Anxiety, Depression and Functional impairment during the COVID-19 Pandemic among Health Care Workers: A Cross Sectional Online Survey

DOI: https://doi.org/10.21203/rs.3.rs-66245/v2

Abstract

Background

COVID-19 is an infectious disease caused by a newly discovered, with more than 24 million cases worldwide. Geometrically increasing numbers of cases and deaths from COVID 19 in the world, both medical staff and the public have been experiencing psychological problems, which can cause disability and functional impairment of the individual. This study aimed to determine the burden of stress anxiety and depression among health care workers.

Methodology

A hospital-based cross-sectional study was carried out among all the employees of Hospital for Children Eye ENT and Rehabilitation Services Bhaktapur during the COVID-19 pandemic lockdown using an online questionnaire. The tools used were adopted from Hospital Anxiety and Depression scale (HADS) Nepali version and WHO Disability Assessment Schedule (WHODAS2.0).

Results

The mean age (SD) of the participants (n=86) was 32.53 (7.92) years. Male and female participants were equal in number. The point prevalence of anxiety and depression was 25.6% and 14.0%, respectively. Females had a higher prevalence of both anxiety (39.5% vs 11.6%, p<0.01) and depression (18.6% vs 9.3%, p=0.351). Clinical and non-clinical staff both had a higher prevalence of both anxiety (31.0% and 20.5%, p=0.265) and depression (16.7% and 11.4%, p=0.478). Mean disability score (WHODAS 2.0) among all participants and participants with anxiety and depression was 19.47 (95% CI: 18.13-20.80), 21.27 (95% CI: 18.08-24.46) and 19.92 (15.28-24.56), respectively.

Conclusion

Anxiety and depression during COVID-19 pandemic lockdown were highly prevalent both in clinical and non-clinical employees, without causing significant functional impairment among health care workers.

Introduction

COVID-19 is a new infectious disease spreading rapidly throughout the world. As of 28 August 2020, COVID-19 accounted more than 24 million confirmed cases and more than 827 hundreds deaths globally 1. The most stressful situation at this time is the unpredictability and seriousness of the risk 2. Before pandemic starts, around 13% people aged 18 years and above had any type of mental disorder in Nepal 3. During pandemic management, the impact of outbreak on mental health is usually neglected though pandemic can trigger common mental disorders 4, 5. Evidence has shown that with the increase in the number of cases and deaths from COVID 19, health care workers have been experiencing psychological problems, with disability and functional impairment 6-9. Thus, this study aimed to determine the burden of anxiety, depression, and functional impairment during COVID-19 among health care workers of tertiary level Eye, ENT hospital in Bhaktapur.

Methods

This is a cross-sectional web-based survey. The data collection was performed between 3rd April 2020 and 2nd May 2020 during the nationwide lockdown. A total of 86 health care workers, including clinical staff - doctors, nurses, paramedics, laboratory staff, radiographers and non-clinical staff - admin, housekeeping, security guards, drivers working in Hospital for Children Eye ENT and rehabilitation services, Bhaktapur participated in the study. Data collection was done through self-administered questionnaire used in Google forms. Nepali version of Anxiety and depression were measured using the 14-item Hospital Anxiety and Depression Scale (HADS) rated in four-point scale from 0 to 3 (Total score: HADS-A 0-21, HADS-D, 0-21) 10. A score of 11 or more in respective subscale was considered to indicate anxiety or depression. Functional impairment were measured using the 12-item WHO Disability Assessment Schedule (WHODAS 2.0) on a five-point Likert’s Scale (total score 12 to 60), higher score indicate higher functional impairment. Both descriptive and inferential statistics were used to analyze the data. Binary logistic regression analysis was performed on variables with p < 0.05 in the bivariate analysis. Ethical approval for the study was obtained from the Nepal Health Research Council (Reg no. 269/2020P). Similarly, online consent was obtained from all the participants before the survey.

Results

The mean age (SD) of the participants (n=86) was 32.53 (7.92) years. Male and female participants were equal in number. More than half of the participants were non-clinical staff. Among all the participants, 11.6% had a history of foreign travel by their family member after the pandemic started in the world. Other sociodemographic characteristics and risk factors are presented in table 1.

