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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 3  |  Page : 270-275

Evaluation of Stress, Depression, and Anxiety among Health-Care Workers doing Duty for COVID-19 Patients in Tertiary Health-Care Facilities


Department of Psychiatry, GCS Medical College, Hospital and Research Center (Affiliated To Gujarat University), Ahmedabad, Gujarat, India

Date of Submission04-Sep-2020
Date of Decision15-Sep-2020
Date of Acceptance16-Oct-2020
Date of Web Publication25-Mar-2022

Correspondence Address:
Dr. Aatman Nimesh Parikh
211, B Block, GCS Medical College, Hospital and Research Center, Naroda Road, Ahmedabad - 380 025, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_304_20

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  Abstract 


Background: The coronavirus pandemic (coronavirus disease 2019 [COVID-19]) has brought the entire world to a standstill, causing an unprecedented impact on people's lives. The most affected population is the frontline health-care workers, including the on-duty doctors and paramedical staff members providing treatment and care to the COVID patients in the wards and intensive care units. Aim: The present study aimed to evaluate, compare, and correlate the prevalent levels of stress, depression, and anxiety among the doctors and the paramedical personnel treating COVID-19 patients. Materials and Methods: Two hundred and eight consecutive medical professionals and 209 consecutive paramedical personnel, fulfilling the inclusion criteria, were evaluated. Sociodemographic and clinical data were gathered using a semi-structured proforma. Assessments were further done using the Depression, Anxiety, and Stress Scale. Chi-square test was used to compare the groups (medical and paramedical staff) and their correlates. Results: Depression was present in significantly higher number of paramedical staff (43.54%) compared to medical personnel (33.17%). Among doctors, the total duty hours had a significant positive correlation (P < 0.05) to the depressive symptoms. In contrast, the anxiety levels were significantly lower (P < 0.05) among those paramedical staff members who performed their COVID duty for more than 2 weeks. Conclusion: The relentless management of COVID patients by the health-care warriors has begotten a high level of psychiatric morbidity among them. Provision of better facilities, adequate information, and appropriate interventions are required in this regard.

Keywords: Anxiety, COVID-19, depression, health-care workers, stress


How to cite this article:
Parikh AN, Dalal YD, Gediya AJ, Shah PD, Gandhi HA. Evaluation of Stress, Depression, and Anxiety among Health-Care Workers doing Duty for COVID-19 Patients in Tertiary Health-Care Facilities. Indian J Soc Psychiatry 2022;38:270-5

How to cite this URL:
Parikh AN, Dalal YD, Gediya AJ, Shah PD, Gandhi HA. Evaluation of Stress, Depression, and Anxiety among Health-Care Workers doing Duty for COVID-19 Patients in Tertiary Health-Care Facilities. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Oct 3];38:270-5. Available from: https://www.indjsp.org/text.asp?2022/38/3/270/340952




  Introduction Top


The first novel coronavirus disease 2019 (COVID-19) case was reported from Wuhan city of the Hubei province of China on December 31, 2019. Its etiological agent was designated as Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). Since then, the disease has spread in an unprecedented way all across the globe, with the World Health Organization declaring it as a pandemic on March 11, 2020.[1] As of July 5, 2020, it has affected more than 11.1 million people worldwide causing 527,835 deaths, making it the most severe disease outbreak of the past century (WHO).[2]

The serious impact of COVID-19 has caused governments all across the globe to enforce “lockdowns” and “social distancing” causing a significant change in our day-to-day lives. The restrictions may have helped limit the spread of infection, but have, in turn, resulted in an increase in mental health problems in general and among frontline health-care workers (HCWs) in particular.[3],[4],[5],[6] Various factors such as long working hours, mental and physical exhaustion, inadequate personal protective equipment,[7] poor health-care facilities,[8] pressure to act promptly and successfully, societal stigma and interpersonal isolation,[9] and risk of contracting infection as well as transmitting it to loved ones are responsible for this phenomenon.[10],[11] As a result, there are high chances of development of psychiatric morbidities such as stress,[12],[13] adjustment problems, anxiety,[14],[15] insomnia,[16] and depression[17] among the HCWs.[18],[19],[20]

There have been relatively few studies in India regarding the impact of COVID-19 on the mental health status of different HCWs. Our study was undertaken with the aim of assessing the level of depression, anxiety, and stress among treating doctors and paramedical staff and help in its better prevention and management.


