Mental health consequences of COVID-19 in house staff physicians

Introduction

The global health emergency caused by the coronavirus disease 2019 (COVID-19) that emerged in the city of Wuhan, capital of Hubei province in China, in late 2019 has posed one of the greatest challenges to frontline health care workers.¹ In Panama, COVID-19 was detected early March 2020; although the country rapidly implemented control and mitigation strategies, Panama has one of the highest cumulative case incidences in the Americas.² By July 7, 2020, COVID-19 seroprevalence in Panama was estimated around 11.7% in health care worker.³

As countries have adopted draconian social distancing measures to reduce infections, there has been an increase in stressors that will likely increase the risk of psychiatric illness in the months following infection waves.⁴ In health care workers, the workload, the scarcity of personal protective equipment and the fear of contaminating family and friends are added to the risk for those who are in the front line of patient care, potentially triggering anxiety, fatigue, depression, irritability, fear, insomnia, among others. However, despite the efforts to comply with governmental plans to control the epidemic, it has been seen in studies related to severe acute respiratory syndrome (SARS) in 2003, that although affected people and health workers were motivated to comply with quarantine to reduce the risk of infecting others, emotional distress tempted some to consider violating disease control measures.⁵

It is evident that the pandemic has led to an increase in the prevalence of mental health disorders in the world's population.⁶ Health care workers are no exception to this reality, so it is necessary to know the factors that influence mental health outcomes due to de COVID-19 pandemic, in order to make a comprehensive approach to support those who are in the first line of care.

Intern physicians carry out visits, prepare clinical histories, evaluate the daily evolutions of the clinical condition of patients, and attend teaching meetings, under the supervision of a medical officer. The responsibilities of resident physicians are established according to each medical residency program in their training hospital, but in general, they admit patients, undertake rotations in different medical specialties, conduct daily patient evaluations, among other responsibilities.

In Panama, medical internship and residency are carried out in public hospitals nationwide and affiliated with the Federación Nacional de Médicos Residentes e Internos (FENAMERI). Being in the front line of care, these physicians spend long working hours in hospitals and care centers, performing shifts on both weekdays and weekends. This poses a greater risk of infection, due to high workloads as the public health system reaches maximum capacity, added to the shortage of personal protective equipment, potentially triggering poor mental health.

Methods

This cross-sectional study was conducted during the COVID-19 pandemic based on a survey of resident physicians and interns working in public health facilities in Panama (potential respondents were 408 resident physicians and 797 interns nationwide) in July 2020 and affiliated with the National Federation of Resident Physicians and Interns (FENAMERI). The minimum respondent number needed was 349 house staff physicians (residents and interns), calculated through the statistical tool STATCALC (Epi Info) for population survey or descriptive study, and expecting a prevalence of mental alteration of at least 35% considering previous evidence following the 2003 SARS outbreak.⁷

The objective of the study was to determine the prevalence of mental health disorders in these populations, and identify associated factors related to sociodemographic characteristics, personal history, and exposure to SARS-CoV-2.

Between July 23 and August 13, a link containing an anonymized, self-report questionnaire was sent, disseminated through emails and WhatsApp using a snowball technique. Approval for this study was obtained from the National Committee on Research Bioethics (CNBI) and participants' informed consent was obtained online. The sampling period corresponded to the period of high incidence of COVID-19 infection, in accordance with high hospital occupancy at the national level.⁸

The questionnaire collected data on sociodemographic variables (sex, age, marital status, occupation), personal history (smoking, harmful use of alcohol assessed by the AUDIT-C scale,⁹ history of psychological trauma, history of psychiatric illness, family history of psychiatric illness) and exposure information (history of COVID-19 diagnosis, family member with COVID-19 diagnosis, infected colleagues, and whether they attended patients with COVID-19 in the last 15 days).

Mental health outcomes were self-reported symptoms of depression, generalized anxiety, and post-traumatic stress, using the nine-item Patient Health Questionnaire (PHQ-9) scales,¹⁰ the seven-item Generalized Anxiety Disorder scale (GAD-7),¹¹ and the 22-item Impact of Events Scale (IES-R).¹²

Study participants were sorted according to the presence or absence of these symptoms with the following cutoff points: at least 10 on the PHQ-9 questionnaire, at least 10 on the GAD-7, and at least 26 on the IES-R. Those who scored higher were considered as having a clinically significant range of mental health impairment. The cut-off points were extracted from the original articles describing each measure.^10–12

In order to protect the confidentiality of the participants, the data on the type of specialty were grouped into: surgical specialties (general surgery, cardiovascular surgery, ophthalmology, otorhinolaryngology, maxillofacial surgery, neurosurgery, vascular surgery, orthopedics), medical specialties (internal medicine and its subspecialties, psychiatry, physical medicine and rehabilitation, pediatrics and its subspecialties, occupational medicine, anesthesiology, preventive medicine), and diagnostic support specialties (pathology, radiology).

To analyse the results, frequencies and percentages were calculated for sociodemographic data, personal and family history, exposure to COVID-19 and prevalence of each mental health finding; then, univariable and multivariable logistic regression models were performed to explore associations between these results.

