Issue 99, Jul 2020
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COVID-19: The psychosocial and mental health toll on health care workers

Zhang Wen-Rui et al. Psychother Psychosom.2020Apr 9; 1-9 doi:10.1159/0000507639 [E Pub ahead of print]

PMID:32272480

Background

COVID-19 is a highly contagious disease. Being on the frontlines takes a toll on the health care workers (HCW). This Chinese study explored whether medical health workers had more psychosocial problems than nonmedical health workers during the COVID-19 outbreak.

Methods

An online survey was run from February 19 to March 6, 2020; a total of 2,182 Chinese subjects participated. Mental health variables were assessed via the Insomnia Severity Index (ISI), the Symptom Check List-revised (SCL-90-R), and the Patient Health Questionnaire-4 (PHQ-4), which included a 2-item anxiety scale and a 2-item depression scale (PHQ-2).

Results

Compared with nonmedical health workers (n = 1,255), medical health workers (n = 927) had a higher prevalence of insomnia (38.4 vs. 30.5%, p < 0.01), anxiety (13.0 vs. 8.5%, p < 0.01), depression (12.2 vs. 9.5%; p< 0.04), somatization (1.6 vs. 0.4%; p < 0.01), and obsessive-compulsive symptoms (5.3 vs. 2.2%; p < 0.01). Both medical health workers and non- medical health workers had significantly increased insomnia, depression, and obsessive-compulsive symptoms. The medical health workers additionally had significantly increased anxiety and somatization.

Conclusions

During the COVID-19 outbreak, medical health workers had psychosocial problems and risk factors for developing them. They required attention and recovery programs.

Clinical Commentary

This is what I would call a “quick and dirty study” done online using shortened versions of questionnaires for anxiety and depression. It is also a cross-sectional and not a longitudinal study. All assessments are self-report and there was no clinical interview done. These are limiting factors. Such studies help get data out quickly and also have a place in alerting us to the psychological issues faced by frontline workers.

The issues faced by health care workers especially nurses and physicians on the frontline may cause moral injury. An act committed by oneself or another individual entity, that violates one's moral code often in a high stakes’ situation is called moral injury. In the case of COVID-19 examples include patients dying alone as loved ones are not allowed to be in the hospital and often the health care worker has been there so the person does not die alone. Another example is when a physician has to make a choice of who goes on a ventilator or get a particular medicine as there may be shortages. Being put in such a position may create guilt, anxiety, and depression. HCW may feel less connected to the patient because of wearing personal protective equipment (PPE).

Other issues such as shortages of PPE leading to fear of lack of protection and getting the disease further add to anxiety, distress, and helplessness in frontline workers.

 Rigorous trials can be designed and started in the future; however, these studies get us oriented quickly to the challenges faced by health care workers. They give us a glimpse as to what is to be expected in the future. 

Summary: Healthcare workers on the frontlines treating COVID-19 patients need to be educated regarding work-related stress, including symptoms and warning signs. I suggest that we support these individuals with therapeutic options to manage anxiety and depression.

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Psychological outcomes and associated physical symptoms amongst health care workers during COVID-19 outbreak

Chew NW et al. Brain Behav Immun. 2020 Apr 21; S0889-1591 (20) 30523-7. doi:10.1016/j.bbi.2020.04.049. [E Pub ahead of print]

Background

The coronavirus 2019 (COVID-19) pandemic has been associated with reports of increased prevalence of physical symptoms observed in the general population. This study investigated the association between psychological outcomes and physical symptoms specifically amongst healthcare workers (HCWs).

Methods

HCWs from five major hospitals, involved in the care of COVID-19 patients, in Singapore and India were invited to participate in a study by performing a self-administered questionnaire from February 19 to April 17, 2020. HCWs included doctors, nurses, allied healthcare workers, administrators, clerical staff, and maintenance workers. The questionnaires collected information on demographics, medical history, and symptom prevalence in the past month. The Depression Anxiety Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R) were used in this study. The prevalence of physical symptoms displayed by healthcare workers and the associations between physical symptoms and psychological outcomes of depression, anxiety, stress, and post-traumatic stress disorder (PTSD) were evaluated.

