Depressive and anxious symptoms and insomnia, and possible associated factors in health workers, in a General Hospital in South America, during the COVID-19 pandemic in 2020.

ABSTRACT

Key words: mental health; COVID-19, pandemic.

INTRODUCTION

In November 2019, a new disease caused by coronavirus 19 was reported in Wuhan (China), since then there was a rapid global spread, it was initially declared a public health emergency and later a pandemic, by the World Health Organization (WHO) in March 2020. By the beginning of March 2021, globally, 113820168 people had been diagnosed with COVID-19 and 2527891 had died(1); by March 2021, there had been 2255260 cases and 59866 deaths(1). In Colombia, the first case was reported on March 6, 2020.

Most people with COVID-19 experience mild or moderate symptoms of the illness. Approximately 10-15% progress to severe disease and 5% become critically ill. Some symptoms may persist or recur after weeks or months of initial recovery, even in people with mild disease.(3)

The rapid spread of the disease has collapsed care systems and generated greater workloads and stress in health teams. According to WHO reports for September 2020, about 570000 health workers had been infected and by May 2021, 115000 had died from COVID-19 in the Americas. The effects of this overload and stress, added to those of working in constant risk of infection, obviously generate mental health problems, no less important than the physical ones, derived from the COVID-19 infection.(4)

Health personnel have been exposed to great challenges during the pandemic, which have imposed a significant emotional and labor burden, which can translate into higher rates of depression, anxiety, insomnia and post-traumatic stress(5).It has been suggested that some specific factors increase the risk of developing mental health problems in health personnel, including working in higher risk environments, isolation, work-related stress and working in some specific hospital areas. Some factors that could be protective have also been identified, such as the perception of safety with personal protection elements and having specialized training.(6)

The short and long-term effects on mental health in health personnel exposed to the psychosocial consequences of the pandemic warrant the implementation of preventive strategies and prompt treatment, to avoid disastrous outcomes or chronification of mental health disorders, reason for which it is relevant to identify who could be the most susceptible people, in order to focus these interventions on those who most require it. In the search for this most vulnerable population, it is pertinent to identify the factors associated with this

affectation.

There are still few studies that focus on the mental health of health workers. In China, rates greater than 50% for depression, 45% for anxiety and 7% for post-traumatic stress disorder have been reported in the most affected areas by the pandemic(5,6). Several studies carried out in Latin America during the pandemic have shown prevalences ranging between 32.2 - 66% for depression, 41.3 - 74% for anxiety and 27.8 - 65% for

insomnia.(6,7)

The objective of this study was to evaluate the frequency of depressive symptoms, anxiety and insomnia of medical and nursing staff, during the first peak of the pandemic and to identify possible factors associated with its development.

METHODS

Study design and context

Cross-sectional study, carried out at the Pablo Tobón Uribe Hospital, a fourth-level institution in the City of Medellín, which has been a reference center during the COVID-19 pandemic; in which 479 medical doctors, 289 professional nurses and 800 nursing assistants work, with a stable employment relationship.

Study population

An invitation to participate in the study was sent to the universe of these personnel, between July 30th and October 23rd, 2020, the time in which the first peak of the pandemic occurred in

the city.

Measurement variables and sources

The data was collected in a self-administered Google forms questionnaire, after accepting an informed consent presented at the beginning of the form.

Basic demographic data included age, gender, marital status, occupation, years of work experience. Age was categorized into three groups, 30 years or younger, 31 to 44, and 45 years or older. Work experience was categorized into 10 or fewer years and more than 10 years. The presence of depressive, anxious and insomnia symptoms prior to the pandemic was inquired about. Variables directly related to the pandemic situation were also evaluated, such as isolation from the family group, change in job role (modification of area/functions), stigmatization as a result of being health care personnel, perception of safety with personal protection elements (PPE), adequate family support, satisfaction of basic needs and knowledge/use of the psychological/psychiatric support service within the

Hospital.

Three self-report scales were used to screen symptoms of depression, anxiety and insomnia; all participants who scored normal were considered asymptomatic and the rest as

symptomatic:

PHQ-9 (9-item Patient Health Questionnaire) Spanish version(8), validated in Chile(9), assesses the presence and severity of depressive symptoms and categorizes the scores as follows: normal 0-4, mild depression 5-9, moderate depression 10-14, severe

depression 15-21.

GAD-7 (7-item Generalized Anxiety Disorder(10) Spanish version(11), assesses the severity of anxious symptoms and categorizes it as follows: normal 0–4, mild anxiety 5–9, moderate anxiety 10–14, and severe anxiety 15–21.

