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 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 155-163

The silent toll of second COVID-19 wave: A dass-21 questionnaire survey among health-care workers at a Tertiary-Care Public Hospital, Mumbai

1 Department of Dentistry, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
2 Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India

Date of Submission10-Apr-2022
Date of Decision16-Apr-2022
Date of Acceptance06-May-2022
Date of Web Publication19-Aug-2022

Correspondence Address:
Dr. Heena Merchant
Department of Psychiatry, OPD-21, OPD Building, Lokmanya Tilak Municipal Medical College and General Hospital, Sion West, Mumbai - 400 022, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_61_22

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Background: The uncontrolled spread of the COVID-19 disease in India's second wave post-February 2021, put to task the public health system across the nation. This, in turn, exhausted our health-care workforce both physically and mentally. To establish the prevalence of psychological symptoms and guide the action plan in place, the present study was undertaken among COVID-19 health-care workers (HCWs) at tertiary-care public hospital, Mumbai. Materials and Methods: The present cross-sectional study was conducted after due institutional ethical clearance among 212 HCWs engaged in the management of COVID-19 patients during the second wave. A Google Form® was created in English, Hindi, and Marathi languages for self-administration. Data were collected under three domains; informed consent, sociodemographic and workplace-related details, and DASS-21 Questionnaire scores. This was further subjected to statistical analysis using SPSS® software. Results: This study included 90 (42.5%) doctors, 91 (42.9%) nurses, and 31 (14.6%) other categories of HCWs. Depression was prevalent in 44.3% HCWs, while 43.9% and 36.3% of the HCWs were affected by anxiety and stress, respectively. Younger population, female gender, and doctors were associated (P < 0.05) with an increased likelihood of either of the prevalent psychological symptoms. Other significantly associated (P < 0.05) factors included COVID-19 vaccination status of the HCW, history of COVID-19 infection, infected colleague at workplace, workplace housing facilities and commute, number of dependents on the HCW and hospitalized family member or close friend. Conclusion: The COVID-19 HCWs were found to be under considerable psychological strain. In essence, screening, identifying, and effectively targeting HCWs for psychological interventions is needed to protect and strengthen the health-care system.

Keywords: Anxiety, COVID-19, depression, health-care workers, stress

How to cite this article:
Khan F, Dewalwar V, Roy P, Merchant H, Das S, Desousa A. The silent toll of second COVID-19 wave: A dass-21 questionnaire survey among health-care workers at a Tertiary-Care Public Hospital, Mumbai. Ann Indian Psychiatry 2022;6:155-63

How to cite this URL:
Khan F, Dewalwar V, Roy P, Merchant H, Das S, Desousa A. The silent toll of second COVID-19 wave: A dass-21 questionnaire survey among health-care workers at a Tertiary-Care Public Hospital, Mumbai. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Dec 8];6:155-63. Available from: https://www.anip.co.in/text.asp?2022/6/2/155/354121

  Introduction Top

Like other regions worldwide, India was hit hard by the second wave, which led to a massive surge of COVID-19 cases and deaths. As of 4:57 pm Central European Time (CET), December 3, 2021, India is the second-leading country based on the number of cases identified, only behind the United States.[1] Beginning around mid-March 2021, the second wave of cases had begun, and on May 07, as per the Union health ministry data, the highest daily rise in cases (4, 14, 188) was identified in the nation.[2] Till December 3, 2021, this was counted as one of the highest recorded increases in COVID infections in a single day globally.[3]

This unprecedented resurgence of COVID-19 infections in the country put a huge strain on the national health-care system.[4] As quoted by Remuzzi and Remuzzi, in communities where the numbers of infected hugely increased, the health-care systems became considerably stretched with health-care workers (HCWs) going under tremendous stress.[5] The health workforce is indeed facing serious harms to their physical and mental well-being while trying to deliver quality care during this pandemic.[6] Literature following the recovery from the 2003 SARS outbreak suggests a high prevalence of mental health problems among HCWs (such as burnout, insomnia, anxiety, depression, and so on). Various biopsychosocial factors had a considerable role to play in this post-pandemic occupational health hazard.[7]

