team involved directly in handling COVID-19-infected patients are at a greater risk than others for developing mental health problems.[1] Increased workload, long work hours, physical exhaustion, inadequate personal equipment, risk of exposure, risk of infections of friends and relatives, isolation and loss of social support, and making ethically difficult clinical decisions may have dramatic effects on their physical and mental well-being. Higher infection rates among doctors and facing public anger and discrimination have created additional strain for them.[2] In addition to their academic training, resident doctors also play a pivotal role in the care of COVID patients and are often the first point of contact. Therefore, they are especially vulnerable to mental health problems, including anxiety, depression, stress, sleep disturbances, and mental and physical exhaustion or burnout.

The existing literature emphasizes that the current pandemic has a highly undesirable impact on frontline healthcare personnel actively involved in this crisis management. However, there is a lack of longitudinal research, and the long-term impact of the pandemic on the mental health of these professionals is unknown. Only a few studies have looked into sleep problems, such as nightmares, and Indian studies regarding burnout among young doctors are also few. Hence, the current study was planned to investigate the prevalence and association of depression, anxiety, stress, burnout, and sleep disturbances (insomnia and nightmares) among resident doctors immediately after being involved in the direct care of patients with COVID-19 during the second wave of the pandemic.

METHODS

The sample recruitment was started in February 2021, after approval from the Institutional Ethics Committee, and enrolment of participants was carried out till June 2021. The study sample consisted of resident doctors who have worked in the COVID-19 units of the institution and fulfilled the selection criteria. Resident doctors aged 22–40 years who had completed posting in COVID-19 wards in the past 2 weeks, had tested negative for COVID-19, and gave informed consent for participation were included in the study. The residents were each posted in COVID-related duty areas for two weeks at a time. Those with a history of prior psychiatric illness or any psychotropic medication use, who tested COVID-19 positive during the assessment, had any history of substance use disorders other than tobacco use disorder or who had a history of any serious physical illness not amenable to interview were excluded. Those with minor medical ailments or medical conditions who are well managed with medications were enrolled in the study if they met other inclusion criteria. After inclusion into the study, those participants who became COVID-19 positive or were lost to follow-up were excluded from the final analysis.

The tools used for the study were semi-structured proforma (for recording sociodemographic and clinical variable details), Depression, Anxiety, and Stress Scale – 21 Items (DASS-21),[3] Insomnia Severity Index (ISI),[4] Single Item Sleep Quality Scale (SQS),[5] Nightmare Experience Scale (NExS),[6] and Burnout Measure – 10-item short version of the BM (BMS).[7]

After inclusion into the study, the participants were sent a link to Google form, for filling in the details on sociodemographic proforma and self-administered questionnaire-based scales. After completing the online assessment, each participant was contacted again telephonically and also sent a text message that included details of how to seek help in case of any mental health issues. After two months of completing the first assessment, the participants were contacted again and requested to participate in the second assessment. To prevent dropouts, the resident doctors were contacted during their convenient time and were requested to complete the assessment forms and recontacted three more times and were sent the link for assessment; in case, the assessment was not completed during the following two weeks, and then the reason for dropout was noted.

Statistical analysis

To analyze the results gathered from this study, the following statistical tests were administered using the Statistical Package for the Social Sciences version 25.0.

RESULTS

In this study, 132 participants were included at baseline and 105 completed both assessments. The most common cause of dropout was an unwillingness to participate in a second assessment or nonresponse within a specified timeframe. The sociodemographic and clinical variables of the participants are summarized in Table 1.

T1
Table 1:
Sociodemographic and clinical variables of the resident doctors

Among the 105 participants, during the baseline assessment, the prevalence of depression, anxiety, stress, insomnia, burnout, and compromised sleep quality was 31.4%, 31.4%, 19%, 35.2%, 37.2%, and 44.7%, respectively. Wilcoxon signed-rank test was conducted to determine the difference in the study variables, i.e., depression, anxiety, stress, insomnia, sleep quality, and burnout assessed on the rating scales in the two assessments, which were spaced 2 months apart. It was seen that there was no statistically significant median difference in depression, anxiety, stress, burnout, sleep quality, or nightmare experience with time, but insomnia severity score (ISI score) had a statistically significant median decrease (z = −3.245, P = 0.001) when participants were assessed two months later in comparison to their first assessment [Table 2].