Results

Out of the 906 HCWs who participated in the survey, 48 (5.3%) screened positive for moderate to very-severe depression, 79 (8.7%) for moderate to extremely severe anxiety, 20 (2.2%) for moderate to extremely-severe stress, and 34 (3.8%) for moderate to severe levels of psychological distress. The most common reported symptom was headache (32.3%), with a large number of participants (33.4%) reporting more than four symptoms. Participants who had experienced symptoms in the preceding month were more likely to be older, have pre-existing comorbidities, and a positive screen for depression, anxiety, stress, and PTSD. After adjusting for age, gender, and comorbidities, it was found that depression, anxiety, stress, and PTSD remained significantly associated with the presence of physical symptoms experienced in the preceding month. The presence of physical symptoms was also associated with higher mean scores in the IES-R, DASS Anxiety, Stress, and Depression subscales.

Conclusions

This study demonstrates a significant association between the prevalence of physical symptoms and psychological outcomes among healthcare workers during the COVID-19 outbreak. We postulate that this association may be bi-directional and that timely psychological interventions for healthcare workers with physical symptoms should be considered once an infection has been excluded.

Clinical Commentary

This is a timely study conducted in Singapore and India between mid-February to mid-April 2020. The sample size is even from the two countries. This study reveals headaches, insomnia, throat pain, lethargy/fatigue, and anxiety as the five most common symptoms experienced by participants. Depression, anxiety, stress, and PTSD were adverse psychological outcomes. The relationship between the physical symptoms and psychological symptoms was bi-directional.

It should be noted that in the time frame when data were gathered, Singapore was at a stage in the pandemic when the number of cases was peaking. They have had a second surge since then in the recent past. In India at that point the prevalence of COVID-19 was low and so was the case rate. New cases are surging now in India starting mid-May and have not peaked as yet. Hence the Indian numbers may not be a true representation. Both countries were at different phases of the pandemic in terms of new infections and COVID-19 cases.

Headache was the most common symptom reported in about a third of the cases. Interestingly lack of smell and taste were not noted or asked about in this group of symptoms. These are now common screening questions.

This study suggests that HCWs need support and treatment depending on the intensity of the symptoms and dysfunction. They need recognition of their work as well, like the fact they are on the frontlines. HCWs may have a greater fear of getting a contagious disease as a result of exposure.

Summary: Health care workers need to be screened for depression, anxiety, and stress. The primary care physicians as well as psychiatrists and other mental health providers should consider the diagnosis of depression and anxiety in HCWs presenting with physical symptoms especially headaches. Post-traumatic stress disorder also needs to be in our differential diagnosis. Hence clinical scales such as PHQ-9 and GAD-7 are excellent screening methods at intake in addition to a good clinical history.

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The mental health of the general population during the COVID-19 pandemic: The Chinese experience.

Wang C et al. Brain Behav Immun. 2020 Apr 13; S0889-1591 (20) 30511-0. doi:10.1016/j.bbi.2020.04.028. [E Pub ahead of print]

PMID: 32298802

Background

Coronavirus disease 2019 (COVID-19) is a highly contagious disease that not only affects physical health but also results in mental health issues. Little is known about the stress, anxiety, and depression during this pandemic. This study was designed to assess the mental health challenges faced by the community.

Methods

This study surveyed the general population twice - during the initial outbreak, and the epidemic's peak four weeks later. The data gathered included demographics, symptoms, knowledge, concerns, and precautionary measures against COVID-19. There were 1738 respondents from 190 Chinese cities (1210 first-survey respondents, 861 second-survey respondents; 333 respondents participated in both). The psychological impact and mental health status were assessed by the Impact of Event Scale-Revised (IES-R) and the Depression, Anxiety, and Stress Scale (DASS-21), respectively. IES-R measures PTSD symptoms in survivorship after an event.

