The COVID-19 pandemic and mental health outcomes – A cross-sectional study among health care workers in Coastal South India

Introduction

The coronavirus disease of 2019 (COVID-19), first identified in Wuhan, China at the end of December 2019, spread rapidly, crossing geographical boundaries and infected millions of people worldwide. The World Health Organization (WHO) acknowledged this outbreak to be of immediate public health concern and declared it a pandemic on March 11, 2020. Now, even after two years of the outbreak, and large-scale vaccination of the susceptible population, there is still no sign of end to the pandemic. As of 10^th October 2022, WHO estimates close to 618 million confirmed cases and around 65 million deaths due to the severe acute respiratory syndrome coronavirus 2 (SARS-COV2) virus worldwide.¹ One of the major contributors to the global tally of COVID-19 cases, India has reported around 44 million confirmed cases and 0.52 million deaths.^1,2

To curb the rapid spread of COVID-19 infection, countries around the world imposed a nationwide lockdown, which was extended with rise in the number of cases reported. Once the lockdown was ceased, quarantine zones were created and region-specific restriction of movement of people was implemented. The social isolation and loss of livelihood brought about by lockdown had a huge impact on the physical and mental wellbeing of the general population.

Not only the general population, the pandemic affected the psychological well-being of the frontline healthcare workers (HCWs). Healthcare workers were one of the professionals who worked relentlessly during the pandemic. They were the professionals who, despite the imposed lockdown had to work not only their own shifts of duty but sometimes work overtime or extra time to compensate for their sick colleagues.

The physical and psychological stress the HCWs undergo has been documented during the past outbreaks of avian and swine influenza and other coronaviruses infection.^3–5 During the pandemic, the HCWs must work relentlessly and for extended hours, attending to huge caseloads and manage unforeseen medical complications. Frontline HCWs are directly involved in care of COVID patients which not only puts them at risk of acquiring infection, but also the potential spread to their family members. This fear of spreading the infection to their near and dear ones, along with unavailability of PPEs and inadequate oxygen supply, lack of standard guidelines for treatment, especially during the initial days of the pandemic and lack of psychological support have made the frontline HCWs vulnerable.⁶

Recent literature from around the world have reported that frontline HCWs are at more risk of developing anxiety and depressive symptoms.^{7–9,11,12,19} A systematic review and meta-analysis of 239 studies involving 2,71,319 subjects reported prevalence rates of anxiety and depressive symptoms of 42% and 33%, thereby providing evidence that HCWs are at increased risk of unfavourable mental health outcomes during the COVID-19 pandemic.¹³

In India, HCWs involved in COVID-19 care were marginalized and stigmatized. HCWs in many parts of India had to perform their duties under the constant threat of aggression and violence from patient caretakers which heightened their mental distress. Refusal of entry into apartments and residences, resistance to the burial of dead bodies of HCWs,^13–15 and abuse of the doctors involved in screening and contact tracing were reported from different parts of the country.¹⁶

Recognizing the early warning signs of mental distress is important in any population, more so among HCWs. Unfavourable mental health outcomes like anxiety, depression, insomnia, psychological distress, and burnout can affect their health, and compromise the patient safety and the quality of care provided.¹⁷ Adequate interventions and coping strategies can be implemented if the mental health status of HCWs is routinely evaluated. With this background and in the context of the current COVID-19 pandemic in the district, the study was carried out to assess the mental health outcomes among the HCWs in Mangalore and the factors associated with these outcomes.

Methods

Results

A total of 245 HCWs, which included 52.2% (n=128) doctors and 47.8% (n=117) nurses were assessed about their mental health status in our study. The mean age of the doctors was 29.7 (±7.9) years, while that of nurses was 26.3 (± 6.2) years. A higher proportion of participants (n=66, 51.6%) among doctors were females. Majority (n=87, 68%) of the doctors and 47% (n=55) of the nurses were involved in the direct care of COVID-19 patients.

The mental health status of the study participants is depicted in Table 1. The proportion of participants with depressive symptoms, anxiety, and insomnia assessed using PHQ-9, GAD-7 and ISI-7 scales were 49% (n=119), 38% (n=93) and 42% (n=102) respectively. The proportion of depression was higher among doctors (51.6%) compared to nurses (45.3%), however, this finding was not statistically significant (P>0.05). The anxiety-related symptoms were similar among doctors and nurses (doctors 39.0% vs. 36.7% in nurses). A higher proportion of nurses experienced insomnia related symptoms compared to doctors (45.2% vs. 38.2%) (P>0.05).

Comparison of mental health outcome scores as assessed by the various scales is shown in Table 2. The median (IQR) scores for depression (PHQ-9), anxiety (GAD-7), and insomnia (ISI-7) for all the participants were 4.0 (1.0-8.0), 3.0 (0.5-7.0), and 6 (2-10) respectively. The median PHQ-9 and GAD-7 scores were higher among doctors compared to nurses, while nurses had a higher ISI-7 median score. However, no significant difference in mental health scores was observed across categories of HCWs, gender of the participants, and involvement in COVID-19 patients’ care (P>0.05).

The risk factors for developing mental health outcomes – depression, anxiety, and insomnia among HCWs is shown in Table 3.

