|Year : 2022 | Volume
| Issue : 1 | Page : 86-94
Mental health problems in health-care workers of tertiary level COVID-19 care centers in Central India
Sudhir Laludeo Mahajan1, Anantprakash Siddharthkumar Saraf2, Harshal Shriram Sathe3, Kshirod Kumar Mishra3, Sally John3, Ahmed Mushtaq Reshamvala3
1 Department of Psychiatry, Government Medical College, Nagpur, Maharashtra, India
2 Department of Psychiatry, BRLSABVM Government Medical College, Rajnandgaon, Chhattisgarh, India
3 Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Submission||08-Aug-2021|
|Date of Decision||28-Aug-2021|
|Date of Acceptance||05-Sep-2021|
|Date of Web Publication||29-Apr-2022|
Dr. Harshal Shriram Sathe
Department of Psychiatry, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The health-care workers (HCWs) who are overburdened during the COVID-19 pandemic are at increased risk of developing psychological disorders. Aim: The aim of this study was to assess the magnitude of psychological problems such as depression, anxiety, and fear of COVID-19 among the HCWs and to study their correlates. Material and Methods: The study is an online multicentric cross-sectional survey of mental health problems in the HCWs of three tertiary level COVID care centers in Central India. HCWs were assessed using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Scale-7 (GAD-7), and Fear of COVID-19 Scale. Results: Out of 467 HCWs assessed, 25.5% of the participants had depression (defined by PHQ-9 score of more than 5), whereas anxiety was present in 24.4% of the study subjects (defined by GAD-7 score of more than 5). Forty-six percent of the participants had medium-to-high levels of fear of COVID-19. Female gender, working in the nonclinical department, direct involvement in care of COVID-19 patients, perceived worsening of physical health status following the pandemic outbreak, and past history of psychiatric problem were the factors significantly associated with presence of depression as well as anxiety. Age of the participant had a positive correlation with fear of COVID-19 and a negative correlation with depression and anxiety levels. Conclusion: HCWs serving in COVID hospitals are vulnerable to develop mental health problems and appropriate screening measures and interventions should be designed so as to preserve mental health of this vital task force.
Keywords: Anxiety, COVID-19, depression, fear, health-care workers
|How to cite this article:|
Mahajan SL, Saraf AS, Sathe HS, Mishra KK, John S, Reshamvala AM. Mental health problems in health-care workers of tertiary level COVID-19 care centers in Central India. Ann Indian Psychiatry 2022;6:86-94
|How to cite this URL:|
Mahajan SL, Saraf AS, Sathe HS, Mishra KK, John S, Reshamvala AM. Mental health problems in health-care workers of tertiary level COVID-19 care centers in Central India. Ann Indian Psychiatry [serial online] 2022 [cited 2023 Mar 27];6:86-94. Available from: https://www.anip.co.in/text.asp?2022/6/1/86/344417
| Introduction|| |
The demand for services of health-care workers (HCWs) such as consultant, resident, and intern doctors and paramedical staff such as nurses and attendants has increased during the COVID-19 pandemic., The HCWs, especially in a low-to-middle-income country like India, have to face situational hardships such as heavy workload; dealing with ever-increasing number of infected cases as well as deaths; and lack of resources such as hospital beds, oxygen, medicine supplies, and personal protective equipment. These overburdened HCWs are at a relatively high risk of themselves being infected while treating ill patients. High likelihood of being infected invokes the fear of spreading the infection to friends and family members, which may force them to go into self-isolation, thereby depriving themselves from company of loved ones. This fear can be further aggravated by lack of adequate financial, social, or medical support. Exposure to the fake news rumors and hateful social media messages directed toward the health-care system further increases this anxiety. Working in these situations increases the risk of developing psychological problems among the HCWs.
Studies previously conducted in the other pandemics, such as the severe acute respiratory syndrome (SARS), Middle East respiratory syndrome, and the Ebola virus outbreak, showed development of significant levels of psychological distress and decline in the health-related quality of life among the frontline HCWs. In a survey on 1257 health workers in Taiwan during SARS outbreak, a surge of anxiety among the health workers was seen in early phase. Depression and avoidance prevailed in the repair phase of the pandemic when the outbreak had been controlled. A similar hospital-based cross-sectional survey was conducted across various hospitals in and outside Hubei province of China in January 2020. It was answered by 1257 participants where more than half of the participants had reported psychological distress and depression whereas nearly 45% of the participants reported anxiety.
