To the best of our knowledge, this was the first study that examined the prevalence, demographic and clinical factors associated with depression among ENT nurses during the COVID-19 pandemic. Some studies, however, examined the epidemiology of depression among health professionals in China. For example, a study found that in early stage of the COVID-19 outbreak (at the end of January 2020), 50.4% of frontline medical workers working in Wuhan and the surrounding areas of Hubei province reported depression as measured by the PHQ-9 with a cut-off value of 5 (Lai et al., 2020). Another similar study used the same cut off value in the PHQ-9 and found that the prevalence of depression among healthcare workers in Wuhan were 36.9% in early stage of the COVID-19 outbreak (between January 29 and February 4, 2020) (Kang et al., 2020). In contrast, the prevalence of depression among frontline medical healthcare workers was 12.2% as assessed by the PHQ-4 with a lower cut-off value of 3 at later stage of the COVID-19 outbreak (from February 19 to March 6, 2020) (Zhang et al., 2020). Our findings emerging from this study (33.75%; 95% CI: 31.59%-35.97%) were similar to some (Kang et al., 2020), but not all studies (Lai et al., 2020, Zhang et al., 2020). Due to the use of different measurement tools on depression, direct comparisons between these studies should be interpreted with caution.
In ENT unit, some asymptomatic and pre-symptomatic patients with COVID-19 may seek help for anosmia (i.e., loss of sense of smell) which was a common infection symptom (Hopkins et al., 2020). In addition, auxiliary examinations of the nasal passages and upper airway, intubation and administration of respiratory treatment may induce cough, nausea, sneezing or vomiting (Lu et al., 2020). The nasal pillow masks for patients with obstructive sleep-apnea may cause airborne virus transmission due to loose sealing (Tran et al., 2012). For instance, in the 2003 SARS outbreak clusters of nosocomial infections were observed among healthcare workers during airway manipulation (JAMA, 2003). All these factors could increase the likelihood of COVID-19 infection for ENT nurses, and subsequently lead to common mental health problems, such as depression.
Similar with previous findings (Lai et al., 2020), frontline ENT nurses who provided direct patient care for COVID-19 patients were more likely to have depression. During the COVID-19 outbreak ENT nurses needed to do the shift duty and usually worked longer hours than usual, which may lead to job dissatisfaction, and high level of perceived stress. In addition, all health professionals must have at least two weeks quarantine after they finished providing care to COVID-19 patients, which may put them in anxiety state and guilty feelings due to social stigma on their families. All these factors could substantially increase the risk of depression. Previous studies found that smoking was associated with higher risk of physical diseases and mental problems (e.g., depression) (Chang et al., 2020, Fluharty et al., 2017, Mathew et al., 2017). We found that depressed ENT healthcare workers were more likely to smoke, which echoed previous findings (Nilan et al., 2019, Schneider et al., 2019)
According to the distress/protection QOL model (Voruganti et al., 1998), QOL was closely associated with the interaction between protective (e.g., high self-esteem and good social support) and distressing factors (e.g., physical and mental distress). We found that ENT nurses with depression had a lower QOL compared to the those without, which is consistent with previous findings (Benedek et al., 2007, Mammen and Faulkner, 2013). This could be explained by the negative health outcomes of depression, such as impaired psychosocial functioning, and somatic symptoms (e.g., fatigue, loss of appetite or weight, and insomnia) (Malhi and Mann, 2018, Rakofsky et al., 2013, Parisi et al., 2014).
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.