Symptoms of Depression, Anxiety, Post-traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic

United States, March-April 2021

Jonathan Bryant-Genevier, PhD; Carol Y. Rao, ScD; Barbara Lopes-Cardozo, MD; Ahoua Kone, MPH; Charles Rose, PhD; Isabel Thomas, MPH; Diana Orquiola, MPH; Ruth Lynfield, MD; Dhara Shah, MPH; Lori Freeman, MBA; Scott Becker, MS; Amber Williams, MS; Deborah W. Gould, PhD; Hope Tiesman, PhD; Geremy Lloyd, MPH; Laura Hill, MSN; Ramona Byrkit, MPH


Morbidity and Mortality Weekly Report. 2021;70(26):947-952. 

In This Article


Among a convenience sample of 26,174 state, tribal, local, and territorial public health workers, approximately one half experienced symptoms of a mental health condition in the 2 weeks preceding the survey, with highest prevalences reported among younger respondents, and transgender or nonbinary respondents. Public health workers who reported certain workplace practices, such as long work hours and the inability to take time off, were more likely to have experienced symptoms of a mental health condition. Implementing prevention and control practices that eliminate, reduce, and manage workplace factors¶¶ that cause or contribute to public health workers' adverse mental health status*** might improve mental health outcomes during this and other public health emergencies.

The overall prevalence of symptoms of mental health conditions among public health workers was higher than previously reported in the general population (approximately 40.9%).[1] Prevalences of symptoms of depression and anxiety among public health workers were similar to those in previous reports among health care workers;[3] however, prevalence of PTSD symptoms among public health workers was 10%–20% higher than that previously reported among health care workers,[2] frontline personnel,[3] and the general public.[1] Symptoms of PTSD disproportionately affected public health workers who experienced work-related traumatic stressors (e.g., felt inadequately compensated or felt unappreciated at work), particularly those factors that affect workers' personal lives (e.g., felt disconnected from family and friends because of workload). Traumatic and stressful work experiences related to the COVID-19 pandemic might have played a role in elevating the risk for experiencing symptoms of PTSD among public health workers.

Increases in adverse mental health symptoms among workers have been linked to increased absenteeism, high turnover, lower productivity, and lower morale, which could influence the effectiveness of public health organizations during emergencies.[8,9] Among public health worker respondents, nearly 20% reported that their employer did not allow them to take time off; the inability to take time off had the largest impact on reporting symptoms of mental health. Approximately one quarter of public health workers did not know whether their workplace offered an employee assistance program. Even where available, employee assistance programs were not commonly accessed. Several strategies could reduce adverse mental health symptoms among public health workers during public health emergencies. For example, expanding staffing size (e.g., recruiting surge personnel to backfill positions) and implementing flexible schedules might reduce the need for long work hours; encouraging workers to take regular breaks and time off could help avoid overwork and reduce the risk for adverse mental health outcomes. In addition, implementing, evaluating, and promoting use of employee assistance programs could improve employee resiliency and coping.

The findings in this report are subject to at least four limitations. First, the study used a nonprobability–based convenience sample of public health worker respondents, and a completion rate could not be determined. Although the participating national public health membership associations reach many public health workers, the findings might not be representative of all state, tribal, local, and territorial public health workers in the United States. Second, self-reported mental health symptoms were assessed using screening instruments, which does not constitute clinical diagnosis of a mental health disorder; however, the screening instruments have been clinically validated.[5–7] Third, participants were surveyed about symptoms experienced in the 2 weeks preceding the survey, which might not reflect all symptoms experienced during the pandemic. Finally, not all traumatic stressors or events experienced by public health workers were assessed by the survey, such as non–COVID-19 illnesses or financial insecurity.

During the COVID-19 pandemic, public health workers have experienced symptoms of depression, anxiety, PTSD, and suicidal ideation. Addressing work practices that contribute to stress and trauma is critical to managing workers' adverse mental health status during emergency responses. Furthermore, strengthening work systems to encourage behavior changes that promote mental health, such as building awareness of symptoms of mental health conditions and developing sustainable coping strategies, might improve mental health conditions, particularly for public health workers who are at increased risk, including those who are younger[10] or transgender or nonbinary persons. In addition, employee assistance programs could be evaluated and adjusted to be more accessible and acceptable to workers and focus more on building workplace cultures that promote wellness and destigmatize requests for mental health assistance.