Since the end of December, 2019, the COVID-19 has spread across the world. Hubei as the epicenter of the outbreak in China faced with the most serious situations of the pandemic. The emotional disturbances of HCWs were at high risk and should receive high attention. This study investigated the prevalence of sleep quality and mental disturbances of HCWs and presented the potential influencing factors including epidemic stage, region and demographic characteristics.
49 (11.6%), 56 (13.3%) and 60 (14.3%) of HCWs were shown to have depression, anxiety and PTSD symptoms in this study. The rates are lower comparing with the results of previous studies on SARS which presented that 18 to 57% of the medical staff endured serious emotional distress during and shortly after the epidemic (12,13,15–17). This may be due to the experience of fighting SARS in 2003 and timely and effective psychological assistance to medical staff during this pandemic.
Few studies have explored the impact of the epidemic stage on sleep quality and mental health of HCWs. This study found that comparing withCOVID-19epidemic stage 1, the sleep quality at stage 2 and 3 were significantly poorer, which might probably be owing to the rapidly rising number of confirmed cases and severe cases over time. This result was contrary to that of Chen (2006) who found that compared with the mean score of PSQI of medical staff before caring for patients, the mean score of PSQI was significantly decreased 2 weeks and 1 month after the initiation of SARS prevention program (31). And the study of Chen also showed that the anxiety and depression level of nursing staff had also been alleviated after 2 weeks of the SARS caring program(31). However, the findings of the current study indicating that the depression and anxiety level of HCWs had no significant difference across 3 stages. The difference might be because that the epidemic stage 1 of our study was the early stage of the prevention program instead of the period before a prevention program began. And the subjects of our study including doctors, nurses, medical technicians and others, which was different with the previous study. What’s more, the medical staff were facing with the different epidemics which have different epidemiological and clinical characteristics. The number of confirmed cases of COVID-19 has far outnumbered SARS outbreak and the longer asymptomatic latent period along with super spreader makes COVID-19 more tricky to handle with. And the source of infection and the patient zero have not been found yet, drugs and vaccines against the disease are also under development. The stage 3 can not be recognized as the stage on which the disease has been better understood or controlled.
During COVID-19 outbreak, HCWs in Hubei province had significantly poorer sleep quality(p < .001). When it comes to the component scores of the PSQI, the study showed that HCWs in Hubei has worse subjective sleep quality, slightly longer sleep latency, shorter sleep duration, worse sleep efficiency, more often use of sleep medications, and daytime dysfunction. Working in Hubei province is a predictor of poor sleep quality. The finding was consistent with that of Grainne M McAlonan et al (2007) who found that High-risk HCWs were more risky of being fatigue and having poor sleep quality during the outbreak of SARS (32). Hubei Province is the center of the epidemic where confirmed cases and severe cases are significantly beyond those in other provinces. Therefore, the workload and work intensity of medical personnel in Hubei Province will be much higher than those in other provinces. Research found that higher workload of nurses were related to poorer sleep quality which could explain the result of the study (33). In addition, female and older age were two well established risk factors for sleep disturbances in our study and previous studies (34).
This study found that HCWs working in or outside Hubei province had equal level of prevalence to have psychological stress and anxiety symptoms. Previous studies also indicated that similar psychological morbidity and perceived stress were found between high-risk and low-risk HCWs (12,32).COVID-19 has a long incubation period and the virus carriers are undetectable and could transmit virus during the latent period. Although non-Hubei provinces are not as severe as Hubei province, the number of confirmed cases was rising rapidly as well. The HCWs outside Hubei provinces did not recognize themselves as exempt from the danger. Moreover, medical staff in Hubei has higher vigilance and confidence as the attention of the whole country was focused on the epidemic in Hubei. Thus medical staff in Hubei had a morale and sense of responsibility to conquer this challenge, which is beneficial for their mental health maintenance. These reasons may help explain the unusual result that HCWs not working in Hubei province had higher risk of depression.
It has not been described before that the status of having children is associated with depression of HCWs. This study showed that having under-age or grown-up children was a protective factor of depression symptom among HCWs. Previous research found that people with older age (46.65 ± 13.82) and coexisting conditions (28.8%) were more likely to be affected by COVID-19 (35). Children were not the main affected group of this outbreak. And the postpone of the reopening of schools and lockdown of the cities made children stayed in home under supervision. These might explain part of the results but still acquire further studies.
Surprisingly, our study suggested that administrative and logistic staff and others working in health care industry had higher prevalence of being depression or PTSD compared with that of doctors. This finding is contrary to previous studies which have suggested that being a nursing professional and providing direct care with SARS patients were the risk factors of high level of job-related stress (12, 36). But the results of our study accords with earlier observations. Attack rate among HCWs during SARS varied by occupations. The attack rate of HCWs in Vietnam, 2003, were 16%, 35%, 2% for doctors, nurses and administrative staff, respectively. Those with highest attack rate was named as “other staff with patient contact” which accounted for 53% (37). A study in Hongkong during SARS outbreak reported the attack rate as follows: nurses (1.21%), medical staff and technicians (0.29%), and others including assistants and cleaners (2.72%) (38).The studies above have indicated that the logistic and administrative staff and others was the most vulnerable groups that withstand the highest attack of SARS virus. This might be one of the reasons why administrative and logistic staff in our study endured with higher prevalence of depression and PTSD. Another reason could be that the logistic staff and others working in hospital might not be as psychologically prepared as doctors and nurses. Furthermore, situations of low exposure can also be risky of getting affected (37) as there were asymptomatic carriers. Administrative and logistic staff and others like cleaners are staff that are easily neglected in a outbreak. We should be more concerned about their mental health.
Our data showed that the risk of having depression, anxiety or PTSD symptoms tended to increase with enhancing PSQI score among HCWs. Previous study found that Service members and veterans who had higher PTSD, depression and anxiety scores were those who had relatively bad or very bad sleep quality (39). A study among South Korean workers found that the variance in weekday and weekend sleep duration are highly associated with PHQ-9 score which indicated depression (40). A recent research suggested that poor sleep quality and social support lead to anxiety, stress and self-efficacy problems among HCWs in China dealing with COVID-19 during early stages of the outbreak (41), which is consistent with our study. Several studies found that insomnia was often accompanied by mental disorders, especially anxiety and depression (42, 43). In fact, longitudinal studies have found that risk of depression and anxiety increased when insomnia existed (44–47) which would even cause the relapses (48). A considerable number of longitudinal studies (49–52) and a meta-analysis (53) suggested that people with sleep disturbances, compared with those without sleep difficulties, have over twice times risk of getting depression symptoms over the next one to three years of follow-up. Insomniac patients with depression have higher prevalence to remain depressed despite standard therapy (54). In this case, sleep disturbances are likely to be the risk factor and consequence of anxiety and depression. In this case, we could deal with mental health problems by coping with sleep disturbances which is less-stigmatizing.
The study has several limitations. Firstly, The study is a cross-sectional study, which can not investigate the causal relationship. Secondly, there is self-report bias because all results were from self-reported questionnaires. And setting up a true control group is impossible for our study for all the HCWs in China who were influenced by the COVID-19 outbreak. Thirdly, the sample of the study is relatively small which might influence the generalization of the results.