A cross-sectional study of anxiety, depression, and stress among health-care workers managing COVID-19 patients in a tertiary care hospital in North India

Aneesha Haryal; Aradhana Singh; Pallavi Abhilasha; Mamta Singla; Divya Salwan; Nidhi Agrawal

doi:10.4103/cjhr.cjhr_26_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 8 | Issue : 3 | Page : 182-186

A cross-sectional study of anxiety, depression, and stress among health-care workers managing COVID-19 patients in a tertiary care hospital in North India

Aneesha Haryal¹, Aradhana Singh², Pallavi Abhilasha¹, Mamta Singla¹, Divya Salwan¹, Nidhi Agrawal¹
¹ Department of Psychiatry, Christian Medical College, Ludhiana, Punjab, India
² Department of Community Medicine, Christian Medical College, Ludhiana, Punjab, India

Date of Submission	21-Feb-2021
Date of Decision	09-Apr-2021
Date of Acceptance	29-Jul-2021
Date of Web Publication	04-Mar-2022

Correspondence Address:
Pallavi Abhilasha
Department of Psychiatry, Christian Medical College, Ludhiana, Punjab
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cjhr.cjhr_26_21

Abstract

Objective: The objective of the study was to identify the incidence of anxiety, depression, and stress in health-care workers managing COVID-19 patients in a tertiary care hospital in North India. Methodology: A cross-sectional online survey was conducted using Depression, Anxiety, and Stress Scale-21 Questionnaire (Google Form). All health-care workers (HCWs) of the hospital were included in the study. HCWs with a past or current history of psychiatric illness and on psychotropic medication were excluded from the study. Results: Two hundred and twenty HCWs answered the questionnaire, of whom 114 (51.8%) were female. Of the 220, 128 (58.2%) were single, 97 (44.1%) were physicians. Level one exposure (direct interaction with COVID-19 patients) was seen in 111 (55.5%). One hundred and thirty-three (60.5%) HCWs worked for 8–12 h/day. Conclusions: Our findings highlight the factors which need to be taken into consideration to protect the mental well-being of doctors while fighting with a disaster that has major impacts on society worldwide.

Keywords: COVID, health workers, psychological effects

How to cite this article:
Haryal A, Singh A, Abhilasha P, Singla M, Salwan D, Agrawal N. A cross-sectional study of anxiety, depression, and stress among health-care workers managing COVID-19 patients in a tertiary care hospital in North India. CHRISMED J Health Res 2021;8:182-6

How to cite this URL:
Haryal A, Singh A, Abhilasha P, Singla M, Salwan D, Agrawal N. A cross-sectional study of anxiety, depression, and stress among health-care workers managing COVID-19 patients in a tertiary care hospital in North India. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28];8:182-6. Available from: https://www.cjhr.org/text.asp?2021/8/3/182/339048

Introduction

A novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in Hubei province of China in December 2019. Since its identification, it has spread rapidly, prompting the WHO to declare it as a public emergency of international concern.^[1] First reported as cases of pneumonia of unknown etiology in Wuhan, China, on December 31, 2019, the epidemic was associated with seafood exposure in one of the markets in Wuhan and later identified as a new strain of coronavirus.^[2] Within a month, a rapid wave of infection affected more than two hundred countries of the world outside China.^[3] By the end of April, the cases exponentially increased to affect >3 million population with >200,000 deaths attributable to COVID-19 globally

Constant increasing of infected cases, rise in death rates, lack of any specific treatment or vaccine, massive overload, lack of personal protective gears, feelings of inadequate support, and extensive mass media coverage lead to a massive toll on the mental health of health-care personnels^[4] and posed an increasing demand for health-care workers (HCWs).^[5] In all these circumstances, it is expected of HCWs to work for long hours while being under pressure. HCWs are even at the risk of getting infected as they were at a close contact of infected patients owing to which they develop anxiety as well as depressive features and long-term psychological problems.^[6] Various local and national mental health centers opened up various telephone, Internet, and application-based counseling and intervention in response to the COVID 19 outbreak to curb the psychological implications arising out of the epidemic^[7] However, evidence-based evaluations and mental health interventions targeting front-line HCWs are relatively scarce.

