COVID-19: 'Striking' Rates of Anxiety, Depression in Healthcare Workers

Megan Brooks

March 26, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's  Coronavirus Resource Center.

A significant proportion of healthcare workers treating patients exposed to COVID-19 have symptoms of depression, anxiety, and insomnia, new research shows.

In a survey of more than 1200 healthcare workers in China, about 50% reported at least mild depression; 14% of physicians and nearly 16% of nurses reported moderate or severe depressive symptoms and about 34%  reported insomnia.

Those at greatest risk for depressive and anxiety symptoms included women, those with intermediate seniority roles (compared with those with junior roles), and those at the center of the epidemic in Wuhan.

"Together, our findings present concerns about the psychological well-being of physicians and nurses involved in the acute COVID-19 outbreak," write the investigators, led by Jianbo Lai, MSc, from Zhejiang University School of Medicine, Hangzhou, China.

The results were published online March 23 in JAMA Network Open.

Need for Rapid Action

The researchers conducted a cross-sectional survey of 1257 healthcare workers in 34 hospitals across China, including the outbreak epicentre Wuhan.

Among survey respondents, 61% were nurses, 39% were physicians, 61% worked in hospitals in Wuhan and 42% were frontline healthcare workers engaged in direct diagnosis, treatment, and care of patients with COVID-19.

The survey took place between January 29 and February 3, a period when the total confirmed cases of COVID-19 in the country topped 10,000.

Symptoms were assessed using the Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale–Revised.

Half of respondents reported symptoms of depression, 45% reported symptoms of anxiety, 34% reported symptoms of insomnia, and about 72% reported psychological distress.

Nurses, women, frontline healthcare workers and those working in Wuhan had more severe degrees of all measurements of mental health symptoms compared with other healthcare workers.

On multivariable logistic regression analysis, healthcare providers outside Wuhan had a lower risk of symptoms of distress compared with those in Wuhan (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.43 - 0.88; P = .008).

Frontline healthcare workers had a higher risk of depressive symptoms (OR, 1.52; 95% CI, 1.11 - 2.09; P = .01), anxiety (OR, 1.57; 95% CI, 1.22 - 2.02; P < .001), insomnia (OR, 2.97; 95% CI, 1.92 - 4.60; P < .001), and distress (OR, 1.60; 95% CI, 1.25 - 2.04; P < .001).

"Protecting healthcare workers is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented, with women, nurses, and frontline workers requiring particular attention," the investigators write.

"Striking" Findings

The rates of anxiety and depression revealed by the survey are "striking," Roy Perlis, MD, associate editor of JAMA Network Open, writes in an accompanying editorial.

Perlis, from Massachusetts General Hospital in Boston, notes that while the "peak of the COVID-19 epidemic remains to be seen, it will ultimately subside." However, the results also provide "a reminder of the toll that will likely linger: the consequences of chronic stress, including major depression and anxiety disorders."

Perlis writes that "just as the world has joined efforts to manage COVID-19 infection, it will be critical not to neglect the mental health consequences of the fight against the epidemic."

In an interview with Medscape Medical News, Jacqueline Bullis, PhD, a psychologist specializing in anxiety, said there are "actionable and feasible" things healthcare providers can do to balance some of the stress they may be experiencing in their day-to-day encounters with patients during the COVID-19 pandemic.

It's important to acknowledge that it is normal to be feeling anxious and worried right now, said Bullis.

"In the case of coronavirus, some amount of anxiety is helpful in reminding us to take precautions and protect ourselves," said Bullis, who is with McLean Hospital's Center of Excellence in Depression and Anxiety Disorders, Belmont, Massachusetts.

Understandably, she added, healthcare providers are probably experiencing heightened levels of anxiety right now that aren't helpful.

"But it's important to practice acceptance of whatever negative emotions they are feeling in the moment and remember that that anxiety will dissipate with time. Be compassionate of their own anxiety and the anxiety of others. Sometimes as healthcare providers we put expectations on ourselves to not feel anxious, but we are all human and all struggling through this," Bullis said.

Importance of Self-Care

She also encourages providers to be proactive and take steps to guard against burnout.

"Try taking some short breaks during each day. Being outside and connecting with nature for 20 to 30 minutes, but even just 10 minutes, has been shown to reduce cortisol levels, the stress hormone," said Bullis.

Practicing gratitude has also been shown to have positive effects on physical and emotional well-being.

"Make a commitment that you will come up with three things every day that you are grateful for," Bullis said. "Tying it to something you do every day, like brushing your teeth or brewing your coffee, will make you more likely to stick to it."

She also believes "daily mini self-check-ins" are important.

"Take several deep breaths and check-in on how you are feeling. Research has shown that just by labeling what you are feeling — 'I'm stressed, my thoughts are raising, my stomach is in knots' — you reduce the intensity of that emotion," said Bullis. 

Finally, and perhaps most importantly, Bullis encouraged frontline providers not to hesitate to get professional help.

"It's gotten better, but there still is a lot of stigma in asking for help. People typically wait until their anxiety and depressive symptoms get really severe before they reach out."

The study was supported by grants from the National Key Research and Development Program of China. The authors have disclosed no relevant financial relationships. Perlis disclosed biotech investments in Outermost Therapeutics, Psy Therapeutics, Burrage Capital, and RID Ventures; and receiving personal fees from Genomind and Tekada Pharmaceutical Company outside the submitted work. Bullis has disclosed no relevant financial relationships.

JAMA Netw Open. Published online March 23, 2020. Full text, Editorial

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