Given these insights, it is vital to further assess the determinants of mental health problems in HCWs to develop a better understanding of the problem. Only a few studies have been conducted in India to assess the psychological disorders among HCWs dealing with COVID-19 patients, and none of them has been multicentric. Hence, this study aims to investigate the magnitude, severity, and correlates of depression, anxiety, and fear of COVID-19 among the HCWs in Central India.
| Material and Methods|| |
This was a multicentric cross-sectional study conducted across three centers in Central India. Two centers are in Maharashtra state, namely Government Medical College is in the city of Nagpur and Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram, is in Wardha district. The third center, also a government-run medical college, is located in the city of Rajnandgaon in the adjoining state of Chhattisgarh. The final approval for the study to be conducted in the present form was given by the Institutional Ethics Committee at Government Medical College and Hospital, Nagpur, on May 30, 2020. Google Forms (freely available Google software) was used to prepare the semi-structured pro forma for data collection. These forms were distributed among the HCWs through E-mail or WhatsApp in a convenient manner (convenient sampling technique). A total of 485 employees working in these institutes answered the form. After removing incomplete forms and duplicate entries, the data of 467 respondents were statistically analyzed.
The questionnaire for the study had four sections which opened in a specific sequence while filling the Google Forms. Once the respondent clicked the link for the form sent to him/her, the first page opened which displayed the study title, name, and E-mail address of the investigators at all the three centers. The informed consent, mentioning the purpose of the study and the declaration of confidentiality of the responses along with the participant's right to withdraw, was mentioned below. Further questions of the form would open only if the user ticked the box titled, “I consent to participate in the study.”
In the next section, the respondents filled up demographic data such as age, sex, educational and occupational status, marital status, and questions relating to socioeconomic status of family such as household income and number of total members in the family. Questions were asked about presence of concurrent physical and psychiatric comorbidities as well as substance use. Perceived health status was assessed using a single-item questionnaire which has been previously validated.
The next three sections comprised the validated scales which measured the levels of fear, depression, and anxiety, respectively, in the HCWs. The “Fear of COVID-19” Scale is a validated self-rated instrument developed after the COVID-19 outbreak and having robust psychometric properties (Cronbach's α: 0.82). The participants have to mark their choice on a 5-point Likert scale for seven questions enquiring about fear of COVID-19 disease. As there is no specific cutoff in the originally published instrument, the authors divided the total scale score into tertiles which represented mild (7–15), moderate (16–25), and severe (26–35) levels of fear for the purpose of statistical analysis. The Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Scale-7 (GAD-7) were used to assess depression and anxiety. Independent use of both these scales has been previously validated for the general population. The score of 5 or above was the cutoff to decide the presence of depression in PHQ-9 and anxiety in GAD-7 as per the published instruction.,,
The data were statistically analyzed using SPSS software version 23.0 (SPSS Inc., Chicago, IL, USA). The categorical variables are presented as number and percentage, and for the continuous variables, mean and standard deviation (SD) have been given. The PHQ-9 and GAD-7 scores have been analyzed as categorical variables (based on cutoff scores) as well as continuous variables (mean scores). Chi-square test was used for categorical variable analysis. KolmogorovSmirnov test was used to assess the normality of the distribution of the variables. Since quantitative variables in the study were found to be nonnormally distributed, MannWhitney U-test was used to compare the mean psychopathology scale scores between independent variables classified into two groups. Spearman rank-order correlation analysis was used to determine the correlations between independent continuous and ordinal variables such as age, education level, income, perceived worsening of health status, and means of psychopathology scale scores.
| Results|| |
In the current study, a total of 485 HCWs completed the questionnaire. After assessing the completeness of responses and removal of duplicate entries, the data of 467 respondents were statistically analyzed. Out of these 467 respondents, 315 (67.4%) were doctors (including consultants, resident doctors, and MBBS interns), 71 (15.2%) were nurses, and the remaining 81 (17.3%) subjects were a heterogeneous group comprising attendants, drivers, laboratory technicians, and clerical staff working in office. Two hundred and eighty-one (60.2%) of the total participants worked in Government Medical College, Nagpur; 80 (17.1%) worked in MGIMS, Sewagram; and 106 (22.7%) worked in Government Medical College, Rajnandgaon (Chhattisgarh state). The mean age of all the respondents of the study was 29.66 (SD: 9.528). A comparable number of males (n = 253, 54.2%) and females (n = 214, 45.8%) had participated in the study. Majority of them were unmarried (n = 321, 68.7%) and had educational qualification of graduate or above (n = 390, 83.5%). The workforce was spread over 20 different clinical and nonclinical hospital departments. Ninety-three (19.9%) respondents were involved in direct care of COVID-19 patients, whereas 318 (68%) expressed that they may have to serve the COVID-19 patients in future. Only a minority (n = 56, 12.1%) had been quarantined. Forty-four (9.4%) participants informed that they had known medical conditions such as diabetes and hypertension. A small number (n = 11, 2.4%) admitted that they currently have psychiatric problems, anxiety being the most common condition among them (n = 7). Seventy-three respondents used substances (alcohol and tobacco) and 17 among them admitted that they were habituated to substance use. When compared with prepandemic times, most of the participants perceived that their current physical health status remained unchanged (n = 356, 76.2%) after the coronavirus outbreak. However, a significant minority (n = 68, 14.6%) reported worsening of perceived physical health status and even smaller number (n = 43, 9.2%) perceived improvement in the same after the COVID-19 outbreak [Table 1].