In the context of the second COVID-19 wave; the unrelenting influx of patients, the mounting deaths, the endless hours of work, the helplessness at the lack of resources, the fears of contracting COVID-19 or infecting their families – everything have added fuel to the already budding mental health crisis in the health-care sector.[8] Mental health issues among HCWs are believed to impact competency, motivation and further increase the risk of emotional exhaustion, hindering their healthcare response to COVID-19.[9] As studied by Angres et al. (2003) and Kalmoe et al. (2019); HCWs, compared to most other professions, have comparably higher rates of psychiatric comorbidity, substance use, and suicidality.[10],[11]

The UN policy brief in their COVID-19 and the need for action on mental health, 2020, recommends that investments now will reduce the mental health effects later.[12] With the discovery of Omicron, the SARS-CoV-2 variant spreading around the world, the most severely altered version to emerge so far, with alterations comparable to those identified in earlier variants of concern associated with increased transmissibility and partial resistance to vaccine-induced immunity, there remains a disparity on upcoming strains as COVID is not over yet.[13] In these lines, it becomes imperative to study the impact of the 2nd COVID-19 wave on the mental health of our COVID warriors and provide them with the best possible support for drawing out of the impact the second wave had on their mental health and enabling them to face upcoming challenges headstrong in the way ahead.

  Materials and Methods Top

Aims and objectives

The aim of the present study is to evaluate the impact of the 2nd COVID-19 wave on the mental health of HCWs at a tertiary-care public hospital, taking into account the following objectives:

  1. To assess the prevalence of depression, anxiety, and stress among various categories of HCWs
  2. To examine whether the nature of occupation and sociodemographic characteristics considered in the study correspond with the prevalence of depression, anxiety, and stress.

Study design and description

The present cross-sectional single centric study was conducted in the Municipal Corporation of Greater Mumbai's Lokmanya Tilak Municipal Medical College and General Hospital. Convenient sampling was done, and the study participants were recruited as per the inclusion and exclusion criteria below.

Inclusion criteria

  • Age of 18–65 years
  • Various categories of HCWs; doctors, nurses, and others (paramedics, ancillary staff, and administrative staff) are actively engaged in the management of COVID-19 patients.

Exclusion criteria

  • Participants who did not wish to be a part of the study did not give consent
  • Participants were not able to comprehend the language or the questionnaire.

Data collection

After identifying the eligible participants as per the recruitment criteria, participants were approached for volunteering in the study. A self-administered questionnaire in the format of Google Form® link was used. The link was shared via social media platforms for self-reporting the survey. There were three sections in the questionnaire. Section-I was the informed consent. Brief personal sociodemographic details and questions based on previous Covid infection and COVID vaccination were asked in Section II. The DASS-21 questionnaire (by the University of New South Wales) is made up Section-III.[14] The original questionnaire was created in English and later translated and back-translated in local languages-Hindi and Marathi. It was kept to the study participants to choose and respond to the questionnaire in their language of choice.

Data analysis

All data were entered into a computer by giving coding system, and proofed for entry errors.

  • Data obtained was compiled on an MS Office Excel Sheet (v 2019, Microsoft Redmond Campus, Redmond, Washington, United States)
  • Data were subjected to statistical analysis using the Statistical Package for Social Sciences (SPSS v 26.0, IBM)
  • Descriptive statistics such as frequencies and percentages for categorical data, Mean and SD for numerical data have been depicted.
  • Inter-group comparison (two groups) was made using the Chi-square test of association.

For all the statistical tests, P < 0.05 was considered statistically significant, keeping α error at 5% and β error at 20%, thus giving a power to the study as 80%.

* = statistically significant difference (P < 0.05).