Results

This study found that there was a statistically significant longitudinal reduction in mean IES-R scores (from 32.98 to 30.76, p < 0.01) after 4 weeks. Nevertheless, the mean IES-R score of the first- and second-survey respondents were above the cut-off scores (>24) for PTSD symptoms, suggesting that the reduction in scores was not clinically significant. During the initial evaluation, moderate-to-severe stress, anxiety, and depression were noted in 8.1%, 28.8%, and 16.5%, respectively and there were no significant longitudinal changes in stress, anxiety, and depression levels (p > 0.05). Protective factors include a high level of confidence in doctors, perceived survival likelihood, and low risk of contracting COVID-19, satisfaction with health information, and personal precautionary measures.

Conclusions

There should be a focus on effective methods of disseminating accurate COVID-19 knowledge, teaching containment methods, ensuring the availability of essential services/commodities, and providing financial support.

Clinical Commentary

This is a unique study providing information about the mental health challenges a population faces during a pandemic in the 21st century. The data is gathered from 190 cities in China where the pandemic originated. The strengths include a large sample and the use of self-report rating scales. The authors call it a longitudinal study which I think is not because the data are gathered cross-sectionally at two-time points four weeks apart. Besides, there were 1738 total respondents of which 333 participated in both assessments. Hopefully, these same individuals are having ongoing follow-up and at 1 one-year time point, we could call it a longitudinal study.

The primary issues were stress, anxiety, and depression. Physical symptoms, poor self-ratings of health status, and a history of chronic illness are associated with increased stress, anxiety, and depression scores.

The PTSD symptoms though decreased in the second survey were still elevated and not statistically significantly better possibly due to the continuing pandemic and increased quarantine of the individuals.

Providing accurate information related to the disease helps build confidence in the public health and medical system and boosts morale.

Summary: During the COVID-19 pandemic the general population suffers from increased stress, depression, and anxiety. Screen for PTSD. It is important to disseminate accurate information on protective measures such as the use of masks in public places, and handwashing. It is important for the public to be educated about disease transmission and have confidence in the medical system. 

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Quarantine vs no quarantine: Chinese data on anxiety and depression

Lei L et al. Med Sci Moni, 2020;26:c94609. Doi:10.12659/MSM.924609. [E Pub ahead of print]

PMID: 32335579

Background

At the end of 2019, the COVID-19 outbreak began in Wuhan, Hubei, China, and spread rapidly to the whole country within 1 month. The pandemic caused significant stress amongst the public. This study aimed to assess the prevalence and associated factors of anxiety and depression among the public affected by quarantine and those unaffected.

Methods

The study included 1593 participants age 18 years and above. The sample was divided into affected (quarantine) and unaffected groups (no quarantine). The participants were grouped as 'affected group' and '-rating unaffected group' based on whether they or their families/colleagues/classmates/neighbors had been quarantined. Data was collected using the self-rating anxiety scale (SAS) and the self-rating depression scale (SDS).

Results

The prevalence of anxiety and depression in the affected group (quarantined) was (12.9%,22.4%) was significantly higher than the unaffected group (6.7%, 11.9%). Lower average household (quarantine) income, lower education level, having a higher self-evaluated level of knowledge, being more worried about being infected, having no psychological support, and lower self-perceived health conditions were significantly associated with higher scores on the SAS and SDS. 

Conclusions

The prevalence of anxiety and depression in the affected group was higher than in the unaffected group during the COVID-19 outbreak in southwestern China.

Clinical Commentary

This is a large study conducted online using Chinese social media We chat (social networking). It is interesting to note the study design had safeguards such as the same IP address could only be used once. Additionally, if less than two minutes was spent on the survey it was considered an invalid response. This study also used rating scales and was cross-sectional.