|Table 1: Sociodemographic, work, and clinical characteristics of study population|
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Magnitude of depression, anxiety, and fear of COVID-19
25.5% of the participants had clinical depression (n = 119) (defined by PHQ-9 score of more than 5), whereas anxiety was present in 113 (24.4%) study subjects (defined by GAD-7 score of more than 5). As many as 11.7% (n = 55) of the participants admitted having passive death wishes or thoughts of hurting self. Most of the participants with clinical depression and anxiety reported mild severity of symptoms (17.3% in depression and 18% in anxiety). More than half of the respondents (n = 252, 54%) reported lower levels of fear, whereas 41.1% (n = 192) scored in the middle tertile of the Fear of COVID-19 Scale. Twenty-three (4.9%) participants had fear scores in the highest tertile [Table 2] and [Table 3].
|Table 2: Level of fear of COVID-19 and severity of depression and anxiety|
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|Table 3: Factors associated with depression and anxiety in health-care workers|
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Being unmarried (P = 0.004), working in nonclinical department, direct involvement in care of COVID-19 patients (P = 0.027), perceived worsening of physical health status following the pandemic outbreak (P < 0.001), and past history of psychiatric problem (P < 0.001) were the factors significantly associated with presence of depression. Gender, education, and designation at workplace did not vary with depression. Depression had a significant association with presence of anxiety (P < 0.001). Female gender (P = 0.046), direct involvement in COVID care (P = 0.022), presence of physical comorbidities (P = 0.018), worse perceived physical health status (P < 0.001), and past history of psychiatric illness (P < 0.001) were significantly associated with anxiety. Anxiety did not show any significant association with the marital status, education, or designation at workplace [Table 3]. Doctors were more likely to have depression as compared to the nurses (P = 0.018), but there was no significant difference in the likelihood of anxiety between these professions. The nurses admitted to have suicidal ideation more than the physicians (P = 0.043).
Factors associated with depression, anxiety, and fear of COVID-19
The mean scores (SD) on the PHQ-9 for depression, the GAD-7 for anxiety, and the Fear of COVID-19 Scale for all the respondents were 3.20 (±4.13), 2.76 (±3.57), and 15.42 (±5.28), respectively. PHQ-9 and GAD-7 scores were significantly higher in females as compared to males (P values were 0.047 and < 0.001, respectively). Unmarried individuals had a significantly higher score than the married people only for depression (P = 0.001). Direct involvement in COVID care was associated with significantly high scores on PHQ-9 (P = 0.005), GAD-7 (P = 0.018), and the Fear of COVID-19 Scale (P = 0.026). A strong association was found between past history of having mental illness and depression, anxiety as well as fear (P < 0.001 for all three domains). Presence of physical comorbidities affecting various body systems such as diabetes, hypertension, and asthma significantly increased the scores for depression (P = 0.017), anxiety (P = 0.014), and fear of COVID-19 (P = 0.042). Working in nonclinical department was associated with significantly higher PHQ-9 (P = 0.007) and GAD-7 (P = 0.011) scores as compared to those who worked in clinical departments. Compared to the nurses, the doctors showed higher mean scores for fear, depression as well as anxiety, however, only the scores for depression showed a significant difference between the two groups (P = 0.030) [Table 4].