** = statistically highly significant difference (P < 0.01).

# = nonsignificant difference (P > 0.05) for all tables.

Ethical considerations

All procedures performed in the study involving human participants were in accordance with the ethical standards of the Institutional ethics committee Human Research, The Staff and Research Society (IEC/56/21) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

  Results Top

The present study included 212 HCWs who were involved in management of COVID-19 patients during the country's second wave of infection. Of these, 90 (42.5%) were doctors, 91 (42.9%) were nurses and 31 (14.6%) were from other categories of HCWs. A majority (74.1%) of them were between 20 and 33 years of age and females (68.9%). More than half of them were unmarried (60.8%) and about 126 (59.4%) had 1–3 family members dependent on them. Around half (49.1%) of the HCWs traveled to and fro daily between home and hospital, while the other half (50.9%) stayed in the hospital campus. More than half of them declared their monthly family income to be below INR 50,000. 161 (75.9%) of them had taken their first dose of the COVID-19 vaccine before the start of second wave. About 29.7% HCWs had been infected with SARS CoV-2 in the past till the end of second wave. Family members or close aides of 25.9% HCWs were hospitalized during the second wave, while 133 (62.7%) of them reported that their colleague at the workplace was infected in the second wave. Furthermore, only 45 (21.2%) HCWs were medically insured for COVID-19 disease [Table 1].
Table 1: Sociodemographic and workplace-related characteristics of HCWs engaged in the management of COVID-19 patients during the second wave

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As shown in [Table 2], up to 44% of HCWs had depression and anxiety. Of the 94 HCWs affected by depression, 43.6% were mild, 36.2% moderate, and 20.2% were severe to extremely severe; and of the 93 HCWs affected by anxiety, 49.5% were mild, 25.8% moderate and 24.7% were severe to extremely severe. More than a third (36%) of HCWs had stress, of which 41.6% had mild form, 37.7% moderate, and 20.7% had severe to extremely severe stress.
Table 2: Prevalence of depression, stress, and anxiety among HCWs engaged in the management of COVID-19 patients during the second wave

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The study population follows Gaussian curve indicating normal distribution, constituted mainly by the younger generation, females and doctors. In the study, several personal and work-related factors were associated with depression, anxiety, and stress. [Table 3] shows a highly significant association between younger age and prevalence of severe to extremely severe stress (P = 0.002), between doctors and severe to extremely severe stress (P < 0.001), between low-income groups and severe to extremely severe stress (P < 0.001), and between prevalence of overall stress in the event of colleague infected at workplace (P < 0.001). Further, a statistically significant association in the prevalence of stress was seen among females (P = 0.029), those traveling to and from home (P = 0.047), those who had completed their first COVID-19 vaccine dose before wave (P = 0.033) and HCWs, family or close friend of whom was hospitalized in the second wave (P = 0.017).
Table 3: Chi square tests of the associations with the prevalence of stress among HCWs engaged in the management of COVID-19 patients during the second wave

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[Table 4] shows a statistically significant association between the overall prevalence of anxiety and the female gender (P = 0.026). Furthermore, those not infected with COVID-19 were more anxious (P = 0.046). Further, severe to extremely severe anxiety was seen among the HCWs whose family member was hospitalized in the second wave (P = 0.019). Having a colleague infected at the workplace was strongly associated with anxiety (P < 0.001). [Table 5] shows a statistically significant association in prevalence of severe to extremely severe depression among the younger age group 20–33 years (P = 0.014), and among the doctors (P = 0.021). Further, depression is seen to be associated with HCWs having 1–3 dependents to look after (P = 0.038), and among those done with their first dose of COVID-19 vaccine (P = 0.026). Highly significant association was seen between prevalence of overall anxiety and overall depression and the HCWs with their colleague infected (P < 0.001) [Table 4] and [Table 5].
Table 4: Chi-square tests of the associations with the prevalence of anxiety among HCWs engaged in the management of COVID-19 patients during the second wave

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Table 5: Chi-square tests of the associations with the prevalence of depression among health-care workers engaged in the management of COVID-19 patients during the second wave

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  Discussion Top

Based on an early study conducted in 2020 by Cheng et al. HCWs exposed to high physical and mental health burdens were at a higher risk of developing psychological disorders.[15] In the same vein, the deadly second wave exhausted our health-care system at a time when we were already short of health-care personnel.[16] Thus, the present study was conducted to assess the toll of the second COVID-19 wave on the mental health of the COVID-19 HCWs, as the prevalence of anxiety and depression of frontline HCWs was much higher than non-frontline HCWs in the meta-analysis conducted by Ping et al. in 2021.

