4. Discussion
In the present study, we assessed fear, anxiety, anxiety sensitivity, burnout, and insomnia of HCWs during COVID-19 outbreak and to identify their relation to sociodemographic and clinical characteristics in this population. Our results showed that the majority of HCWs had a fear of infecting their loved ones; the number of HCWs working in the COVID-19 wards and ICUs and experiencing burnout and insomnia was significantly higher; and female HCWs had a higher degree of anxiety, fear, burnout, and insomnia than male HCWs. In addition, the mean CAS and ISI scores were significantly higher among nurses, while the mean ASI-3 of the other HCWs and MBI scores of physicians were significantly higher. There was also a mild-to-moderate, positive, statistically significant correlation between the FCV-19S, CAS, ASI-3, MBI, and ISI scores.
It has been estimated that about 10 to 20% of all COVID-19 cases are HCWs19,20. As the HCWs have often a close contact with suspected or confirmed COVID-19 cases, they are at a high risk for being infected, making them asymptomatic COVID-19 carriers and a potent source of transmission out of the hospital21. The majority of HCWs experience psychological distress due to overwhelming workload and fear of being infected and infecting their loved ones3. Similarly, 95.2% of the HCWs had a fear of infecting their loved ones in our study. Self-isolation of HCWs to protect their family members and loved ones increases the psychological distress and mental health problems. Therefore, protection of HCWs with appropriate measures which minimize the infection risk, decreasing their workload, and providing physical and psychological counseling are recommended to reduce mental health problems among HCWs.
In the current study, the mean CAS, FCV-19S, MBI, and ISI scores were significantly higher in women than men. However, no statistically significant difference was observed in the mean ASI-3 scores between the two sexes. In the literature, it has been well documented that women more frequently experience depression and anxiety than men with a significantly higher rate of mental health problems. Previous studies reported that the rate of depression and anxiety was significantly higher among female HCWs than male HCWs22-25. In addition, the rate of depression was 1.6-fold higher in women than men, suggesting that sex is a risk factor for psychiatric illnesses26,27. This can be attributed to more frequent hormonal fluctuations in women than men and sex-specific frailty. The significantly higher CAS, FCV-19S, MBI, and ISI scores in female HCWs can be explained by this concept, requiring additional protective measures for this population during the COVID-19 pandemic.
Furthermore, the mean MBI and ISI scores were significantly higher in HCWs working in the COVID-19 clinics and ICUs than those who were not working in our study. However, we found no significant difference in the mean CAS, FCV-19S, and ASI-3 scores. In a study, individuals living in Wuhan, Hubei province of China, where the first case of COVID-19 was identified, more frequently experienced psychological problems than those living outside of Wuhan22. In addition, the authors reported that HCWs who involved in the care of confirmed cases experienced more depression, anxiety, and burnout symptoms7. However, some authors showed no significant difference in the depression and anxiety scores between HCWs working in the COVID-19 clinics and those who were not28. Nonetheless, having a closer contact and providing care to the confirmed COVID-19 cases in the pandemic clinics and ICUs may make HCWs susceptible to infection and transmit the disease to their loved ones, which pose a psychological distress for this population. Consistent with the literature, the mean ISI and MBI scores were significantly higher in HCWs working in the pandemic wards and ICUs. Although there are some findings supporting our results22, some authors have reported controversial results7. The significantly higher rate of burnout in our study can be attributed to the excessive workload, long hours of working, and uncertainty over the end of the pandemic. The significantly higher ISI scores can be explained by long hours of working and working in shifts (day/night). Unlike previous findings, however, we found no statistically significant difference in the mean CAS, FCV-19S, and ASI-3 scores between HCWs working in the COVID-19 clinics and those who were not, probably due to the fact that not only HCWs working in the pandemic clinics or ICUs, but also all HCWs experience fear and anxiety stemming from excessive workload, long hours of working, constant exposure to massive data about COVID-19 in visual and print media, and a poor social support network due to COVID-19 restrictions.
