Status of and Factors Influencing the Anxiety and Depression of Front-line Medical Staff Supporting Wuhan in Containing COVID-19

Background: The novel coronavirus pneumonia (NCP) has the novel coronavirus as its pathogen. At present, more than 30,000 medics from nationwide medical teams have supported Wuhan. However, some medical workers have been seriously infected in Wuhan and other parts of Hubei Province, with over 3,000 medical staff having been confirmed of infection. Therefore, it is necessary to analysis the emotional status of front-line medical staff and their influencing factors in dealing with the NCP so as to provide an objective basis for prevention and intervention measures. Methods: This research aimed to shed light on the relation between the personality characteristics of front-line medical workers and their anxiety and depression, to provide the basis and reference for targeted mental health education and for relevant departments to formulate relevant policies. This study adopted a convenient sampling method and examined the psychological status of 150 front-line medical workers from Zhejiang Province with questionnaire surveys using the Hamilton Anxiety and Depression Scale. Results: The participants had severe anxiety and depression; the top three items under the category of anxiety were genitourinary symptoms, behavior at interview, and respiratory symptoms, whereas the top three items under depression were feelings of guilt, weight loss, and retardation. Among all personal data, the following factors influenced anxiety, in decreasing order: degree of suspicion of being infected when showing associated symptoms, degree of fear of yourself and your family being infected, and the affiliated hospital (P <0.05). The first two factors similarly influenced depression (P <0.05). Conclusion: The front-line medical staff were found to have serious anxiety and depression when dealing with the outbreak of the novel coronavirus pneumonia, and have enormous psychological stress in the face of the growing number of confirmed cases and current absence of special treatment. Targeted mental health promotion work must be carried out to alleviate the psychological pressure of front-line medical staff and enhance their physical and mental health so that they can better contribute to the efforts against the current epidemic. and intervention measures.

The novel coronavirus pneumonia (NCP) has the novel coronavirus as its pathogen. On January 12, 2020, WHO officially named the disease as the 2019 coronavirus disease . The first case of COVID-19 was found in Wuhan on December 12, 2019 [1][2] . Although COVID-19 shares some similarities with SARS-CoV and MERS-CoV, the rapidly increasing number of cases and evidence of more human-to-human transmission have shown that COVID-19 is more contagious than the other two, and that it is a new strain of coronavirus that had never been found in human beings [3][4] .
The common signs of the NCP infections include fever, cough, shortness of breath, and breathing difficulties. In more severe cases, pneumonia, severe acute respiratory failure, renal failure, and even death can occur [5] . There is currently no special treatment for NCP. The main therapy includes symptomatic treatment and prevention of complications, with auxiliary care for infected people also being very effective. The incidence of confirmed cases has increased rapidly within a short period of time, with confirmed cases exceeding 80,000 and deaths reaching 2,912 by March 1, 2020 [6] , plus secondary infections, all of which have placed a huge burden and pressure on local prevention and treatment.
At present, more than 30,000 medics from nationwide medical teams have supported Wuhan [6] , which has eased the pressure on local rescue work for treating critically ill patients with NCP.
However, some medical workers have been seriously infected in Wuhan and other parts of Hubei Province, with over 3,000 medical staff having been confirmed of infection [7] , which has greatly intensified the psychological stress of the front-line medics. Facing such catastrophic emergency as NCP and influenced by various subjective and objective factors, the front-line medical staff can manifest some psychological disorders, as a form of stress response, which is an explanatory, emotional, and defensive response process within the human body, as well as also a physiological response of the human body to its needs or potential harm. Therefore, this study analyzes the emotional status of anxiety and depression of front-line medical staff and their influencing factors in dealing with the NCP so as to provide an objective basis for prevention and intervention measures.

Study design
This study used convenient sampling to collect information from 150 front-line medics from hospitals in Zhejiang Province between February 1 and 20, 2020. The inclusion criteria were as follows: 1. They were front-line medical workers; 2. They consented to voluntary participation in the study. Meanwhile, those who did not wish to participate in this study were excluded.