The mean (SD) anxiety, depression and functional impairment scores were 7.27 (4.62), 5.13 (4.02) and 19.47 (6.23), respectively. The point prevalence of anxiety and depression were 25.6% and 14.0%, respectively. Females had a higher prevalence of both anxiety (39.5% vs 11.6%, p<0.01) and depression (18.6% vs 9.3%, p=0.351). Both clinical and non-clinical staff had a higher prevalence of anxiety (31.0% and 20.5%) and depression (16.7% and 11.4%). There was no significant difference in the prevalence of anxiety (p=0.265) and depression (p=478) among clinical and non-clinical staff.

Table 1: Different characteristics and point prevalence of anxiety and depression

Characteristics

n

%

Anxiety (%)

χ2

p-value

Depression (%)

χ2

p-value

All

 

86

 

25.6

 

14.0

 

Gender

Male

43

50.0

11.6

<0.01

9.3

0.351*

Female

43

50.0

39.5

 

18.6

 

Age group

< 35 years

56

65.1

21.4

0.228

12.5

0.595

<= 35 years

30

34.9

33.3

 

16.7

 

Employees type

Clinical

42

48.8

31.0

0.265

16.7

0.478

Non clinical

44

51.2

20.5

 

11.4

 

Educational level

Literate or High school

35

40.7

28.6

0.599

20.0

0.180

University degree

51

59.3

23.5

 

9.8

 

Marital status

Married

57

66.3

33.3

0.041*

15.8

0.491*

Unmarried

29

33.7

10.3

 

10.3

 

Staying with

With family

77

90.6

27.3

0.191†

15.6

0.594†

Single

8

9.4

0.0

 

0.0

 

Children or elders in family

Yes

61

70.9

31.1

0.115*

13.1

0.994*

No

25

29.1

12.0

 

16.0

 

Living in

Own home

55

64.0

21.8

0.287

12.7

0.662

Rented room

31

36.0

32.3

 

16.1

 

Foreign travel history

Yes

10

11.6

30.0

1.000

20.0

0.919

No

76

88.4

25.0

 

13.2

 

Family member with chronic disease

Yes

39

45.3

23.1

0.628

15.4

0.727

No

47

54.7

27.7

 

12.8

 

Cough/ sore throat/common cold

Yes

10

11.6

10.0

0.415

10.0

1.00

No

76

88.4

27.6

 

14.5

 

* chi-square test with continuity correction            † Fisher's exact test was performed

Females had a very strong association with both anxiety (AOR=5.008 (95% CI; 1.593-15.741)) and depression (AOR=2.173 (95% CI; 0.599-7.882)). Likewise, married participants had a positive association with anxiety (AOR 4.379 (95% CI; 1.121-17.106)) and depression (AOR 1.542 (95% CI; 0.379-6.276)) (Table 2).

Table 2: Unadjusted and adjusted odds ratios of anxiety and depression among different genders and marital statuses

 

Anxiety

Depression

 

OR (95% CI)

AOR (95% CI)

OR (95% CI)

AOR (95% CI)

Gender

 

 

 

 

Male

1

1

1

1

Female

4.969

(1.63-15.15)

5.008

(1.593-15.741)

2.229

(0.62-8.05)

2.173

(0.599-7.882)

Marital status

 

 

 

 

Unmarried

1

1

1

1

Married

4.333

(1.162-16.155)

4.379

(1.121-17.106)

1.625

(0.404-6.531)

1.542

(0.379-6.276)


The mean functional impairment score among all participants, participants with anxiety and depression were 19.47 (95% CI: 18.13-20.80), 21.27 (95% CI: 18.08-24.46) and 19.92 (15.28-24.56), respectively. There was slight increase in impairment score among the participants with higher anxiety and depression score, thought the difference is not statistically significant. The first quartile, median and third quartiles for the mean score were higher among the participants with higher anxiety and depression score except in the first quartile among group of participants with different depression score (Table 3). There was moderate positive relationship (r=0.570) found between anxiety and depression. The relationship between functional impairment with both anxiety (r=0.404) and depression (r=427) was found weak positive (Table 4).