Correlates of depression, anxiety, and fear of COVID-19
Spearman rank-order correlation analysis showed that age of the participant had a positive correlation with fear of COVID-19 (R = 0.168, P < 0.001) and a negative correlation with depression (R = −0.239, P < 0.001) and anxiety levels (R = −0.094, P < 0.001). Perceived worsening of health status had high likelihood to increase the mean score of PHQ-9 (R = 0.262, P < 0.001), GAD-7 (R = 0.251, P < 0.001) as well as fear (R = 0.236, P < 0.001). Higher scores on all the three scales had a strong positive correlation with each other (P < 0.001). No significant correlation was found between the psychopathology and education or income of the individual [Table 5].
| Discussion|| |
This cross-sectional survey assessed 467 HCWs working in three different tertiary level COVID-19 care centers in Central India. Approximately 25.5% and 24.2% of all the respondents screened positive for the problems of depression and anxiety, respectively, and 46% of the participants had medium-to-high levels of fear of COVID-19. Our findings matched with those of the study done in southern India which found depression in 28% and anxiety in 35% of the participants. These figures were far lower than the study conducted in Wuhan and Hubei provinces of China which reported the rates of depression and anxiety among HCWs to be approximately 50% and 44%, respectively. Similar proportions (depression 59% and anxiety 42%) were reported in quarantine and nonquarantine Egyptian hospitals' survey. Sociocultural differences between these geographically distinct populations, differences in psychopathology measuring tools, and data collection at a different stage of pandemic could account for these differences. The magnitude of depression and anxiety found in the HCWs in our study was nearly three times higher than the general population prevalence of these problems in India. Similar magnitude of problems among the Indian doctors was found by the researchers in studies conducted in the year 2018 (prepandemic times).,
Female gender, younger age, being in nonclinical specialties, past history of psychiatric illness, and presence of physical comorbidities were significantly associated with depression and anxiety. Being unmarried was a significant factor only for depression and not for anxiety disorder or fear of COVID-19. A higher level of psychopathology in females can be due to biological susceptibility, sociocultural factors such as gender discrimination, greater household responsibilities, and perinatal issues. Our finding of higher depression and anxiety in younger doctors matched with a research in South Indian faculty doctors wherein it was hypothesized that younger doctors are more likely to work on frontline as compared to senior consultants who predominantly handle advisory and administrative responsibilities. Marriage has been known to be protective against depression and loneliness makes an individual vulnerable to the psychiatric illnesses., These findings were echoed in our study where being unmarried was associated with depression. A previous research found higher neurotic problems in the clinical specialty doctors compared to nonclinical specialties. However, in the context of pandemic, shortage of HCWs propels the administration to post the nonclinical doctors in the service of the patients. Factors such as lack of experience or necessary clinical skills for patient care may lead to increased anxiety and despair in these doctors.
Fear is a characteristic emotional problem associated with outbreak of infectious diseases. It is directly associated with the ease and speed of transmission and mortality of the infectious disease. A previous study conducted on fear among HCWs during SARS outbreak in 2004 showed that more than half of the HCWs developed fear of being infected themselves or being the source of infection for the others. These findings were replicated in the present study where nearly 46% of the participants had medium-to-high levels of fear of COVID-19. The sources of fear may be concerns about spread of virus to the family and others, missing the diagnosis, being carriers, or concern over the adequate availability of resources such as personal protective equipment. These issues are faced mainly by the doctors or HCWs who come in direct contact with the infected patients. In accordance with these findings, our study found increased fear levels to be associated with direct involvement in care of COVID-19 patients. A study in Cuban general population during COVID-19 pandemic found increased vulnerability of fear in females. However, such vulnerability was not found in our study. One explanation could be the similarity of roles and responsibilities of males and females in the professional sphere. Similar findings were shared by Urooj et al. who did not mention any significant difference in vulnerability for fear between male and female doctors in their publication.
Quarantine has adverse psychological impacts such as posttraumatic stress symptoms and irritability. Duration of quarantine, fear of infection, boredom and frustration, financial losses, stigma, and misinformation are associated factors. In the current study, the participants previously quarantined showed higher levels of fear which may be due to the situational difficulties faced during the quarantine period. It is well known that the patients who have chronic illness have increased likelihood to contract psychological disorders. Similar findings were observed in our study where presence of chronic illnesses and worsening of self-perceived physical health status were significantly associated with the development of depression, anxiety disorder as well as higher levels of fear.
Self-rated questionnaires were used to assess the symptoms of depression and anxiety in a cross-sectional manner. However, a structured clinical interview was not conducted for diagnostic confirmation. The study was unable to distinguish between newly developed psychological disorders after pandemic outbreak against the preexisting mental illnesses. The study may be afflicted by response bias as the psychopathological status of nonrespondents is not known.
| Conclusion|| |
Our study highlights the fact that HCWs are vulnerable to develop psychiatric problems. Cognizance of the same needs to be taken by policymakers and appropriate interventions should be designed to preserve the mental health of this vital task force.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mehta S, Machado F, Kwizera A, Papazian L, Moss M, Azoulay É, et al.