T2
Table 2:
Psychiatric symptoms, insomnia, sleep quality, and nightmares among the resident doctors during both assessments

On analysis using Spearman’s correlation, there was a strong positive correlation between depression, anxiety, stress, insomnia, and burnout scores [Table 3]. Binomial logistic regression analysis was used to identify risk factors for the presence of depression, anxiety, stress, and insomnia. The logistic regression models used were statistically significant and the independent variables analyzed included age, gender, type of family, current living status, marital status, highest educational qualification, current post, academic status, status of upcoming duty, number of times of COVID posting, place of posting, sleep quality, and burnout. It was seen that resident doctors who did not have a good or excellent sleep quality had higher odds to develop depression (OR = 11.36, P < 0.001), anxiety (OR = 8.62, P < 0.001), stress (OR = 58.82, P = 0.001), and insomnia (OR = 28.57, P = 0.001) than doctors with good or excellent sleep quality. Resident doctors who were suffering from burnout had higher odds of developing depression (OR = 7.82, P = 0.011), anxiety (OR = 7.24, P = 0.013), and insomnia (OR = 53.52, P = 0.008) than those who were not. Female doctors (OR = 6.7, P = 0.042) and doctors who were part of joint family (OR = 9, P = 0.019) had a higher risk of developing stress than male doctors and those with nuclear families. Unmarried doctors had higher odds (OR = 17.24, P = 0.025) than married doctors for developing insomnia.

T3
Table 3:
Spearman’s rank-order correlation test depicting relationship among the depression, anxiety, stress, insomnia, and burnout in the resident doctors

DISCUSSION

The current study was a longitudinal study to explore the psychiatric aspects of resident doctors working in a COVID hospital. One of the key findings of the study was the prevalence of major psychological outcomes among them, which was a significant proportion during the baseline and even after two months. The current study found a prevalence of depression, anxiety, and stress to be 29.6%, 28.6%, and 18.1%, respectively, during the final assessment. The present findings lead to a similar conclusion as has been reached in other studies conducted among doctors in the wake of COVID-19 pandemic in India using self-reported measures, one which was conducted among frontline dermatologists engaged in direct contact with patients which found the prevalence of depression and stress to be 26.82% and 29.2%, respectively, and another among frontline armed forces doctors which found the prevalence of anxiety and depression to be 35.2% and 28.2%, respectively.[8,9]

The results of the study demonstrated the prevalence of insomnia to be 22%. This is somewhat lower than what has been seen in previous studies, although the prevalence of insomnia estimated during the first assessment, i.e., 35.2%, was in concordance with previous studies.[10-12] The current study had a significant decrease in insomnia after two months of not being in close contact with COVID patients, which could be the lower prevalence of insomnia compared to existing evidence. This proportion of doctors affected by insomnia is significant, given the detrimental impact of sleep deprivation.

Another important aspect which was explored in the current study was that of sleep quality. Among the 105 participants, 43.8% did not have good or excellent sleep quality during the final assessment. This was in line with the findings obtained in another Indian study, which examined sleep quality using self-reported responses among 368 healthcare workers (HCWs) majority of whom were doctors. It found a similar proportion, i.e., 31.5% of participants had poor-to-fair sleep quality.[13] However, when comparing the results to other previous international studies, the prevalence of impaired sleep quality in the current study was much lower.[12] These discrepancies in the prevalence of sleep quality among healthcare professionals during this crisis of the COVID-19 pandemic could be partly attributed to the difference in the population characteristics and the rating tools.

A novel finding in the study was that very few participants had dream-related sleep disturbances. There have been limited studies on the dream experience of frontline doctors during the COVID-19 pandemic, and they have shown a much higher prevalence of nightmares among frontline healthcare workers, including doctors than seen in the current study.[14] It is possible that the prevalence of nightmares obtained in the present study may not be an actual representation or a generalizable result.