 

Table 3: Mean 12-item WHODAS 2.0 total scores and percentiles in participants

Group

Mean WHODAS 2.0 score (95% CI)

p-value

Quartiles

Q1

Median

Q3

All participants

19.47 (18.13-20.80)

 

15.00

18.50

23.50

Anxiety score < 11

18.84 (17.40-20.29)

0.115

14.25

18.00

22.75

Anxiety Score ≥ 11

21.27 (18.08-24.46)

 

15.00

20.00

28.00

Depression Score < 11

19.39 (17.98-20.80)

0.788

15.00

18.00

23.25

Depression Score ≥ 11

19.92 (15.28-24.56)

 

12.75

19.50

26.00

 

Table 4: Correlation among Anxiety, Depression and Functional impairment score

 

Anxiety Score

Depression Score

Functional Impairment Score

Anxiety Score

1

0.570**

0.404**

Depression Score

0.570**

1

0.427**

Functional Impairment Score

0.404**

0.427**

1

** correlation is significant at the 0.01 level (2-tailed)

Discussion

This study assessed the prevalence of anxiety, depression and functional impairment among employees of the Hospital for Children Eye ENT and Rehabilitation Services, Bhaktapur, during the early phase of the COVID-19 pandemic. This study revealed that a significant proportion of the participants experienced mental health symptoms/problems such as anxiety (25.6%) and depression (14.0%). The prevalence rates found in this study are in contrast with the studies done in Nepal and other countries at the time of the pandemic.

A study performed among health workers using the similar tool in Nepal showed that anxiety was found in 18.3% of participants and depression in 13.5% of participants 11.  Similarly, a study in China using different tool (9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder) showed that anxiety and depression were prevalent among 44.6% and 50.4% of the participants, respectively 12. Another study in China using WHO five well-being Index and generalized anxiety disorder scale in general population during pandemic revealed that out of all participants, 22.6% had experienced anxiety, and 48.3% had a certain level of depression13.

Similarly, depression was prevalent among 32% of the participants, as depicted by a study in Italy 14. Anxiety and depression were 16% and 28%, respectively, as shown by a recent systematic review of the COVID-19 and mental health literature 15. This shows that there is a wide variation in the prevalence. The reasons behind this variation could be due to the variation in sample size, study population, instruments used and fewer cases with no fatality in the country during the data collection period.

In this study, female participants had a higher prevalence of both anxiety (39.5% vs 11.6%, p<0.01) and depression (18.6% vs 9.3%, p=0.351). Such gender difference has been reported mostly due to biological component and different coping strategies they have. This finding is in line with studies conducted in Nepal, China, India and Italy 12, 14, 16. In this study, both anxiety and depression were found to be associated with marital status. However, in a recent study performed among health workers in Nepal, marital status was not associated with mental health symptoms 11.

Period of

Study ref

Country

Methodology

demography

Tool used

Sample size

Anxiety, depression

April 3 to May 2, 2020 (This study)

Nepal

Online

Clinical and non-clinical health care workers

HADS,

WHODAS 2.0

86

A - 25.4%

D- 14.0%

 

April 26 to May 12,

2020 9

Nepal

Online

Clinical and public health practitioners

HADS

475

A - 18.3

D – 13.5

January 29 to February 3,

2020. 10

China

 

Physicians

Nurses

PHQ-9,

GAD -7

1,257

A – 12.3%

D – 14.8%

January  31 to February 2,

2020 11

China

 

General population

 (WHO-5),

 (GAD-7)

5,851

A –22.6%

D – 48.3%

18–22 March 2020 12

Italy

Online

General population

DASS-21

2,766

A – 18.7%

D – 32.8%

The low total functional score indicating low functional impairment among the participants was quite surprising during restricted normal outdoor activities during lockdown due to the COVID-19 pandemic. The low average functional impairment score may be due to the loose travel restriction to health care workers having hospital employees’ hospital identity card.