To address this gap, the aim of the current study was to evaluate mental health outcomes among HCWs treating patients with COVID-19 by quantifying the magnitude of symptoms of depression, anxiety, and stress in a tertiary care hospital in North India. This study aimed to provide an assessment of the mental health burden of HCWs, which can serve as important evidence to direct the promotion of mental well-being among HCWs.

Materials and Methods

Ethics

The study was approved by the institutional ethics committee via REF: IECCMCL/08-6462020. Online written informed consent was obtained from all potential participants.

Study design and eligibility criteria

This was a cross-sectional, observational study carried out on health workers working in a tertiary care hospital in North India. An online semi-structured questionnaire was developed, with a consent form attached to it. The questionnaire was in all three languages that is English, Hindi, and Punjabi. For the HCWs who were not technology-friendly and had difficulty in operating computers and e-mails, questionnaires were administered on them individually. We used an online survey to minimize face-to-face interactions and to facilitate the participation of HCWs who work extensively during this emergency period. The link of the questionnaire was sent through e-mails, WhatsApp, and other social media targeting doctors, nurses, cleaners involved in triage, screening, diagnosing, and treatment of COVID-19 patients and suspects. On receiving and clicking the link, the participants got auto directed to the information about the study and informed consent. Once they accepted to take the survey, they filled up the demographic details. Then, a set of several questions appeared sequentially, which the participants were to answer.

Instruments

The questionnaire was formed on three sections:

The first section was for background data which included age, gender, place of practice, qualification, specialties, and comorbidities;

The second section comprised a set of questions prepared by expert opinion targeting attitude and knowledge regarding COVID-19.

In the third section, the Depression, Anxiety, and Stress Scale (DASS)-21 was applied. The DASS-21 is based on three subscales of depression, stress, and anxiety, and each subscale consists of seven questions each.

The rating of DASS subitems such as depression, anxiety, and stress can be rated as normal, mild, moderate, and extremely severe. Each item is scored on a self-rated Likert scale from 0 (did not apply to me all) to 3 (much or mostly applied to me) in the past 1 week.^[8] The scale does not cover several domains of depression such as sleep, appetite, and sexual functions, so it cannot be used as a diagnostic tool but can be applied as an aid to diagnostic tool as well as to measure treatment response. Both English and non-English versions have high internal consistency (Cronbach's alpha scores >0.7). The DASS scale has shorter version and longer version (comprising 21 and 42 items, respectively). In DASS-21, the final score of each item is multiplied by two to obtain the final score.^[9]

On piloting, it was found that it takes approximately 5 min to complete each form. Those forms with complete responses were finally analyzed. While collecting data, confidentiality and anonymity were maintained. It was assured that the interpretation of this study will not be utilized for commercial purposes. Anyone can opt out from the study if they do not want to submit the data in the midway of this survey. Collected data were checked for completeness and consistency.

Data cleaning was done and then data were entered in the computer on Excel data sheets (Microsoft Excel, 2013). SPSS version 25 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. For comparisons between the groups, t-test was used for continuous variables and Chi-square tests were used for categorical variables. Statistical significance was determined at P < 0.05. Significant predictors were further analyzed using logistic regression.

Sample size estimation

According to a study done by Bhattacharyya et al., the incidence of depression in HCWs managing COVID-19 patients is 34%. The sample size for this study was calculated to be n = 220 using the formula n = Z _α/2²p*(1-p)/d², where Z _α/2 is the critical value of the normal distribution at α/2 (For our study the confidence level of 95%, α is 0.05 and the critical value is 1.96, P = 34% is incidence of depression and d = 6.3% absolute precision.

Results

The total responses received were 220. The sample has a mean age of 30.45 years.