Instrumentation
(1) Questionnaire for the demographic characteristics of medical staff with 16 items: hospital, department, occupation, sex, age, highest level of education, years of service, technical titles, marital status, having children or not, residence, having training regarding response to public health emergencies or not, having family support for controlling the epidemic at the front-line or not, level of fear for the staff surveyed and their family getting infected, level of worry about getting infected when having symptoms associated with NCP, and recent completion of comprehensive medical observation.
(2) The Hamilton Depression Scale, compiled by Hamilton in 1960, is the most used scale for the clinical evaluation of depression status. This scale has 17 entries and adopts a five-point scoring method with points ranging from 0 to 4: (0) absent; (1) mild; (2) moderate; (3) severe; (4) incapacitating. The less severe the depression, the lower the total score; the more serious the depression condition, the higher the total score. If the score is less than 7, the participant is regarded as having no depression; with a score between 17 (included) and 24, the participant is considered as having mild or moderate depression; and a score of 24 and above indicates severe depression. The reliability coefficient r of the scale is between 0.88 and 0.99, and content validity coefficient at 0.80 or above, showing good reliability and validity [8] .
(3) The Hamilton Anxiety Scale, compiled by Hamilton in 1959, is one of the most commonly used scales in psychiatric clinics and has 14 items rated using a five-point score of 0 to 4, with standards at all levels being (0) absent, (1) mild, (2) moderate, (3) severe, and (4) incapacitating. If the total score is 29 points or more, the respondent may suffer from serious anxiety; if the score is higher than 21 (included), the participant has obvious symptoms of anxiety; if the score is more than 14 (included), the participant has anxiety; if the score is more than 7, the respondent might have anxiety; if the score is less than 7, the respondent does not have symptoms of anxiety. This scale has a reliability coefficient of 0.92 and content validity coefficient of 0.86, suggesting good reliability and validity [9] .

Ethical considerations
This study adopted an online questionnaire method and the researchers conducted the survey after unified training. All procedures were approved by the Ethics Committee of Ningbo College of Health Sciences(NCHS-062). We approached the medical staff on the front line and explained the research objectives, methods, and other relevant information to them to facilitate cooperation. After obtaining their agreement, we then requested them to sign a letter of consent online, informing them that participation was fully voluntary and that they could choose to withdraw from the research at any time. We then conducted online survey by sending the questionnaire link to a total of 180 medical staff.

Statistical methods
(1) We used SPSS 22.0 and performed data analysis after logical testing. P <0.05 was considered as statistically significant.
(2)Statistical description: We used mean, standard deviation, and frequency values to describe the demographic data of the front-line medical staff; we also used mean and standard deviation values to describe the anxiety and depression scores of front-line medical workers who were supporting Wuhan in its efforts to control NCP.
(3)Statistical inference: We adopted multi-linear regression to analyze the influence of the demographic data of medical workers on their anxiety and depression.

General information of front-line medical workers
A total of 180 questionnaires were distributed, and 150 valid ones were collected, with an effective recovery rate of 83.33%. The detailed personal information collected is listed in Table 1.

Status of anxiety and depression among front-line medical staff
According to the total score of anxiety and depression among the front-line medical staff, the results showed severe anxiety and depression; the top three items under the category of anxiety were genitourinary symptoms, behavior at interview, and respiratory symptoms; and the top three depression items were feelings of guilt, weight loss, and retardation. The details are shown in Table 2.

Analysis of factors of anxiety and depression, influence on front-line medical staff
Progressive linear regression analysis was conducted, with the total scores of anxiety and depression as the dependent variables. Sixteen items of personal data were the independent variables: hospital level, department, occupation, sex, age, highest level of education, years of working experience, technical titles, marital status, having children or not, living conditions, participation in training for response to public health emergencies, family support to work at the front-line of anti-epidemic efforts, level of fear for one's own and family getting infected, level of worry about getting infected when having symptoms associated with NCP, and having undergone any medical observation lately.
The assignment method is detailed in Table 3. The values for entering into and deleting from a regression equation were set as 0.10 and 0.15, respectively. The research results showed that factors influencing anxiety could be arranged in decreasing order of influencing degree as follows: level of worry about getting infected when having symptoms associated with NCP, level of fear for one's own and family getting infected, and affiliated hospital (P <0.05). The factors affecting depression could be ordered as follows, with the influencing degree from high to low: level of worry about getting infected when having symptoms associated with NCP and level of fear for one's own and family getting infected (P <0.05), as detailed in Table 4.

Status of anxiety and depression among medical staff on the front line
NCP is an acute infectious disease. Because of its extreme infectiousness, many people are fearful of it, and even turn pale at the mention of "corona," the influence of which can be reflected on the frontline medical staff. The present results showed that front-line medical workers had serious anxiety and depression, with the top three items under the category of anxiety being genitourinary symptoms, behavior at interview, and respiratory symptoms, and the top three depression items being feelings of guilt, weight loss, and retardation. Specifically, as the front-line medical staff are in direct contact with patients infected with NCP, they are among the people with the highest risk of contracting NCP.
Meanwhile, they have a profound understanding of the harmful effects of NCP and are thus susceptible to anxiety and depression. In terms of the depression items, when dealing with NCP, frontline medical workers had to go through cumbersome protective procedures and wear tight protective equipment every day.
Currently, protection equipment is in shortage in Wuhan, and as such, some medical staff members wear only one set each day to avoid waste, which compels them to refrain from drinking water. Some have gone so far as to wear diapers for urination, which can lead to genitourinary symptoms, if not  [10] .

