The mental health of healthcare workers in the COVID-19 pandemic: A systematic review

Abstract

This paper is a systematic review that discusses the consequences of the current COVID-19 pandemic scenario on healthcare workers' mental health outcomes. The sources from which the articles used in this paper were systematically researched are PubMed, Lilacs, and BVS. The search for articles occurred between January to October of the year 2020. In searching the electronic databases, the following keywords were employed to create a search strategy: nervousness or social anxiety or anxieties, depressive or depression or emotional depression, mental or mental hygiene or hygiene, social or anxiety, mental and COVID-19 or Coronavirus, social or social anxieties or anxiety and depressions or depressive symptoms or depressive symptom or symptom, emotional or depressions, emotional or emotional depressions, and health. The systematic review findings showed that exposure to COVID-19 increased the incidence rate of symptoms of mental conditions such as anxiety and depression. The conclusion drawn from the review's findings is that lifestyle strategies aided by psychological care can be fundamental in improving the consequences of the mental conditions caused by the COVID-19 pandemic. 

Introduction

The recent outbreak of the novel COVID-19 disease put much strain on the healthcare systems, particularly on the healthcare workers (Muller, Stensland & van den Velde, 2020). The World Health Organisation (WHO) has put forward this immense strain imposed on healthcare workers who are in the duty of saving lives during the outbreak and called for measures to relieve this burden to protect the physical and mental well-being of healthcare workers (WHO, 2020).

From the history of previous viral outbreaks, it is apparent that frontline and non-front line healthcare workers are at a higher risk of infection and other adverse physical health outcomes (Muller et al., 2020). During and up until after the years of an epidemic, the occupational activities of healthcare workers put healthcare workers at risk of developing mental health problems with symptoms such as post-traumatic stress, depression, burnout, and anxiety. Moreover, during the events of the current global health crisis, reports of the mental toll on healthcare workers have persistently appeared (Tsamakis et al., 2020).

The symptoms of psychological distress and mental illness which have been observed in the general public in the present time are attributed to the distressing nature of the widespread COVID-19 pandemic; these symptoms are even more exaggerated in the healthcare workers who are dealing with patients infected with the disease (Thapa et al., 2020). There have been various research efforts to appraise healthcare workers' mental distress during pandemic events and introduce measures that relieve this mental stress.

PICO clinical question

This aim of this current research is to determine: How has the current COVID-19 pandemic (I) affected (C) healthcare workers' (P) mental status (O)?

Aim of review

This review aims to create a summary of existing literature that addresses the mental health outcomes on society and, in particular, healthcare workers by creating a literature base of research work relevant to this issue.

Literature review

The events of every major epidemic outbreak greatly increase the demand for healthcare workers. Moreover, the scenarios of these outbreaks are usually similar for healthcare workers; there is a constant rise in the number of the infected, a rise in the number of the dead, a lack of medicine or vaccine to combat the disease, extensive media coverage of the outbreak, a large workload, lack of adequate personal protective equipment and feelings of inadequate support. All these contribute to the mental distress healthcare workers suffer during these times (Vizheh et al., 2020). To keep up with the heavy demand for medical aid during disease outbreaks, healthcare workers work long hours under great pressure, being exposed to a high risk of contracting the disease when treating patients. Moreover, healthcare workers are susceptible to the public's same foibles by becoming anxious after listening to fake news and rumors. In the initial stage of the COVID-19 outbreak, 29% of all hospitalized patients were healthcare workers who had contracted the disease (Vizheh et al., 2020). Studies to find out how the infections came about indicate that the healthcare workers became infected due to the close contact maintained with patients while administering treatment (Xiao et al., 2020). A combination of all these factors raises the risk of healthcare workers developing a psychological illness and physical and emotional distress. 