ISI (7-item Insomnia Severity Index, range 0 to 28 points)(12), Spanish version(13), assesses insomnia and is categorized as follows: normal 0–7, subthreshold 8–14, moderate insomnia 15–21, and severe insomnia 22–28.

At the time of data collection, none of the scales had been validated in Colombia, later the PHQ-9 was validated in the

country.

Analysis of data

Qualitative variables are presented as absolute number and percentage. The quantitative variable age is presented with mean and standard deviation. The association between the characteristics identified in the literature and contemplated in the protocol and the appearance of symptoms of depression, anxiety and insomnia was evaluated. A priori, the variables that could influence the appearance of the conditions were defined. Univariate and then multivariate analysis were performed with a logistic regression model with the enter mode in SPSS 23 software. The ORs are presented, both crude and adjusted, with their 95% confidence intervals.

Ethical aspects

This study was approved by the Research Ethics Committee of the Pablo Tobón Uribe Hospital. The participants were offered the possibility of having a telephone contact for guidance in case of doubts or in case of any affectation as a result of emotional reactions, which could have been triggered by the content of the

survey.

RESULTS

Demographic characteristics of the participants

From a total of 1568 health workers at the Pablo Tobón Uribe Hospital, data were collected from 876 people (55.8%) between 18 and 66 years old (M = 34.2; SD = 9.96), the majority were women, under 44 years old, with satisfied basic needs and good family support (Table 1). 15% did not feel safe with the PPE provided by the hospital, 43.6% felt stigmatized for being health personnel, 22.6% had a change of work role, and 25.8% isolated themselves from their family nucleus due to the pandemic.

Frequency of depressive, anxiety and insomnia symptoms

Of the total participants, 26 (3%) reported that they had symptoms of depression, 28 (3.2%) anxiety, and 54 (6.1%) insomnia prior to the pandemic. At the time of answering the survey, 357 (40.8%) people had depressive symptoms, 300 (34.2%) anxious symptoms and 317 (36.2%) insomnia. The frequency of depressive symptoms in medical doctors was 34.4%, in nurses 46.2% and in nursing assistants 42.2%. The frequency of anxious symptoms in doctors was 27%, in nurses 24.3% and in auxiliaries 48.7%. The frequency of insomnia in doctors was 22.4%, in nurses 26.5% and in nursing assistants 51.1%.

Factors associated with depressive symptoms, anxiety and insomnia

After controlling for other factors that potentially influence its appearance, female sex, previous anxiety and insomnia, social isolation, change in job role, stigmatization, lack of perception of safety with PPE, lack of family support and having unsatisfied basic needs were independently associated with the presence of symptoms of depression (Table 2). Being a nursing assistant, which in the univariate analysis shows an increase in risk (OR 1.4 95% CI 1.0-1.9), after adjustment for other characteristics becomes a protective factor (OR 0.5 9% CI 0.3-0.8) , compared to being a medical doctor. History of depression did not influence after controlling for other factors. (Table 2)

Being under 44 years of age, a history of anxiety, the feeling of stigmatization for being health personnel, the perception of lack of safety with PPE, poor family support and having unsatisfied basic needs were associated with an increase in the appearance of anxiety symptoms. Being a nursing assistant and being single, seem to decrease the frequency of these symptoms. (Table 3)

Being separated, having a history of insomnia, and feelings of isolation, stigmatization, and not having basic needs met, were associated with an increased occurrence of insomnia symptoms. Being aware of psychological support, even if it had not been used, was associated with a decrease in this symptom (Table 4).

Symptoms of depression, anxiety and insomnia were simultaneously observed in people who perceived that their basic needs were not met and in those who felt stigmatized for being health personnel. On the other hand, being a nurse, having a history of depression or years of work experience were not associated with any of the three outcomes.

DISCUSSION

In this investigation it was found that a few weeks after exposure to the pandemic, which involves, among other aspects, the attention of infected patients, social isolation, the socioeconomic consequences of measures to contain it and job changes, among others; increased significantly the presence of symptoms of depression, anxiety and insomnia in health personnel potentially exposed to the care of patients with COVID-19, regardless of their profession.The frequency of symptoms of depression, anxiety and insomnia in this study was 40.8%, 34.2% and 36.2%, respectively; ten times higher than what they perceived before the start of the pandemic.