Table 5: Comparison of Anxiety and depression during COVID-19

Limitations

This study has several limitations that need to be acknowledged. First, it was limited in hospitals, thus limiting the generalization of the findings. Second, long-term psychological problems could not be assessed while the situation worsened. This is because this study was performed during the early weeks of lockdown due to the COVID-19 pandemic. We don’t have baseline information for all scales/tools we used. The scores might not be only due to COVID-19 as they might show the caseness prior to our study. There might be respondent bias because a face-to-face interview was not possible during which we may have missed information on sensitive issues. Additionally, the findings are based on self-reports, so there was no means of clinical verification.

Conclusion

Anxiety and depression during the COVID-19 pandemic were highly prevalent both in clinical and supporting health care workers without causing significant functional impairment. Multicenter anxiety, depression and functional impairment studies with larger sample sizes, including all health care workers, are recommended.

Declarations

Acknowledgement

We would like to thank the management of BPEF/CHEERS for allowing us to conduct this study in this hospital. We would also like to thank all the staff of BPEF/CHEERS hospital for participating in this survey.

Conflict of Interest

The authors do not have any conflict of interest

References

  1. WHO Coronavirus Disease (COVID-19) Dashboard. [cited 2020 August 7]. Available from: https://covid19.who.int/.

 

  1. Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. The Lancet. 2020;395(10224):e37-e38.

 

  1. Jha AO, SP; Dahal, S; BK, RK; Jha, BK; Pradhan, A; Labh, S; Dhimal, M. A report on pilot study of national mental health survey, Nepal. Kathmandu. Council NHR; 2018. Nepal Health Research Council.

 

  1. Dar KA, Iqbal N, Mushtaq A. Intolerance of uncertainty, depression, and anxiety: Examining the indirect and moderating effects of worry. Asian journal of psychiatry. 2017;29:129-133.

 

  1. Naser AY, Dahmash EZ, Al-Rousan R, Alwafi H, Alrawashdeh HM, Ghoul I, Abidine A, Bokhary MA, AL-Hadithi HT, Ali D. Mental health status of the general population, healthcare professionals, and university students during 2019 coronavirus disease outbreak in Jordan: a cross-sectional study. medRxiv. 2020.

 

  1. Xiang Y-T, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, Ng CH. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. The Lancet Psychiatry. 2020;7(3):228-229.

 

  1. Jaiswal P, Dalal P, Tripathi A, Singh S, Jain S. Relationship of Depression, Disability and Quality of Life in Depressive Patients‑A Case Control Study. J Fam Med. 2015;2:1-6.

 

  1. Tanner J, Zeffiro T, Wyss D, Perron N, Rufer M, Mueller-Pfeiffer C. Psychiatric symptom profiles predict functional impairment. Frontiers in psychiatry. 2019;10:37.

 

  1. Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, Wang Y, Hu J, Lai J, Ma X. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. The Lancet Psychiatry. 2020;7(3):e14.

 

  1. Risal A, Manandhar K, Linde M, Koju R, Steiner TJ, Holen A. Reliability and Validity of a Nepali-language Version of the Hospital Anxiety and Depression Scale (HADS). Kathmandu University medical journal. 2015 Apr-Jun;13(50):115-24. Epub 2015/12/15. doi:10.3126/kumj.v13i2.16783. Cited in: Pubmed; PMID 26657079.

 

  1. Khanal P, Devkota N, Dahal M, Paudel K, Joshi D. Mental health impacts among health workers during COVID-19 in a low resource setting: a cross-sectional survey from Nepal. 2020.

 

  1. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, Du H, Chen T, Li R. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA network open. 2020;3(3):e203976-e203976.

 

  1. Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, Wang Y, Fu H, Dai J. Mental health problems and social media exposure during COVID-19 outbreak. PloS one. 2020;15(4):e0231924.

 

  1. Mazza C, Ricci E, Biondi S, Colasanti M, Ferracuti S, Napoli C, Roma P. A nationwide survey of psychological distress among italian people during the COVID-19 pandemic: Immediate psychological responses and associated factors. International journal of environmental research and public health. 2020;17(9):3165.

 

  1. Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian journal of psychiatry. 2020:102066.

 

  1. Rehman U, Shahnawaz MG, Khan NH, Kharshiing KD, Khursheed M, Gupta K, Kashyap D, Uniyal R. Depression, Anxiety and Stress Among Indians in Times of Covid-19 Lockdown. Community mental health journal. 2020:1-7.