There were more females than males (51.8%), most of them were single (58.2%), graduates (47.3%), and physicians were more compared to any other profession (44.1%). Health workers were going to work as usual amounting to 67.3%. About 50.5% of the HCWs were in direct interaction with the COVID-19 patients which is referred to as level 1. The HCWs worked for 8 to 12 h which amounts to 60.5%. About 65.9% worked in COVID exposed areas. About 94.1% were free of any psychiatric illness. About 93.2% were free of any medical illness. The mean age was 30.45 and standard deviation (SD) was 7.27. The mean and SD of DASS score were 33.14 and 26.87, respectively.

This is a chart showing the degrees of severity of depression, anxiety, and stress in DASS-21 scoring. There was a higher percentage of anxiety, depression, and stress seen among HCWs working in COVID areas [Figure 1] and [Figure 2].

Figure 1: Question wise analysis for occurrence

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Figure 2: Prevalence of anxiety, stress, and depression among health-care worker

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A statistically significant association was found between education, current level of working, and anxiety, significant association between education and depression, stress, and education. A significant association was found between DASS score and people with mental disorders and history of current medication.

Discussion

In our study, the physicians were affected more compared to other HCWs involved in the care of COVID-19 patients. The current study highlighted that females were affected slightly more than the males amounting to 51.8% out of which 58.2% were single and 47.3% were graduates. Our study showed the prevalence of anxiety and depressive symptoms as 61% and 54%, respectively. Our study showed a higher prevalence of stress, anxiety, and depression as compared to Chinese study on COVID-19, which revealed the prevalence of anxiety and depression as 44.6% and 50.4%, respectively.^[7] This could be because of social and cultural differences, the level of health-care infrastructure, apprehension due to the pandemic, long hours of duty, limited resources, demanding patients, uncertainty about disease course, potential mortality, inadequate infrastructure, lack of adequate protective equipment, lack of definitive drug treatment or prophylaxis, lack of a vaccine, high incidence of infection among frontline health-care workers, apprehension of transmitting the disease to the family members, and less family time [Table 1].

Table 1: Classification on the basis of Depression, nxiety, and Stress Scale.21 score

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In India, the prevalence of anxiety and depressive symptoms is higher in doctors as compared to the general population.^[10] Recently, a study from China during the COVID-19 pandemic on insomnia and related factors revealed the prevalence of symptoms of stress, anxiety, and depression among HCWs to be 73.4%, 44.7%, and 50.7%, respectively.^[11] A study from China estimated that the prevalence of symptoms of anxiety, depression, and both among doctors was 25.67%, 28.13%, and 19.01%, respectively, during non-COVID days in 2014.^[12]

In our study, the females were affected more which is consistent with the findings and study from India and other countries. This could be due to greater family responsibilities, sociocultural factors, and gender discrimination.^{[13],[14],[15]} This finding is in line with the findings reported by Lai et al., where women are at increased odds of developing distress (odds ratio [OR]: 1.45; P = 0.01), depression (OR: 1.94; P = 0.003), and anxiety (OR: 1.69; P = 0.001).^[4] About 58.2% were found to be single who are greatly affected due to pandemic. This could be because of loneliness as they are staying away from home or at hostel or were staying at temporary accommodations. These people were two times at risk of developing depression anxiety and stress.^[16] The mean age of HCWs developing anxiety depression and stress was 30 years which could be due to long working hours and greater exposure to COVID-19 patients. A study on faculty doctors from the southern part of India revealed high perceived job stress among doctors aged <45 years (73%) compared to 18% of those aged >45 years.^[17] A statistically significant association was found between education, current level of working, and anxiety, significant association between education and depression, stress, and education. The factors causing anxiety could be due to long medical training hours in India associated with burnout, and routine exposure to a variety of infectious diseases.^[18] Our study also showed that the people who are more educated had more prevalence of depression, anxiety, and stress which is similar to study done in nepal^[19] Higher DASS score was found in women, graduates, physicians and level 1 workers, people already diagnosed with mental disorder and on-going treatment for medical illness. In our study, health workers who had a history of medication for mental health problems had higher odds of exhibiting anxiety, depression, and stress compared with those without such history. A similar finding was observed in a study conducted in China where health workers with a history of mental health problems were more likely to have anxiety, depression, and stress.^[20] Similar to our findings, Lai et al. indicated that women and frontline workers had a greater risk for developing adverse psychiatric outcomes during the COVID-19 outbreak in China.^[4] Finally, feelings of occupational competence during COVID-19 related tasks seem to be related with the psychological burden of workers. Providing adequate prejob training on those who will work in the frontline, explaining accurate information on the disease, risk of contagion, and ways of protection, establishing systematic diagnostic and treatment protocols with clear guidelines may help relieve stress and increase occupational confidence [Table 2].