Regardless of the pandemic situation, several factors are considered to be associated with the appearance of depressive and anxiety symptoms (female sex, previous anxiety and insomnia, lack of family support and not having basic needs met). Others, such as isolation, lack of perception of safety with PPE, stigmatization, and change in work role, are situations typical of the pandemic that impose additional stress and have already been described in other studies.(14)

During the pandemic, there have been behaviors of discrimination and aggression towards health personnel, considering them guilty of the spread of the virus and causing stigmatization in this group; stigma can make people feel isolated, abandoned and more prone to emotional affectation.(15,16)

On the other hand, for many people the pandemic brought economic consequences, unemployment in household members, decrease in family income and, therefore, difficulty in accessing essential goods and services to satisfy basic needs.(17)

The most significant finding of this study was the association between the feeling of stigmatization and the perception of not having basic needs met, with the affectation of mental health, reflected in greater symptoms of depression, anxiety and insomnia. In our study we did not find an association between symptoms of depression, anxiety or insomnia with the employment role of the participants, contrary to what was observed in other studies that have found higher rates of affective symptoms in nursing staff.(18)

Paradoxically, our findings suggest that being a nursing assistant, under equal conditions with respect to the other variables, was protective for having symptoms of depression and anxiety, which is striking and likely to be evaluated in future research.

Comparing our findings with other studies, using similar measurement instruments, a lower frequency of symptoms of depression, anxiety and insomnia, compared to other countries (with the exception of Paraguay), was found. A Chinese study(19), reported 50.4%, 44.6% and 34%, respectively; in one made in Chile(7), 65%, 74% and 65%, respectively; in Paraguay(twenty)32.2%, 41.3% and 27.8% respectively and in Turkey(twenty-one), 77.6%, 60.2% and 50.4%, respectively.

This lower frequency of involvement in the population evaluated in this study could be explained by the measures implemented for safety at work (PPE, evaluations through teleconsultation in patients of covid units) and the availability of psychotherapeutic support to staff.

There are few studies carried out before the pandemic regarding the prevalence of depressive, anxious and insomnia symptoms in the health population (in nurses it has been described a prevalence of depression of 32.4%, anxiety of 41.2% and insomnia of 31%)(22), which limits the possibility of comparing the findings with this research.

Similar to what was found in the literature, our study shows that younger patients present more frequently anxious symptoms, which suggests the need to reinforce coping strategies in new generations(20). Other authors have reported an association of depression, anxiety, and insomnia with being a woman, being a nurse, having a history of mental illness, and having had psychiatric support during the pandemic.(18,19,21)

Various strategies have been proposed to mitigate the impact on the mental health of workers during the pandemic, including providing adequate PPE and rotating shifts that allow adequate rest(23). Another strategy is to have specialized mental health services, for the intervention of health personnel who care for patients infected with COVID-19.(24)

A focus of attention has been the stigma in relation to health workers who care for patients with COVID and its potential effect on mental health. The impact of stigma is very serious, however, health personnel are often unaware of these behaviors and attitudes(16,25).There are few studies in the literature that correlate stigma with depression, anxiety, and insomnia. An investigation carried out in Nepal shows an adjusted OR for depression of 2.05 (95% CI: 1.34-3.11), for anxiety of 2.47 (95% CI: 1.62-3.76) and for insomnia of 2.37 (95% CI: 1.46-3.84)(26) findings similar to ours.

To date, we have not found other studies that relate unsatisfied basic needs with symptoms of depression, anxiety and insomnia; as found in this investigation.

Limitations

The survey was completed by only 55.8% of the Hospital’s health personnel, possibly due to the conditions caused by the pandemic and the demands for the health sector.

Some variables that could have had an impact on the appearance of symptoms of depression, anxiety and insomnia, such as having been infected or having had an infected family member, were not evaluated.

We do not have previous objective measurements regarding the frequency of depression, anxiety and insomnia in the care staff of our institution, to compare with the findings during the pandemic, but the differences in the frequency found with respect to the report of previous symptoms, allows us to propose that the increase found is real.

A face-to-face interview with staff was not conducted, which could limit the understanding of some of the questions in the online survey.

CONCLUSION

Our study showed significant rates of depressive, anxiety, and insomnia symptoms in health workers during the COVID-19 pandemic, however, the figures were not as high as those reported in other countries (China, Chile, and Turkey).

Feeling stigmatized and not having basic needs met were factors associated with the three outcomes. It is recommended to monitor affected personnel during the pandemic to assess whether symptoms persist and to offer prompt psychological and/or psychiatric intervention.

It would therefore be of great importance that, from the occupational health and psychology area of health institutions, direct work be established with the staff to identify their needs, provide support if necessary, and strengthen their coping capacity and tolerance in the face of behaviors of the general population. Stigmatization arises, in part, from ignorance and fear of contracting the disease, in this sense, it is vitally important to educate people about the mechanisms of transmission of the virus, to avoid discriminatory behavior towards health personnel.

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