COVID-19: A heavy toll on health-care workers. Lancet Respir Med 2021;9:226-8.
Kumar J, Katto MS, Siddiqui AA, Sahito B, Ahmed B, Jamil M, et al.
Predictive factors associated with fear faced by healthcare workers during COVID-19 pandemic: A questionnaire-based study. Cureus 2020;12:e9741.
Bong CL, Brasher C, Chikumba E, McDougall R, Mellin-Olsen J, Enright A. The COVID-19 pandemic: Effects on low- and middle-income countries. Anesth Analg 2020;131:86-92.
Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, et al.
Risk of COVID-19 among front-line health-care workers and the general community: A prospective cohort study. Lancet Public Health 2020;5:e475-83.
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.
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.
Khee KS, Lee LB, Chai OT, Loong CK, Ming CW, Kheng TH. The psychological impact of SARS on health care providers. Critical Care and Shock. 2004;7:100-6.
Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 2018;87:123-7.
Lehmann M, Bruenahl CA, Addo MM, Becker S, Schmiedel S, Lohse AW, et al.
Acute Ebola virus disease patient treatment and health-related quality of life in health care professionals: A controlled study. J Psychosom Res 2016;83:69-74.
Chong MY, Wang WC, Hsieh WC, Lee CY, Chiu NM, Yeh WC, et al.
Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. Br J Psychiatry 2004;185:127-33.
Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, et al.
Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun 2020;87:11-7.
Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The fear of COVID-19 scale: development and initial validation. Int J Ment Health Addict. 2020 Mar 27:1-9.
Beard C, Hsu KJ, Rifkin LS, Busch AB, Björgvinsson T. Validation of the PHQ-9 in a psychiatric sample. J Affect Disord 2016;193:267-73.
Beard C, Björgvinsson T. Beyond generalized anxiety disorder: Psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. J Anxiety Disord 2014;28:547-52.
Spitzer RL, Williams JB, Kroenke K. Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures; 2014. Available from: https://
. [Last accessed on 2018 Dec 14].
Gupta S, Kohli K, Padmakumari P, Dixit PK, Prasad AS, Chakravarthy BS, et al.
Psychological health among armed forces doctors during COVID-19 pandemic in India. Indian J Psychol Med 2020;42:374-8.
Youssef N, Mostafa A, Ezzat R, Yosef M, El Kassas M. Mental health status of health-care professionals working in quarantine and non-quarantine Egyptian hospitals during the COVID-19 pandemic. East Mediterr Health J 2020;26:1155-64.
Reddy VM, Chandrashekar CR. Prevalence of mental and behavioural disorders in India: A meta-analysis. Indian J Psychiatry 1998;40:149-57.
] [Full text]
Grover S, Sahoo S, Bhalla A, Avasthi A. Psychological problems and burnout among medical professionals of a tertiary care hospital of North India: A cross-sectional study. Indian J Psychiatry 2018;60:175-88.
] [Full text]
Dave S, Parikh M, Vankar G, Valipay SK. Depression, anxiety, and stress among resident doctors of a teaching hospital. Indian J Soc Psychiatry 2018;34:163. [Full text]
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.
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.
] [Full text]
Frech A, Williams K. Depression and the psychological benefits of entering marriage. J Health Soc Behav 2007;48:149-63.
Erzen E, Çikrikci Ö. The effect of loneliness on depression: A meta-analysis. Int J Soc Psychiatry 2018;64:427-35.
Saini NK, Agrawal S, Bhasin SK, Bhatia MS, Sharma AK. Prevalence of stress among resident doctors working in medical colleges of Delhi. Indian J Public Health 2010;54:219-23.
] [Full text]
Ho SM, Kwong-Lo RS, Mak CW, Wong JS. Fear of severe acute respiratory syndrome (SARS) among health care workers. J Consult Clin Psychol 2005;73:344-9.
Urooj U, Ansari A, Siraj A, Khan S, Tariq H. Expectations, fears and perceptions of doctors during COVID-19 pandemic. Pak J Med Sci 2020;36:S37-42.
Broche-Pérez Y, Fernández-Fleites Z, Jiménez-Puig E, Fernández-Castillo E, Rodríguez-Martin BC. Gender and fear of COVID-19 in a Cuban population sample. Int J Ment Health Addict. 2020 Jun 12:1-9.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al.
The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
Turner J, Kelly B. Emotional dimensions of chronic disease. West J Med 2000;172:124-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]