Table 2: The relationship between depression, anxiety, stress, and overall Depression, Anxiety, and Stress Scale-21 and the demographic characteristics of the explores subject

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Conclusion

The study finds that HCW particularly single, women, physicians, and graduates are more vulnerable to developing anxiety, stress, and depression. The respective hospital administers and policymakers need to control modifiable factors such as limited work hours, surplus equipment, and psychological support for primordial prevention of anxiety, stress, and depression in HCWs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same measures as for SARS? Lancet Infect Dis 2020;20:e102-7.
2.	World Health Organization Corona Virus Disease COVID-2019 Situation Reports; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports.
3.	World Health Organization. WHO Timeline_COVID_19. [Last accessed on 2020 Mar 18].
4.	Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
5.	Schwartz J, King CC, Yen MY. Protecting healthcare workers during the coronavirus disease 2019 (COVID-19) outbreak: Lessons from Taiwan's severe acute respiratory syndrome response. Clin Infect Dis 2020;71:858-60.
6.	Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv 2004;55:1055-7.
7.	Lee AM, Wong JG, McAlonan GM, Cheung V, Cheung C, Sham PC, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry 2007;52:233-40.
8.	Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 1995;33:335-43.
9.	Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community sample. Psychol Assess 1998;10:176-81.
10.	Sagar R, Dandona R, Gururaj G. The burden of mental disorders across the states of India: The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61.
11.	Zhang C, Yang L, Liu S, Ma S, Wang Y, Cai Z, et al. Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psychiatry 2020;11:306.
12.	Gong Y, Han T, Chen W, Dib HH, Yang G, Zhuang R, et al. Prevalence of anxiety and depressive symptoms and related risk factors among physicians in China: A cross-sectional study. PLoS One 2014;9:e103242.
13.	Atif K, Khan HU, Ullah MZ, Shah FS, Latif A. Prevalence of anxiety and depression among doctors; the unscreened and undiagnosed clientele in Lahore, Pakistan. Pak J Med Sci 2016;32:294-8.
14.	Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, Murray CJ, et al. Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Med 2013;10:e1001547.
15.	Picco L, Subramaniam M, Abdin E, Vaingankar JA, Chong SA. Gender differences in major depressive disorder: Findings from the Singapore Mental Health Study. Singapore Med J 2017;58:649-55.
16.	Mushtaq R, Shoib S, Shah T, Mushtaq S. Relationship between loneliness, psychiatric disorders and physical health ? A review on the psychological aspects of loneliness. J Clin Diagn Res 2014;8:E01-4.
17.	Chichra A, Abhijnhan A, Tharyan P. Job stress and satisfaction in faculty of a teaching hospital in south India: A cross-sectional survey. J Postgrad Med 2019;65:201-6. [PUBMED] [Full text]
18.	Diwan V, Minj C, Chhari N. Indian medical students in public and private sector medical schools: Are motivations and career aspirations different? Studies from Madhya Pradesh, India. BMC Med Educ 2013;13:127.
19.	Khanal P, Devkota N, Dahal M, Paudel K, Joshi D. Mental health impacts among health workers during COVID-19 in a low resource setting: A cross-sectional survey from Nepal. Glob Health 2020;16:89.
20.	Zhu Z, Xu S, Wang H, Liu Z, Wu J, Li G, et al. COVID-19 in Wuhan: Sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers. EClinicalMedicine 2020;24:100443.