Research conducted on the consequences of outbreaks of other infectious diseases such as Severe Acute Respiratory Syndrome (SARS), the Ebola Virus, and the Middle East Respiratory Syndrome (MERS) indicates that a significant number of healthcare workers active during these events suffer a high level of emotional distress (Lee et al., 2018). A study conducted on 1257 healthcare workers treating SARS-infected patients revealed somatic and cognitive symptoms of anxiety in a significant number of healthcare workers. These symptoms are attributed to the rapid proliferation of the infection in the initial phase of the epidemic, the feeling of uncertainty healthcare workers experience, the constant threat to life, and the feeling of vulnerability brought on by the event (Chong et al., 2004). A further study conducted after the outbreak showed symptoms such as depression, anxiety, burnout, traumatic stress, and avoidance. The consequences of poor mental health caused by the current outbreak are more worrying, considering that the number of the infected and the dead due to SARS-CoV-2 are several times more than that of SARS. The disastrous impact of SARS-CoV-2 has been so great; the outbreak has received some reference as a world-ending event. The hospitals are ill-equipped to keep a handle on the situation, and there is a growing concern for the public's survival (Lima et al., 2020). A crisis of this magnitude is unprecedented, and healthcare workers active during this time are susceptible to psychological problems. In light of this circumstance, all medical staff's mental health should be a priority public health concern. 

The knowledge of the mental health consequences acquired from the history of past global outbreaks tells of the need for early assessment of medical staff's mental health and psychological strategies to manage any problem that might arise (Xiang et al., 2020). At this present time, very few studies have appraised the mental health of healthcare workers active during the current COVID-19 outbreak, but this study discusses the few research work that has made investigations into the topic. This work also provides several psychological strategies to assist healthcare workers during this time. 

Methodology

The systematic review method is employed for conducting this study and is used as per the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Search strategy

The search for the scientific literature used in this review started in January 2020 and ended in October 2020. The search was conducted on three databases: PubMed (Medline), Lilacs, and Virtual Health Library (BVS). The keywords used for the search are:

• "mental health" AND "healthcare" AND ("workers" OR "givers" OR "providers" OR "professionals") AND "COVID-19."

• "mental health" AND (" doctors" OR "nurses") AND "COVID-19".

Eligibility and Inclusion Criteria

The literature used in this study were selected by two reviewers using the following inclusion criteria: 1) written in English, 2) dated from January to October 2020, involving studies, 3) COVID-19/coronavirus, 4) mental health, conducted in human studies. The literature works were further reviewed by two other independent researchers who, by consensus, eliminated articles that did not meet the inclusion criteria. From articles considered eligible, the data extracted are the study's methodology and the main results of the study.

Extract data

The initial publications considered for use in this review were selected by a single reviewer (SN) using an examination of the titles and abstracts of available publications to make a selection. Two reviewers (SC and SN) independently examined each full-text study using an identical study selection criteria to eliminate studies that do not meet the inclusion criteria. A final examination was performed by a third reviewer (CN) on studies that required further consideration.

Results

The flowchart below shows the successive steps to select the studies for a systematic review (Figure 1). The summary of each study on mental health outcomes in the COVID-19 period used in this review is presented in Table 1.

Figure 1: Records review for inclusion flowchart

Table 1. Summary of included articles

Table 1. Summary of included articles

Reference 

Country or region

Objective

Type of study 

Sample description 

Mental health manifestations

Huang & Zhao (2020).

China

To evaluate the mental stress of the public during the COVID-19 outbreak and to identify the high-risk group.

Cross-sectional

7,236 men and women were included in the study [3,284 (45.4%) male and 3,952 (54.6%) female]. the average age of participants is 35. 3 with a standard deviation of ± 5.6 years. The participants were divided into two age groups, one group for those < 35 years of age and the other for those  ? 35 years of age. All the participants in the study are Chinese.

Depressive symptoms, anxiety symptoms, and poor sleep quality were identified in 35.1%, 20.1%, and 18.2% of the population. Little statistical difference was found in the appearance of mental stress by gender (p>0.05). The occurrence of anxiety symptoms and depressive symptoms was significantly higher in the participants below 35 years of age than the participants aged 35 years or older (p<0.001).

Gao et al., 2020]

China

This literature aims to describe the occurrence and distribution of two mental disorders (anxiety and depression) among the Chinese population and examine the association of these mental health disorders with social media exposure during the COVID-19 outbreak.