Results

Discussion

Our findings document a high prevalence of symptoms associated with mental health disorders during the first peak of COVID-19 cases in Panama. We found prevalence rates of 25.3% for depression, 13.7% for anxiety, and 12.2% for post-traumatic stress disorder, comparatively similar to those found in Dutch¹⁴ and Italian¹⁵ health personnel, but below those found during this outbreak in China.¹⁶

In high-incidence areas, an epidemic event of this magnitude is comparable to previous events such as SARS, during which a large percentage of health care workers in high-risk situations reported symptoms related to mental health disturbances.¹⁷

Female respondents were 1.74 to 4.34 times more likely to report a mental health disturbance compared to male participants, consistently with a systematic review by Ricci et al. where women were more likely than men to report mental health disorders, especially for schizotypal personality disorder (STPD).¹⁸ The history of psychological trauma in females as a risk factor for the development of mental health disorders may be attributed to gender differences in the rates and types of trauma exposure (e.g., natural disasters, motor vehicle accidents, rape, physical attack, combat).¹⁹

Most participants were medical interns, indicating that most of them had fewer years of work experience and were probably exposed to a higher risk of infection. The present study results indicated that having a history of psychological trauma and psychiatric pathology was associated with experiencing depression, generalized anxiety and post-traumatic stress disorder outcomes, in all models conducted. This is consistent with the findings of Young et al., in which healthcare workers with a history of mental illness were at increased risk for significant emotional symptoms.²⁰

Being married was associated with depressive symptoms, which may be due to competing family responsibilities and/or fear of partner contagion. This pattern was also observed during the SARS epidemics in 2003 in China²¹ and Canada.²² On the other hand, occupying physician in surgical specialties roles reduced the risk of post-traumatic stress and of developing at least one mental health disorder. Elective surgeries were suspended in all hospitals in the country, as a preventive measure adopted by the Ministry of Health, to limit transmission risks in hospital settings.²³

As previous studies indicate, smoking is an important mental health aggravating factor, and in this study, smokers had a two to five times greater risk of PTSD, and a two-fold greater risk of at least one mental health disturbance compared to non-smokers.²⁴ These findings could be in part due to the pandemic generating factors that contribute to smoking initiation, or the vulnerability of people with a significant psychological history having triggered the habit of smoking.²⁵

A troubling finding emerging from the depression data is the rate of individuals reporting positive responses to item 9 of the PHQ-9 questionnaire (“How often do you think you would be better off dead or hurt in some way?”). Of the respondents, 9.3% reported having suicidal thoughts; among them, 0.8% reported having suicidal ideation half of the days and 8.5% reported experiencing it almost every day. This result indicated elevated suicidal ideation above that found in U.S. health care workers by Young et al.²⁰ and close to that reported by the CDC, with 10.7% of persons experiencing suicidal thoughts associated with the COVID-19 pandemic.²⁶

In a study to determine whether responses to the PHQ-9 questionnaire predict subsequent suicide attempt or death by suicide, Simon et al. found that those individuals with positive responses to item 9 of the PHQ-9 were six times more likely to attempt suicide and five times more likely to die by suicide within one year than those who did not report such thoughts.²⁷ Another study by Rossom et al. demonstrated that patients with any level of suicidal ideation on item 9 of the PHQ-9 were almost twice as likely to attempt suicide in the following year.²⁸

Additionally, our findings indicate that exposure to COVID-19 at work or at home through the a family member being ill with COVID-19, independently contributed to presenting with all three mental health disturbances together and post-traumatic stress, respectively. Similar results were evident during the SARS epidemic in 2003 where having had a family member or friend with SARS was a strong predictor of the level of post-traumatic stress symptoms, suggesting a special feature of the psychosocial effects of infectious disease outbreaks, which can be differentiated from other disasters.²¹

Previous studies have shown that young physicians are a vulnerable professional group, requiring professional support to prevent mental health disorders due to long working hours, and support from senior physicians may have a positive effect on some of these disorders, especially in global health emergencies.²⁹

Despite a response rate of 42.9%, non-response bias may exist if the remaining resident physicians and interns showed less interest in participating because they were not as emotionally affected by the current pandemic. Therefore, it is difficult to estimate how representative the responses are of the resident and intern population, or how biased the estimates might be due to nonresponse. On the other hand, we assume that the reliability of the responses is high, because the data collected in the survey are familiar to residents and interns and they are able to recognize the mental illnesses studied here. With the aim of assessing mental disturbances at the time of response, the questionnaire focused on symptoms during the last 15 days.

In summary, with a response rate of 42.9%, one third of our sample presented at least one clinically significant mental health disturbance (including suicidal ideation), with women being the most affected in all analyses. Our findings raise concerns about the psychological well-being of resident physicians and interns involved in care during the first wave of the COVID-19 epidemic in Panama. It is essential for institutions to intervene with those most at risk of presenting psychiatric symptoms and offer them sources of support to mitigate the emotional impact and increase resilience in situations of occupational stress.

Data availability