In our study, the prevalence of burnout was 32.4%. Previous studies, although few that have been conducted in the Indian settings, also show a high proportion of HCWs to be affected by burnout.[15,16] As per an umbrella review of systematic review and meta-analyses based on international studies concerning burnout syndrome during viral outbreaks, the pooled prevalence of burnout among healthcare workers ranged from 28% to 34.4%, i.e., almost one-third, a finding which has been reproduced in the current study.[17] Moreover, the current study involved resident doctors belonging to younger age group with lesser years of experience, and it has been seen in previous studies that there is an inverse relationship between the prevalence of burnout syndrome and the age or experience of physicians, which may also explain the high prevalence of burnout in the current study.[18]

The current study found a statistically significant positive correlation of the subscales of DASS-21, i.e., depression, anxiety, stress scores with each other. Other studies conducted among doctors in India amid the COVID-19 using the DASS-21 score have also found the subscale scores to be positively correlated.[19-21] Depression, anxiety, and stress scores are strongly correlated with insomnia and burnout scores. The positive correlation of the DASS-21 subscale with ISI score was also obtained in other Indian studies.[21,22]

The current study also revealed that female doctors had higher odds than male doctors for developing stress. This result ties well with previous studies among HCWs during the pandemic, wherein the female gender has been significantly associated with the development and reporting of stress and related symptoms.[23–25] The current study found that doctors who were part of a joint family had a higher risk of having stress than those with nuclear families. The high levels of stress among healthcare workers, especially during the pandemic, are highly influenced by the fear of contracting the viral infection and transmitting the virus to one’s family or friends, as has been seen in the Indian context too as per a qualitative study.[26]

In the current study, the same individuals were assessed two months later after being posted for COVID duty, during which they did not have direct contact with patients infected with COVID-19. It was seen that the ISI score showed a statistically significant median decrease in insomnia severity score when participants were assessed two months later in comparison to their baseline assessment, z = −3.245, P = 0.001. The rest of the variables studied, i.e., depression, anxiety, stress, sleep quality, nightmare experience, and burnout, did not show any statistically significant rank differences from baseline. There are few studies that have examined the longitudinal changes in these psychiatric aspects, and no studies exist that have recorded changes in nightmare experiences during the pandemic. Some studies conducted internationally favor that psychological disturbances due to COVID-19 among healthcare workers show an increasing trend.[22,27-29] Some research also suggests that there might decrease in these symptoms over time.[30,31] In the current study, depression, anxiety, stress, and insomnia showed decreasing trend; sleep quality improved over time; and nightmare experience remained relatively unchanged. However, statistically significant decrease was only seen in insomnia. This finding could be attributed to many factors. First, the final assessment was carried out two months after the COVID posting, during which residents might have recovered from memories of losing patients, being quarantined and being away from family and friends, and relieved on completing the duty without being infected. Moreover, compared with the unprecedented situation residents were faced with during the initial part of the pandemic, they gradually might have adapted to the situation over time. The significant decrease in insomnia levels could be attributed to the transition from multiple changes in a shift during COVID duty to relatively regular working hours in their respective departments.

There is a scarcity of especially Indian studies conducted among doctors during the COVID-19 pandemic, which had assessed the psychological parameters longitudinally. One of the strengths of the current study was that the symptoms of depression, anxiety, stress, insomnia, and burnout at two time points were more than two months apart. The study constituted young postgraduate trainee doctors, especially a vulnerable group, and studies in this particular homogenous group of doctors are limited. Another uniqueness of the current study was that it assessed sleep-related variables, including sleep quality and nightmare experience, which are important sleep disturbances that have been very sparsely examined in this population. This study is not establishing any causality between psychological distress and COVID-duty; rather, it explains the association of psychological distress with the doctors working during COVID pandemic. A better study design and having a control group in future research may give insight into the causality of psychological distress among healthcare workers during the COVID-19 pandemic.

The limitations of the study were as follows. The sample was small and was collected from a single institute and only among doctors; hence, the finding cannot be generalized as different institutes have their protocols, infrastructure, and other facilities relating to the COVID-19 pandemic. The prevalence of the psychiatric phenomenology, i.e., depression, anxiety, stress, and insomnia, was made on the inference obtained on the rating scales and not as per standard diagnostic criteria. The rating scales were self-administered scales and not adequately supported by psychiatric interviewing, and this could have interfered with the validity of the results. The study parameters did not consider various other factors, including other life events, personality characteristics, vaccination status, loss of a family member or colleague due to COVID-19, details of personal protective measures, etc., which could have acted as confounders. Similarly, not having a control group can be a limitation of the study.

CONCLUSION

The current study demonstrates the significant negative impact the COVID duty had on the mental well-being of young resident doctors and highlights the need for targeted interventions, including mental health promotion and encouraging early help-seeking in this group.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

Anxiety; burnout; depression; COVID-19; resident doctors; sleep disturbances; stress

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