Cross-sectional

4872 participants were included in this study. The participants are of the age of 18 years or above. The participants were selected from 31 provinces and autonomous regions in China. All the participants in the study are Chinese.

The distribution of depression, anxiety, and (CDA) was identified to be 48.3% (95% CI: 46.9% -49.7%), 22.6% (95% CI: 21.4% -23.8%) and 19.4% (95% CI:18.3% -20.6%) throughout the COVID-19 outbreak in Wuhan, China. After controlling for covariates, frequently SME had been positively linked with a high risk of anxiety (OR=1.72, 95% CI: 1.31–2.26) and CDA (OR=1.91, 95% CI: 1.52–2.41) when compared to less SME.

Lai et al. (2020)

China

To evaluate mental health and the factors that can affect healthcare workers' mental health providing medical aid to COVID-19 patients in China.

Cross-sectional

1257 healthcare workers from 34 hospitals in China.

Symptoms of depression were identified in the participants (n=634 [50.4%]), anxiety (n=560 [44.6%]), insomnia (n=427 [34.0%]), and distress (n=899 [71.5%]). Nurses were identified to have the highest levels of depression, anxiety, insomnia, and distress (statistics of the prevalence of severe depression between physicians and nurses: 24 [4.9%] vs. 54 [7.1%];p = .01; statistics of the occurrence of severe anxiety between men and women: 10 [3.4%] vs. 56 [5.8%]; p = .001; a comparison of the statistics of severe insomnia occurrence among frontline workers vs. second-line workers: 9 [1.7%] vs. 3 [0.4%]; p < .001; statistics of the appearance of severe distress among workers in Wuhan vs. workers in Hubei outside Wuhan, and among workers outside Hubei: 96 [12.6%] versus. 19 [7.2%] among those in Hubei outside Wuhan, as well as 17 [7.2%] among those outside Hubei; p <.001).

Zhang & Ma, (2020)

China

To provide an assessment of the consequences on mental health and the quality of life brought about by the onset of the COVID-19 outbreak among local Chinese residents of Liaoning Province, mainland China, 18 years and over. 

Cross-sectional

There were 263 participants in the study (106 male and 157 female) with the participants' range of age between 18 and 30 years. All the participants in the study are Chinese.

Very little stress was identified in the population, with no significant statistical difference between genders [p=0.173]. The average intrusive score registered in men was higher than that registered in women (13.0 vs. 12.3) [P=0.027].

74.5% of the participants reported no significant increase in home life stress. The emotional responses of the participants on the pandemic registered during the study are a feeling of horror [p=0.002], a feeling of apprehension [p=0.001], and a feeling of helplessness [P=0.049].

Li et al. (2020)

China

To assess the outcome of the COVID-19 pandemic on the populace's mental health, assist the government by introducing ideas of actionable policies, and help clinical social workers (social workers, psychiatrists, and psychologists) provide medical aid to affected populations.

Cross-sectional

17,865 active Weibo users were ranging from 9 to 40.1 years old. The study analyzed the participants' Weibo posts using the approach of (OER) based on several machine-learning predictive models.

The study identified an increase in negative emotions among the participants, emotions such as anxiety (p<0.000), depression (p<0.000), and indignation (p<0.000); and sensitivity to social risks were also recorded to have increased, while positive emotions among the participants such as Oxford happiness) Life satisfaction was registered as reduced (p<0.0002) due to the COVID-19 pandemic.

Wang et al. (2020)

China

This is a study on the mental welfare of China's population to identify symptoms of mental disorders such as anxiety, depression, and stress during the immediate period following the COVID-19 outbreak. 

Cross-sectional

1210 participants from 194 cities in China. 67.3% of the participants were women with an age range between 21.4 to 30.8 years of age.

Minimal psychological impact was identified in 296 (24.5%) of the study sample (score<23); 263 participants (21.7%) reported mild psychological impact (scores 24-32); and 651 participants (53.8%) reported moderate or severe psychological impact (score>33).