Factors influencing the anxiety and depression of front-line medical staff
Influence of the level of worry about getting infected when having symptoms associated with NCP and the level of fear for oneself and one's family getting infected on the medical worker's anxiety and depression The source of NCP infection is mainly patients infected with NCP, and people with recessive infection (i.e., asymptomatic infection) may also become the source of infection [11] . Front-line medical staff members face high risks of getting infected because of frequent close contact with patients in the treatment of and care for the latter [12] . Among the 138 patients admitted to Zhongnan Hospital of Wuhan University between January 1 and 28, the proportion of medical workers was as high as 29% .
A retrospective analysis of the 1,099 patients diagnosed with NCP (diagnosis date as of 29 January) in 552 hospitals in 31 provinces found that the proportion of medical staff was 2.09%. Therefore, medical workers belong to the high-risk group and experience great psychological pressure. If they are infected when supporting anti-epidemic efforts in Hubei province, the effects are not only on their own physical and mental health but also those of their families. Thus, with the appearance of symptoms and corresponding increase in the degree of worry, especially for 15.3% of the front-line medical workers who were under medical observation, their anxiety and depression would become aggravated, which could heavily affect their physical and mental health and, subsequently, the treatment of patients infected with NCP. Therefore, targeted psychological interventions are needed for the front-line medical workers who appear to have related symptoms and those receiving medical observation to relieve their physical and psychological burdens and facilitate speedy recovery.

Impact of hospital to which they belong on anxiety
From the perspective of the hospital level, medical professionals from high-level hospitals have high scores of anxiety and depression (i.e., having more psychological problems). In the present study, the front-line medical personnel were sent to different levels of hospitals, including level 3 grade A, level 3 grade B, level 2 grade A, and level 2 grade B. Hospitals of a higher level are equipped with more medical equipment and receive more patients with NCP, who also tend to be in a more serious stage. Therefore, the higher the hospital level, the heavier its anti-epidemic tasks, and the higher the professional and technical requirements for the medical workers. Meanwhile, society, including the media, tends to pay the highest attention to medical workers in high-level hospitals; thus, the latter have to set a leading model role in the efforts against the epidemic, and also endure more physical and mental pressure compared with their counterparts in lower-level hospitals. Previous studies on mental health at the time of similar events have reported the same insights [10] .

Limitations and further research
The generalizability of the research results is limited by its cross-sectional design using convenient samples from front-line medical workers in one province. Based on the current study, future research may use a longitudinal approach with a wider scope of samples to measure the psychological state of front-line medical professionals from multiple dimensions. This approach is expected to identify the interaction between demographics and psychological states in a more comprehensive manner.

Conclusion
In the face of such catastrophic emergency as the COVID-19 epidemic, and influenced by various subjective and objective factors, the presence of some psychological disorders is a form of stress response for front-line medical staff. These disorders can also be seen as an explanatory, emotional, and defensive response process within the human body, and also the body's physiological response to physical needs or harm. While working in such unique environments, front-line medics can experience disorders with respect to their work, life, emotions, and other normal states. Owing to the requirements for isolation and disinfection, medical workers have to wear several layers of isolation gowns, which adds to their physical labor, consumes a large amount of energy, and leads to a severe lack of oxygen, resulting in physical and psychological symptoms. When confronted with a disaster, people in good mental health would take the initiative to adopt countermeasures, such as speaking out, shifting attention, compensating, relaxing, and turning to humor, self-comfort, and reason. The present results demonstrated that front-line medical workers experience serious anxiety and depression in their efforts to control the NCP epidemic. The psychological testing showed that people experience a process of adaptation to catastrophic emergencies, from initial unacceptance, shock, and fear, to routine, acceptance, and calmness, until co-existence is reached, which is a process with its order. Facing such sudden disasters as the NCP outbreak, both medical professionals and patients experience psychological clinical symptoms. For front-line medical staff, while ensuring the completion of their duties, keeping good mental health is crucial. Given the special circumstances, it is urgently worth discussing how to strengthen the mental health monitoring of front-line medical workers and establish an active, systematic, and scientific system for psychological protection.