  Materials and Methods Top


The study performed was cross sectional. The doctors and paramedical staff who have done duty in the COVID wards or intensive care units (ICUs) in our institute were included in the study after a written informed consent. Inclusion criteria included all consenting HCWs who performed their duties for COVID-19 patients in the last 2 months, aged between 18 and 70 years. The study was completed over a period of 4 weeks. A semi-structured proforma consisting of demographic details was initially filled up by all the participants who included 208 doctors and 209 paramedical staff members.

The participants were then assessed using the Depression, Anxiety, and Stress Scale (DASS). It is a self-report instrument consisting of a total of 42 questions where each question is rated from 0 to 3. DASS has 3 different subscales designed to evaluate the three related negative emotional states. Each subscale includes 14 questions and is rated from normal to extremely severe. The DASS has been demonstrated to be a reliable and valid measure which was previously used in research related to SARS.[21] Cronbach's internal consistency of DASS-42 is 0.89; test–retest and split-half reliability coefficient scores are 0.99 and 0.96, respectively.[22]

All the data collected were entered into an excel sheet and a master chart was prepared. The variables from both the groups, medical professionals and paramedical staff members, were compared using the Chi-square test. The clinical correlates impacting the levels of depression, anxiety, and stress in the study population were further evaluated. Ethical Clearance was obtained from the local Ethics Committee to conduct the study.


  Results Top


As shown in [Table 1], our sample consisted of 417 HCWs who performed their duty in COVID wards/ICUs after taking their informed consent. Out of them, 208 were medical professionals (Group A) and 209 were paramedical staff members (Group B).
Table 1: Sociodemographic correlates of COVID health-care workers

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Majority of the HCWs were <30 years old. About 195 out of the 208 people in Group A (93.75%) and 147 of the 209 personnel (70.33%) belonged to this category. Among both the groups, there were a total of 214 males and 203 females, with a preponderance of males in Group A (63.94%) and of females in Group B (61.24%).

Most of the HCWs were unmarried (66.9%) and belonged to the Hindu religion (84.4%). A vast proportion of them had an urban domicile (83.9%), whereas 230 out of the total 417 health-care professionals (55.15%) belonged to nuclear families.

As shown in [Table 2], there was no significant difference between Groups A and B regarding total duty hours as well as addictions or having preexisting psychiatric or medical illnesses. However, there was a significant difference in their place of duty. More number of doctors had been doing their duty in ICUs (61.06%) as compared to paramedical staff (40.67%). Very few of the HCWs had tobacco (1.92%) or alcohol addictions (0.72%). About 1.2% had preexisting psychiatric illness, whereas 4.32% had preexisting medical illnesses.
Table 2: Clinical correlates of the two groups of health-care workers

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As depicted in [Table 3] and [Figure 1], there was no significant difference in the mean score of depression among both the groups (medical HCWs = 11.32 and paramedical HCWs = 11.68). However, on further evaluation, Group B showed 43.54% of the paramedical personnel to have depression as against 33.17% of doctors in Group A. This difference was statistically significant (P = 0.0295).
Table 3: Depression among health-care workers doing COVID duty

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Figure 1: Comparison of depression, anxiety, and stress between Group A (medical HCWs* n = 208) and Group B (paramedical HCWs* n = 209). *HCWs = Health-care workers