This study indicated that, following the second COVID-19 wave in the country, out of the 212 study participants, 44.3% HCWs had depression (79.8% of that was mild to moderate and 20.2% was severe to extremely severe), 43.9% had anxiety (75.3% of that was mild to moderate and 24.7% was severe to extremely severe) and 36.3% experienced stress (75.3% of that was mild to moderate and 24.7% was severe to extremely severe) [Table 2]. This roughly corresponds to the cross-sectional study conducted by Chatterjee et al.(2020) on doctors in India, wherein out of 152 study participants, 34.9% were depressed and 39.5% and 32.9% had anxiety and stress, respectively.[17] The higher prevalence in our study can be attributed to the virulent delta strain circulating in the country, causing 400,000+ daily cases and thousands of deaths coupled with overwhelmed hospitals, critical oxygen supplies, and the struggle to immunize the largest democracy in the world.[18]

In line with the study findings, the results of a systemic review and meta-analysis of 47 studies conducted in 2021 indicated that a large proportion of HCWs suffered from the adverse psychological impact of COVID-19. The study analyzed anxiety and depression as indicators of psychological effects in HCWs with respective values of 37% (31%–42%), 36% (31%–41%).[19] In a similar systematic review with meta-analysis involving literatures published in any language from November 1, 2019 to September 20, 2020, in electronic databases of PUBMED, EMBASE, and WEB OF SCIENCE, the pooled prevalence of anxiety was 37% from 44 studies and the pooled prevalence of depression estimated in 39 studies was 36%.[20] Furthermore, in the findings of Dutta et al., the estimated overall prevalence among HCWs were; depression at 32.4%, anxiety at 32.5%, and stress at 37.7%.[21] Likewise, in another systematic review conducted by Santabarbara et al., it was suggested that HCWs were experiencing significant levels of anxiety during the COVID-19 pandemic. The pooled prevalence of anxiety in HCWs was found out to be 43% in frontline HCWs.[22] The pooled prevalence of depression in HCWs was 43% in the systematic review and meta-analysis done by Olaya et al. in 2021.[23] This accurately corresponds to the present study findings.

The proportion of the “mild” group in the study conducted by Ping et al. was higher than that of the “moderate-severe” group in line with the prevalence of anxiety in the present study, where mild anxiety was prevalent in 49.5% of the affected and moderate-to-severe anxiety was seen in 37.6% In contrast to this, the proportion of the “mild” group for depression in the present study is marginally lower than that of the “moderate-severe.” In elaboration, mild depression was found to be prevalent in 43.6% of the affected while moderate-to-severe depression was seen in 51.1%.[19] The present study adds to the stress category not considered in the study of Ping et al.; wherein mild stress was found to be prevalent in 41.6% of the affected, while moderate–to-severe stress was seen in 53.3%. Further, a relatively higher prevalence was seen in Elbay et al.'s study, which reported that 64.7% had symptoms of depression, 51.6% anxiety, and 41.2% stress.[24] The marginally lower prevalence in our study can be loosely attributed to the mental health initiatives in place post the first COVID-19 wave. In contrast, a 2020 study conducted by Tan et al. in Singapore reported a significantly lower prevalence of depression, anxiety, and stress at 8.1%, 10.8%, and 6.4%, respectively. These low rates of psychological distress could be attributed to improved mental health preparedness and rigorous infection control measures in Singapore in the wake of the SARS outbreak epidemic.[25]

Further, the present study showed a gender gap of psychological disturbances with a higher prevalence of anxiety and stress among women than men. In agreement, the Ping et al.'s study showed that the incidence of anxiety was significantly increased in females, as seen in this study.[19] In addition, the subgroup analysis in Silva et al.'s study showed a higher incidence of anxiety and depression among women and doctors compared to men and other HCWs, respectively, in line with the study.[20] Elbay et al. conforms with our association between the female gender and the high prevalence of anxiety and stress.[24] Study in India conducted by Suryavanshi et al. concluded that the association between depression and gender was not statistically significant, which holds true in our study. However, the same study negates a statistically significant association between HCW role and prevalence of depression and stress, which is in contrast to the present study, wherein we found depression and stress to be more profound among doctors than other HCWs.[26]

