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.