Mild depression symptoms were identified in 167 participants (13.8%) (score: 10–12); 148 participants (12.2%) suffer from mild depression (score: 13-20); and 52 participants (4.3%) were considered to suffer from severe or extremely severe depression (score: 21-42).

The investigation on anxiety levels revealed that 91 participants (7.5%) report mild levels of anxiety (score: 7-9); 247 participants (20.4%) suffer from moderate anxiety (score: 10-14); and 102 participants (8.4%) suffer from severe or extremely severe anxiety (score: 15–42).

In the analysis of stress levels, 292 participants (24.1%) were considered to suffer from low levels of stress (score: 11-18); 66 participants (5.5%) have moderate stress levels (score: 19–26); and 31 participants (2.6%) suffer high or extremely high levels of stress (score: 27-42).

The COVID-19 pandemic has caused the manifestation of different forms of mental health issues. Five studies which analyze the variety of the mental issues caused by the pandemic isolate depression and anxiety as the conditions with the highest incidence rates (Gao et al., 2020; Huang & Zhao, 2020; Lai et al., 2020; Li et al., 2020; Wang et al., 2020). 

Two studies (Gao et al., 2020; Huang & Zhao, 2020) identify the negative effects the COVID-19 pandemic scenario has on sleep quality/insomnia. Other studies observed increased stress levels (Lai et al., 2020; Wang et al., 2020; Zhang & Ma, 2020), sensitivity to social risks (Li et al., 2020), and a sensation of horror (Zhang & Ma, 2020).

The assessments in each of the studies are made as per some international regulations. The analysis of Gao et al. (2020) on current mental health is made through the questionnaire of the Five-Well-Being Index (WHO-5), and the anxiety study is measured on the generalized anxiety disorder scale (GAD-7), both in the Chinese version. Huang et al. (2020) also employed the GAD-7 scale to measure anxiety symptoms but used the Centre for Epidemiology Scale for Depression (CES-D) to analyze the depression symptoms. Lai et al. (2020) created an evaluation of anxiety using the GAD-7 scale but employed a questionnaire for insomnia study and the Impact of Event scale Revised (IES-R) for depression. Zhang et al. (2020) applied the IES-R to analyze psychological effects such as the impact of events, stress, and anxiety. Wang et al. (2020) used the Depression, Anxiety, and Stress Scale (DASS) to evaluate mental health status. LI et al. (2020) used the following tools for analysis: word frequency, emotional indicator scores (anxiety, depression, indignation, and Oxford happiness), and cognitive indicators (social risk judgment and life satisfaction). 

Discussion

The studies included in this review have identified a significant impact of the COVID-19 pandemic on mental health. Each study examined mental health using means such as websites and questionnaires. In the studies conducted, depression and anxiety are identified to have the highest incidence rates in the general population and among healthcare workers, from among the various mental problems engendered by the COVID-19 pandemic (Lima et al., 2020). The studies indicate that these two disorders' genesis is attributable to physiological, biochemical, and behavioral factors (Tsamakis et al., 2020). Measures implemented to mitigate the virus-spread, such as social isolation, can have adverse effects on mental well-being and lead to depression or anxiety conditions. 

The findings in this study have established that exposure to COVID-19 can result in insomnia, heightened social risk sensitivity, and increased stress levels caused by a reduction in mental well-being due to the pandemic's traumatic events. Studies have indicated that prolonged exposure to stress increases the hormone cortisol levels, which impede the activities of the immune system components (immunoglobulin A, neutrophils, anti-inflammatory cytokines), resulting in increased susceptibility to infection (Khanal et al., 2020). The current studies are insufficient to fully represent the impact of the COVID-19 pandemic on the population and healthcare workers' mental health, and further studies are required to achieve this purpose.

Limitations of studies

A majority of the studies included in this review collected information through online surveys and self-reports, both of which have inherent limitations.  None of the studies employed longitudinal studies, and as such, the long-term psychological impact cannot be accounted for. The studies were also influenced by the social insecurities that abound during the studies, such as psychological risk factors and the effects of stigma.