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[Table 4] and [Table 5] and [Figure 1] show that a majority of health-care personnel reported symptoms of anxiety and stress while doing their COVID duties. About 52.4% of doctors and 58.37% of paramedical staff reported anxiety according to their DASS score. One hundred and nine out of 208 doctors (52.40%) reported having stress which was similar to the paramedical personnel (57.42%).
Table 4: Anxiety among health-care workers doing COVID duty

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Table 5: Stress among health-care workers doing coronavirus disease duty

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We further tried to assess the impact of the total number of duty hours on the level of depression, anxiety, and stress. As shown in [Table 6]a, we found that those medical professionals who performed duty for more than 2 weeks (i.e., >112 h) had a significantly higher prevalence of depression (38.28%) as compared to the ones who had performed <2 weeks of COVID duty (25%) (P = 0.0478). In [Table 6]b, we found that those paramedical staff who had done <2 weeks of COVID duties had a statistically significantly higher level of anxiety (67.68%) than those who performed their duties for more than 2 weeks (50%)(P = 0.0096).


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  Discussion Top


Although there have been quite a few studies assessing the psychological impact of COVID-19 on HCWs, studies comparing the same in doctors versus paramedical professionals are rare. In our study, as regards sociodemographic correlates, a gross majority of medical personnel belonged to the <30 years age group (93.75%). This points to an important aspect of our health-care delivery system wherein resident doctors doing their postgraduate medical studies in various departments execute the major portion of treatment provision to COVID-19 patients. Fewer senior consultants are posted in these wards and ICUs. They are instead involved in policy decision-making, preparing treatment algorithms according to the changing WHO and ICMR guidelines, training, delegation, and administration.

Among the paramedical staff, the difference in age is not that stark; 70.33% are <30 years of age. Among nursing staff as well, the junior staff is more likely to be posted in the wards. Younger attendants are posted in the wards because of their physical fitness to better cope with the manual tasks.

Out of 208 doctors, 133 were male (63.94%), whereas 75 were female (36.06%). This is in accordance with the majority of male doctors in India overall. Among paramedical staff, 128 (61.24%) were female, whereas 81 (38.76%) were male out of 209. Majorities were Hindu, unmarried, and belonged to urban domicile.

An interesting difference was found in the family type where majority of the medical professionals (75.96%) lived in a nuclear family, whereas majority of paramedical staff (65.55%) lived in a joint family. This could be attributed to the fact that most on-duty medical personnel were resident doctors, who lived in hostels during their residency, whereas most of the paramedics lived at their homes except during COVID duties.

In our study, doctors were posted in higher numbers in the ICUs as compared to the paramedical staff. This difference was statistically significant and can be explained by the intensive and urgent medical decision-making and execution required in the ICUs as compared to the stable wards.

Of all the HCWs, 38.37% reported symptoms of depression which falls within the range of 22%–75% as reported by various studies.[7],[13],[23] Chong et al. found an estimated prevalence of psychiatric morbidity in health workers to be about 75%.[4] In our study, 91 (43.54%) paramedical personnel reported depression, which is in accordance with other studies. This was statistically significantly higher (P = 0.029) than the 69 (33.17%) doctors who reported depression. Reasons for this may be the fact that doctors are given priority as regards to the facilities provided, including accommodation, food, and personal protective equipment. The paramedical staff members including the nurses and the attendants are also answerable to their superiors as well as the doctors on duty.

Our study shows that more than half (55.39%) of the total sample including medical and paramedical staff reported anxiety symptoms as per their DASS score. We found no significant difference in the incidence of anxiety between the two groups. Many studies which have assessed anxiety in HCWs have reported an incidence from 20.1%[11],[23] to 45%, which was found in a study conducted in China.[4] The fear of contracting coronavirus, passing it on to family members, and the higher mortality rate among HCWs vis-à-vis in the general population can be the factors contributing toward the higher prevalence of anxiety in our study.

