Prevalence of Depression and its Impact on Quality of Life among Frontline Otorhinolaryngology Nurses During the COVID-19 Pandemic in China: A National Survey

Objective: Exposure to the coronavirus disease 2019 (COVID-19) was associated with high risk of mental health problems among frontline nurses. This study examined the prevalence of depressive symptoms (depression hereafter) and its impact on quality of life (QOL) among otorhinolaryngology (ENT) nurses during the COVID-19 pandemic in China. Methods: A national online study was conducted between March 15 and March 20, 2020. Depression and QOL were assessed using standardized instruments. Results: A total of 1,757 participants were recruited. The prevalence of depression was 33.75% (95% CI: 31.59%-35.97%). Results emerging from multiple logistic regression analysis showed that direct care of COVID-19 patients (OR: 1.440, 95% CI: 1.031–2.012, P= 0.032), and current smoker (OR: 3.143, 95% CI: 1.020–9.690, P = 0.046) were signicantly associated with depression. After controlling for covariates, ENT nurses with depression had a lower overall QOL compared to those without (F (1, 1757) =536.80, P<0.001). Conclusions: Depression was common among ENT nurses during the COVID-19 pandemic in China. Considering the negative impact of depression on QOL and care quality, regular screening for depression should be conducted among ENT nurses and timely treatments should be provided for those in need.


Introduction
The novel coronavirus disease (COVID- 19) was initially emerged in Wuhan, China at the end of 2019. Since then, the disease has been transmitted to more than 200 countries, and COVID-19 has been declared a global public health emergency (World Health Organization, 2020). The reproduction number of COVID-19 ranges . In order to reduce the risk of depression and develop appropriate preventive measures, it is important to understand the epidemiology of depression. In addition, as a comprehensive health outcome, quality of life (QOL) has been gaining attention in the past decades. To date, there seemed to have no studies examining the epidemiology of depression and its impact on QOL in ENT healthcare workers. Therefore, this study was set out to examine the prevalence of depressive symptoms (depression hereafter) and its association with QOL among frontline ENT nurses in China during the COVID-19 pandemic. 3) able to understand the assessment content and provide written informed consent. The research protocol was approved by the Institutional Review Board of the University of Macau.

Instruments
Basic socio-demographic and clinical variables, such as gender, age, marital status, educational level, years of working experience, living circumstances, rank (junior or senior), hospital setting (primary or tertiary), shift duty requirement, unit nature (inpatient or outpatient department), smoking status, and experience of ghting the SARS outbreak on 2003, were collected. Three additional standardized questions were also asked using dichotomous response (yes/no): 1) whether the participant was directly engaged in clinical services for COVID-19 patients; 2) whether they had friends, colleagues, or family members infected with COVID-19; and lastly 3) the number of COVID-19 con rmed cases in the province they lived in.
The self-report Chinese version of the Patient Health Questionnaire-9 (PHQ-9) was used to measure the severity of depression. The PHQ-9 had been validated in the Chinese population with a sensitivity of 0.89 and a speci city of 0.77 (Chen, 2015). Each item scored from 0 to 3, with the total score of ≥ 5 indicating "having depression" (Wittkampf et al., 2007). The total score of "5-9", "10-14", "15-19", and "20-27" indicated "mild depression", "moderate depression", "moderate-to-severe depression", and "severe depression", respectively Data were analyzed with the IBM Statistical Package for Social Science (SPSS) software version 24.0. Normality of the data was assessed using the Kolmogorov-Smirnov test. Comparison between depression and no depression groups, in terms of demographic and clinical characteristics, were conducted by Chisquare tests, two samples independent sample t-tests and Mann-Whitney U test, as appropriate. QOL was compared between the two groups using analysis of covariance (ANCOVA) after controlling the potentially confounding effects of variables with signi cant group difference in univariate analyses. The independent demographic and clinical correlates of depression were examined using multiple logistic regression analysis with the "Enter" method with depression as the dependent variable. All variables with a P-value of less than 0.1 in univariate analyses were entered as independent variables. A P-value of less than 0.05 was considered statistically signi cant (two-tailed).

Results
A total of 1,757 frontline ENT nurses participated in this study. The overall prevalence of depression was 33.75% (95% CI: 31.59%-35.97%). Among the healthcare workers with probable depression (N = 593), 421 (24.0%) reported mild depression, 116 (6.6%) moderate depression, 42 (2.4%) moderate-to-severe depression, and 14 (0.8%) severe depression. The mean total score of the PHQ-9 scale was 3.73 (± 4.43) in the whole sample. Table 1 shows the demographic and clinical characteristics of the whole sample separated by depression. Univariate analyses revealed that direct care with con rmed COVID patients (P = 0.025), current smoking behaviors (P = 0.033), and years of working experience (P = 0.020) were signi cantly associated with depression. After controlling for covariates, nurses with depression were more likely to have overall lower QOL than those without (F (1, 1757) = 536.80, P < 0.001). Multiple logistic regression analysis revealed that direct care of COVID-19 patients (OR = 1.440, P = 0.032) and current smoking status (OR = 3.143, P = 0.046) were independently associated with higher risk of depression (Table 2).

Discussion
To the best of our knowledge, this was the rst study that examined the prevalence, demographic and clinical  The strengths of this study include the large sample size and the use of standardized instruments.
Nevertheless, several limitations should be addressed. First, the use of cross-sectional survey indicated that the causality of demographic and clinical variables and depression could not be established. Second, data were collected by online self-report survey, therefore, participants might misunderstand some of the questions being asked. Third, due to logistical reasons, some factors related to depression in ENT nurses, such as lifestyles, perceived family support, and sleep-related variables were not obtained.

Conclusions
In conclusion, depression was common among ENT nurses during the COVID-19 pandemic in China.
Considering the negative impact of depression on QOL and care quality, regular screening for depression should be conducted for ENT nurses and timely treatments should be provided for those in need.

Consent for publication
Not applicable.

Ethical Approval and Consent to participate
This study was approved by the Institutional Review Board of the University of Macau (BSERE20-APP002-FHS) and all participating hospitals. All the study procedures were carried out in accordance with relevant guidelines. All participants provide informed consent in the study.