Younger age was a major significant predictive factor in the Chatterjee et al.'s study. This aligns with our study wherein the younger age group is associated with symptoms of depression and stress. The less years of expertise, lack of knowledge, changing job demands, unfamiliar tasks, changing working conditions and work overload leads to such findings in the younger age group.[17] Further abiding to this finding, being young was found to be significantly associated with depression and stress findings at Elbay et al.'s study.[24]

Cheng et al.'s study showed that the COVID-19 HCWs did not want their families and friends worry about them and were afraid of bringing the virus to their home. This coincides with the highly significant association between the colleagues infected at workplace and the prevalence of depression, anxiety, and depression among the HCWs.[15] Given that the delta variant dominantly circulating in the second wave caused more severe form of disease and the overwhelmed hospitals, statistically significant profound prevalence of depression, anxiety and stress was found among HCWs in the event of their family member or close aide hospitalized.[18] In addition, fear of infection and concern about family were brought up as one of the main stress factors in a study by Cai et al.[27] Frontline health-care professionals treating patients with COVID-19 are likely to be exposed to the highest risk to be infected because of their close, frequent contact with patients and longer hours than usual. In addition, these people are exposed to emotionally challenging interactions with the sick and critically ill patients, and they tend to pay more attention to their own and their families' health.[28] Consequently, the HCWs who were not infected since the start of the pandemic were more anxious during the second wave. On the same lines, HCWs catering to 1–3 dependents, were found to be depressed. This finding is in contrast to the Elbay et al. study, wherein having a dependent was associated with lower scores in each subscale, including depression.[24]

Furthermore, in contrast with the findings of Elbay et al.'s study, there was no statistically significant association in our study between the marital status of the HCW and the depression, stress, and anxiety; whereas being single was significantly associated with higher levels of stress and depression in the former study. Support from the hospital, government, and community was identified as a protective theme in De Kock et al. rapid review.[29] As a result, HCWs traveling every day to and from home due to a lack of on-campus accommodation were considerably found stressed in our study. Among the relatively low-income group, COVID-19 had a significantly greater negative impact on stress and discord in the family.[30] In the present study, HCWs in the low-income group were strongly associated with stress findings compared to those in the high-income groups. It was found that the person experienced lower stress levels after being vaccinated with the first dose of the COVID vaccine.[31] Thus, the HCWs vaccinated with their first dose before the start of the second COVID wave were less prone to being stressed and depressed as compared to their unvaccinated counterparts. The health insurance industry contributed and waived patient cost-sharing requirements for COVID-19 treatment for most privately insured people.[32] However as the study was done in the public hospital, whether the HCWs had a medical insurance or not, did not affect the prevalence of stress, anxiety, and depression in our study, for the municipal body covers their health costs.

This is the first study which considers variables like Vaccination status and mode of commute to workplace, having practical implications. Nevertheless, there are some limitations that should be addressed. Because the cross-sectional study had limitations in distinguishing pre-existing from new symptoms, and studying whether HCW psychological symptoms have been worsening or not, a longitudinal study is needed. In addition, because of the lockdown, the only way to access HCWs was via the online survey. As a result, nonrespondent bias may undermine the generalizability of the study, as their characteristics will differ from those of the respondents.[33] Due to this bias, we did not ask respondents to reveal their identities or include sensitive questions. Moreover, the proportion of HCWs other than physicians and nurses needed to be merged into one group to achieve statistical power, even though some professions, such as paramedics and radiology technicians, might be more vulnerable than pharmacists.

  Conclusion Top

Our findings suggest that sociodemographic and personal factors in the workplace play a key role as risk factors and protective factors for mental health outcomes in this pandemic. We recommend that a holistic approach to HCWs psychological well-being is made that includes personalized interventions alongside necessary structural changes to create a healthy, safe and supportive work environment. We call for collaborative efforts between the scientific community and the policymakers to build burnout prevention programs and resources in the wake of this pandemic and better prepare us for the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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