Depression was more likely to be experienced by HCWs aged >27 years (OR,1.19; 95% CI, 0.70-2.05), female HCWs (OR,1.03; 95% CI, 0.58-1.84), and HCWs involved in COVID-19 care (OR 1.22;95% CI,0.73-2.04). Insomnia was more likely to be experienced by HCWs aged >27 years (OR,1.59; 95% CI, 0.91-2.79) and HCWs with work experience of more than 10 years (OR,2.08; 95% CI, 1.10-3.92). Anxiety was more likely to be experienced by HCWs aged >27 years (OR,1.63; 95% CI, 0.92-2.91), nurses (OR,1.10; 95% CI, 0.66-1.85), and HCWs with work experience of more than 10 years (OR,1.53; 95% CI, 0.82-2.92). However, none of these factors was significantly associated with mental health outcomes (P>0.05), except HCWs with work experience of more than 10 years, which was significantly associated with experiencing insomnia symptoms (P<0.05).

Discussion

Health-care workers (HCWs) have been at the forefront since the beginning of the pandemic providing uncompromising care to those infected with COVID-19. However, the extended period of duty hours and the constant fear of getting infected or spreading the infection to family members has negatively impacted their physical and mental health. Unfavourable mental health outcomes – depression, insomnia and anxiety were also reported among our study participants.

The prevalence of depression was 51.5% in our study. Anxiety was reported among 38%, while insomnia was present in 42% of the participants. The prevalence of unfavourable mental health outcomes in our study is high compared to a similar study from another part of India where depression was reported among 47.4% of the HCWs, while anxiety and insomnia were seen among 29.0% and 32.2% of the participants respectively.²⁵ Similar studies conducted among the HCWs during the pandemic from different parts of the world have reported a prevalence of depression ranging from 8.9% to 77.2%,^{7–12,26–36} anxiety 14.5% to 88%,^{7–12,26–29,31–34,38–41} and insomnia 8.3% to 85.4%.^{16,27,28,30–41}

Many factors can contribute to unfavourable mental health outcomes among HCWs. The long duty hours and overflowing outpatient departments (OPDs), along with acute shortage of trained staff and personal protective equipment (PPE), fear of contracting the infection and spreading the disease to their family members, and continuous performance evaluation results in psychological distress in most HCWs, ultimately leading to burnout. HCWs are also faced with several decision-making dilemmas during a pandemic including allocation of resources, care for a severely ill/dying patient, and aligning patient needs with those of family members further resulting in moral distress. All this is compounded by a prolonged period of separation from family members or a lack of any other form of support system.^41,42

Studies from different parts of the world have reported a variety of factors contributing to unfavourable mental health outcomes. A study from the Eastern Mediterranean region reported that the presence of a pre-existing mental illness, being isolated for COVID-19, and having children was significantly associated with experiencing depressive symptoms³⁴ while insomnia was significantly associated with HCWs working in an isolation unit in a study in China.³² The absence of psychological support at the workplace as a factor for experiencing poor mental outcomes was reported in studies conducted in China and Albania,^32,35 while fear of getting infected and transmitting COVID-19 was associated with experiencing depressive symptoms among HCWs in Switzerland and China.^31,32

The frontline HCWs being directly involved in the examination, diagnosis, and treatment of COVID-19 makes them more vulnerable to contracting the infection. The constant fear of being at risk of getting infected may lead to psychological distress and burnout among them. Several studies have reported that the HCWs involved in direct care for COVID-19 patients were found to have unfavourable mental health outcomes.^20,27,32,35

In our study, unfavourable mental health outcomes – depression, anxiety and insomnia were observed among participants >27 years of age, nurses, and HCWs having work experience of more than 10 years. Similar observations were reported in various studies among HCWs around the world. Nurses were found to have a higher risk of experiencing poor mental outcomes in studies conducted in Asia and Africa^20,25,28,40 whereas another study from Africa reported male HCWs and physicians to be more at risk for experiencing distress.^35,36 In general, female HCWS were found to be more vulnerable to experiencing depression and insomnia related symptoms.^{20,25,28,30,31,39,40} Younger HCWs in the age group between 21-30 years were also found to experience unfavourable mental health outcomes in several studies.^27,36,40,41

Our study has many clinical implications. The presence of clinically relevant anxiety and depressive symptoms among 38% and 49% HCWs respectively in our study draws attention to the importance of regular and systematic tracking of mental health status of HCWs during this ongoing pandemic. The result of our study reiterates the need for periodic monitoring of the mental health status of the HCWs, especially during pandemic and provide appropriate and timely interventions, not only to improve the quality of life of HCWs, but also the quality of patient care provided. It is important that the measures taken address the key concerns of healthcare workers who are working in frontline such as adequate availability of PPE, sufficient time to spend with family, and acceptable compensations to their family in case of death.

Conclusions

A higher proportion of doctors compared to nurses had symptoms of depression and insomnia, while the proportion of doctors and nurses experiencing anxiety related symptoms is almost similar. Overall 49% of the HCWs had clinically relevant depressive symptoms and 38% had clinically relevant anxiety symptoms. This draws attention to the importance of systematically tracking the mental health of HCWs during this ongoing pandemic. The healthcare workers should monitor their stress reactions and seek appropriate help both on a personal and professional level. Appropriate workplace interventions including psychological support should be provided to HCWs, to ensure a sound mental health, so as to provide uncompromised quality health care to the patients.

Data availability

Reporting guidelines

Open Science Framework: STROBE checklist for ‘Covid 19 pandemic and mental health outcomes – A study among health care workers in Coastal South India’. https://doi.org/10.17605/OSF.IO/MU9E8.⁴²

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).