Majority (54.92%) of HCWs in our study had symptoms of stress. As per meta-analysis done by General Hospital Psychiatry, 59% of HCWs had moderate-to-severe levels of perceived stress;[14] in a mini review by Jansson and Rello, HCWs in Pakistan reported moderate distress in 42% and severe distress in 26%.[21] Pappa et al. reported symptoms of stress in 38% of HCWs,[11] whereas Temsah et al. reported the same in 41.4%.[1] Various causes such as emergency postings without prior notice, not being able to take leave due to the Pandemic Act, not being able to meet family members during duties and quarantine periods, and the complete and sudden change in lifestyle and routines may be responsible for stress. Other important factors include the need to wear personal protective equipment for continuous 8 h without any breaks leading to excessive perspiration and dehydration causing subsequent weakness and malaise, lack of provision of rest areas, less than smooth administration in emergency situations leading sometimes to unnecessary duplication of efforts, and sometimes negligence of important issues.

When we assessed the correlation of the prevalent depression, anxiety, and stress with the number of duty hours, we interestingly found that depression was significantly higher (P = 0.0478) in medical staff who had performed COVID duties for more than 2 weeks (112 h), whereas paramedical personnel had a statistically significantly higher proportion (P = 0.0096) of anxiety during their first 2 weeks of COVID duty which then went down during their further postings. We have not come across studies emphasizing the correlation between COVID duty hours and prevalence of depression, anxiety, and stress among HCWs.

Doctors are likely to feel more depressed as their duty period extends, due to their position of responsibility, and decision-making. They are also likely to feel guilty for lost patients and might have to deal with the grief of distraught relatives. For the resident doctors, COVID has meant a complete upheaval in their training schedule-no routine OPDs, indoor admissions or surgeries, indefinite postponement of examinations, lagging behind in their thesis and research work, etc., These factors combined with the prolonged phase of rising COVID cases having no end in sight are likely to engender a feeling of hopelessness, helplessness, and negativity among medical personnel.

The paramedical staff members feel anxiety significantly more during the first 2 weeks of their duty probably because of incomplete information about the illness, leading to uncertainty and confusion. During the sudden influx of large number of COVID patients in the hospital, many paramedical personnel had to be deployed to the COVID wards without sufficient training. This might have led to a feeling of being overwhelmed leading to a degree of chaos. However, as their duty progresses, they might feel familiar and well versed doing the duty, better adapted and equipped to handle the demanding situations arising in the COVID wards and ICUs, and therefore feel less anxious.

Limitations

Our study is cross sectional, whereas a follow-up study would show the level of variation over time. This study has been conducted in a small population; the work environment and patient population variables could, therefore, not be fully assessed. A larger-scale study would probably lead to a more accurate measure of the prevalent mental health morbidity among the primary health-care providers.


  Conclusion Top


The degree of depression, anxiety, and stress faced by the HCWs is high in this pandemic due to extraordinary work pressure, physical exhaustion, extreme uncertainty, inadequate personal protective equipment, and high contagion rate. Longer COVID duty is positively correlated with the prevalence of depression among medical HCWs. There was a higher level of anxiety among paramedical personnel in the first 2 weeks of COVID duty. This implicates the need for mental health training before the assignment of COVID duty, provision of adequate supplies and rest areas, limitation of shift hours and duty spells, and availability of multidisciplinary mental health teams for counseling and pharmacotherapy as and when required.[24] Clear communication and easy access to up-to-date guidelines on the management of COVID-19 could help reduce the perceived stress of the HCWs. Regular use of relaxation techniques and Yoga may also help in alleviating anxiety.

Acknowledgment

We would like to thank Dr. Minakshi Parikh (BJ Medical College, Ahmedabad), Dr. Nimesh Parikh (NHLMMC and SVP Hospital, Ahmedabad), and Dr. Archana Dalal (NHLMMC and SVP Hospital, Ahmedabad) for their guidance and technical support in completing this research article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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