It is interesting to note that the resilience of individuals varies concerning getting through a pandemic. This includes psychological as well as economic resilience. Those individuals with a lower income level were more likely to have psychological problems as it is hard to survive economically.

The uncertainties created by the pandemic have also been a source of anxiety as the future becomes unclear.

It was clear that those in quarantine fared worse in terms of anxiety and depression compared with those not in quarantine.

There is a COPE wellness interactive app that can help with stress. It is available for free on the app store and the google play store.   

Summary: In my opinion, individuals undergoing quarantine should be screened for depression and anxiety using rating scales and treatment offered. Some approaches that may help include mindfulness-based stress reduction, acceptance commitment therapy, resiliency training, and crisis counseling.

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COVID-19 Outbreak: Mental health issues and social media exposure

Gao J et al. PLoS One, 2020 Apr 16;15(4):e02319242 doi:10.1371/journal,pone.0231924ecollection 2020.

PMID:32298385

Background

Individuals spent a lot of time on social media during the COVID-19 crisis. This study investigated the prevalence of mental health problems and examines their association with social media exposure.

Methods

This was a cross-sectional study that was conducted in Wuhan, China between Jan 31st to Feb 2nd, 2020 during the pandemic.    The participants were age 18 years and older and participated in this online survey to do a rapid assessment. Besides demographics and social media exposure (SME), depression was assessed by the Chinese version of the WHO-Five Well-Being Index (WHO-5), and anxiety was assessed by the Chinese version of generalized anxiety disorder scale (GAD-7). Multivariable logistic regressions were used to identify associations between social media exposure with mental health problems after controlling for covariates.

Results

The sample included 4872 participants. The prevalence of depression, anxiety, and a combination of depression and anxiety (CDA) was 48.3%, 22.6%, and 19.4% during the COVID-19 pandemic in Wuhan, China. More than 80% of participants reported frequently being exposed to social media. After controlling for covariates, frequent social media exposure (SME) was positively associated with high odds of anxiety (OR = 1.72) and CDA (OR = 1.91) compared with less SME.  There is a high prevalence of mental health problems, which are positively associated with increased SME.

Conclusions

These findings suggest that greater attention needs to be paid to mental health problems, especially depression and anxiety among the general population especially those with high SME during the pandemic.

Clinical Commentary

This is a “quick and dirty” study that has been conducted amid a pandemic using rating scales providing useful information. Please note the WHO-5 is a five-question survey of well -being but not specific for depression, unlike the GAD-7 which is specific for anxiety. They could have used one of the self-report depression questionnaires. The sample is large and there may be cultural nuances but the message is clear and food for thought.

The prevalence of anxiety and depression was higher in those with social media exposure in the context of having a higher prevalence in the population during the pandemic.

SME was also a necessary evil as important information is updated using the We Chat. This media is used by about 1 billion users monthly (CNBC) and became one of the world’s largest standalone apps in 2018. The minimum age to use is 13 years. This is a Chinese multi-purpose, messaging, social media, and mobile payment app developed by Tencent in 2011.

The 31-40 years age groups had the highest frequency of depression and this needs to be paid attention to by the mental health field.

Summary:  In my professional opinion, we should routinely ask all patients regarding SME. The phone provides that information. This is helpful not only towards assessing the causes of depression and anxiety but also sleeping problems. This is another avenue we should work on with our patients. They may need behavior modification concerning SME.

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Sanjay Gupta, MD
Clinical Professor of Psychiatry, SUNY Buffalo

GME Research Review is a monthly newsletter edited by Sanjay Gupta, MD, Clinical Professor of Psychiatry, SUNY Buffalo. Dr. Gupta selects, summarizes, and provides a clinical commentary on the latest published research in psychiatry. 

We are always carefully evaluating which research papers to discuss in GME Research Review. Have come across a research paper published in the last 6 months that you thought is clinically relevant? Do you want me to analyze it for you and for the benefit of others? Please email Dr. Gupta the citation at [email protected]