Several studies have shown that HCWs are exposed to many psychosocial stressors, leading to mental health problems including depression, anxiety, insomnia, and burnout4,22,25,29. In a study, 56.59% of HCWs reported anxiety, depression, and insomnia symptoms, while the symptoms were mild in 38.47% and moderate in 18.12% of them30. In this study, these symptoms were most frequently seen in nurses and less frequently seen in residents. In another study investigating the prevalence of burnout in HCWs, the overall burnout rate was 31.4% with the highest rate among nurses29. In a Chinese study, HCWs providing care to COVID-19 cases experienced more frequent anxiety, depression, and insomnia symptoms and these symptoms were more prevalent among nurses than physicians22. In another study investigating the psychological effect of COVID-19 and coping strategies of frontline HCWs, nurses felt more anxious and nervous while working on the ward than the other HCWs31. Similarly, the mean CAS and ISI scores were significantly higher in nurses in our study, while the mean ASI-3 scores of the other HCWs and MBI scores of the physicians were significantly higher. However, there was no significant difference in the other variables among the work groups. It has been well established that HCWs are at a high risk for mental health problems with varying complaints in different settings. Although it is difficult to describe these problems as a single entity, HCWs are clearly at a high risk for COVID-19 infection, irrespective of the work description. Therefore, it would be wise to protect HCWs with appropriate measures, improve the working conditions and settings, decreasing their workload, providing social support network, and increase their awareness on mental health problems.
Previous studies have demonstrated that the presence of accompanying chronic diseases is a risk factor for psychiatric illnesses during the COVID-19 pandemic32-34. In their study, Özdin and Özdin33 assessed the degree of depression, anxiety, and health-related anxiety during the pandemic and found that 15.7% of the participants had an accompanying chronic disease with a significantly higher anxiety level. Moreover, elderly and those with chronic diseases were shown to be at a higher risk for COVID-19 infection35 and advanced age and accompanying chronic diseases were the major risk factors for COVID-19-related mortality36. Consistent with these findings, we also found significantly higher MBI scores in HCWs having an accompanying chronic disease. An excessive amount of news and reports released since the start of pandemic regarding the increased risk for COVID-19 in individuals with chronic diseases; relevant expert statements in mass media; and the particular emphasis on this subject for COVID-19 restrictions may have put an additional pressure on this vulnerable population, as well as HCWs, and made them feel less secure.
Furthermore, several studies have suggested that individuals with an accompanying psychiatric illness are more affected by COVID-19 pandemic-related consequences and more prone to mental health problems32-34,37. In a study carried out during the peak of the pandemic with strict lockdown measures, symptoms of depression, anxiety, stress, and insomnia were more severe with a higher rate of impulsivity and intense suicidal ideation in psychiatric patients than healthy controls34. Immediate changes such as infectious disease outbreaks can cause emotional distress and anxiety, adversely affecting the health of psychiatric patients and disrupting their access to the healthcare services38. Throughout the world, many hospitals have deferred non-urgent visits and procedures of non-COVID-19 patients and mostly admitted only COVID-19 cases. This is one of the main reasons for the inability to access to psychiatry services for all individuals including HCWs with a psychiatric illness. Undoubtedly, it is essential to take necessary measures and maintain treatment of these patients in the practice of psychiatry. Consistent with the literature, the mean CAS, MBI, and ISI scores of the HCWs with an accompanying psychiatric illness were significantly higher in our study, indicating a greater risk for this population.
Mental health of HCWs should be evaluated from various aspects. A series of factors should be considered to implement psychological interventions, including external factors (i.e. , social support and demographic risk factors)39. In a study, severe PTSD and burnout symptoms persisted in HCWs for 13 to 26 months after the 2003 SARS outbreak40. The spread of COVID-19 as a pandemic has also affected the mental health of HCWs adversely due to its high impact on the healthcare services. Therefore, longitudinal follow-up of this group of workers is critical for the accurate evaluation of mental health problems, and preventive measures should be taken and novel therapeutic options should be developed.
Furthermore, we found a mild-to-moderate, positive, statistically significant correlation between the FCV-19S, CAS, ASI-3, MBI, and ISI scores using a structural equation model. Accordingly, anxiety sensitivity showed a significant effect on increased CAS, FCV-19S, and MBI scores, leading to the sleep problems.