key: cord-0738418-3t0y8l0f authors: Pedraz-Petrozzi, Bruno; Krüger-Malpartida, Hever; Arevalo-Flores, Martin; Salmavides-Cuba, Frine; Anculle-Arauco, Victor; Dancuart-Mendoza, Mauricio title: Emotional impact on health personnel, medical students, and general population samples during the COVID-19 pandemic in Lima, Peru date: 2021-06-05 journal: Rev Colomb Psiquiatr DOI: 10.1016/j.rcp.2021.04.006 sha: 14f53dbab0d7b67b1fdfaeff874f5e631a4b4ba2 doc_id: 738418 cord_uid: 3t0y8l0f Background: The aim of the study is to compare the emotional effects of COVID-19 among three different groups, namely: health personnel, medical students, and a sample of the general population. Methods: 375 participants were recruited for this study, of which 125 were medical students (preclinical studies, 59; clinical studies, 66), 125 were health personnel (COVID-19 frontline personnel, 59; personnel not related with COVID-19, 66), and 125 belonged to the general population. The PHQ-9, GAD-7, and CPDI scales were used to assess the emotional impact. A multinomial logistic regression was performed to measure differences between groups, considering potential confounding factors. Results: Regarding CPDI values, all other groups showed reduced values compared to COVID-19 frontline personnel. However, the general population, preclinical and clinical medical students showed increased PHQ-9 values compared to COVID-19 frontline personnel. Finally, confounding factors, gender and age correlated negatively with higher CPDI and PHQ-9 scores. Conclusions: Being frontline personnel is associated with increased COVID-19-related stress. Depression is associated, however, with other groups not directly involved with the treatment of COVID-19 patients. Female gender and younger age correlated with COVID-19-related depression and stress. Métodos: Se incluyó a 375 participantes en este estudio, de los que 125 eran estudiantes de Medicina (estudios preclínicos, 59; estudios clínicos, 66), 125 eran personal de salud (personal de primera línea contra la COVID-19, 59; personal no relacionado con la COVID-19, 66) y 125 pertenecían a la población general. Las escalas PHQ-9, GAD-7 y CPDI se utilizaron para evaluar el impacto emocional. Se realizó una regresión logística multinomial para medir las diferencias entre grupos, considerando posibles factores de confusión. Resultados: Con respecto a los valores del CPDI, todos los demás grupos mostraron valores reducidos en comparación con el personal de primera línea contra la COVID-19. Sin embargo, la población general y los estudiantes de Medicina preclínica y clínica mostraron un aumento de los valores del PHQ-9 en comparación con el personal en primera línea. Por último, los factores de confusión, sexo y edad se correlacionaron negativamente con puntuaciones más altas del CPDI y el PHQ-9. Conclusiones: Ser personal de primera línea se asocia con más estrés relacionado con la COVID-19. Sin embargo, la depresión está asociada con otros grupos que no están directamente involucrados en el tratamiento de los pacientes con COVID-19. Las mujeres y los participantes más jóvenes se correlacionaron con la depresión y el estrés relacionados con la COVID-19. Palabras clave: Salud mental Pandemias América Latina [1] Introduction Since the first case reports, the coronavirus disease of 2019 (COVID-19) has spread rapidly and has caused diverse negative changes in the world population. These involved not only social restrictions, but also negative consequences for the mental health of society. Different groups, who work actively with COVID-19 1 as well as those who have to comply with the COVID-19 lockdown rules, 2 are exposed to higher stress, anxiety, and depression rates. For instance, two cross-sectional studies revealed that during the COVID-19 pandemic, college students reported high levels of mental health distress and academic difficulties, 3, 4 causing a significant negative impact on their mental health. 3, 4 Another study in Pakistan, which involved active COVID-19 frontline health personnel, found higher prevalence rates with moderateto-severe anxiety and depression scores. 5 Similar results have been found in the study of AlAteeq et al. This study revealed that depression and anxiety symptoms are prevalent among COVID-19 health personnel. 6 Depression and anxiety are not only prevalent in health personnel, but also in medical students, who are health personnel in training. In this case, a study with medical students reported that almost twothirds of the medical students showed moderate-to-severe symptoms of depression. 7 Furthermore, the same study found that half of these students showed higher anxiety symptoms. In this case, and similar to the health personnel, medical students are affected severely by mental health issues related to the COVID-19 pandemic- [7] [8] [9] These negative consequences of the COVID-19 pandemic have also affected the general population not related directly to COVID-19. A Peruvian study showed that almost half of the participants showed mild to severe scores related to COVID-19 related stress. 10 Other non-healthcare workers have reported that processing COVID-19 information is correlated positively with distress levels. 11 Another example with the general population not related to health professions is the study of Zhang et al. Higher levels of depression were found among the general population during the COVID-19 pandemic, mostly related to stress and hopeless feelings. 12 Pandemics (e.g., are mostly related to higher rates of depression, [13] [14] [15] anxiety 16, 17 and stress 18, 19 reported in general population, health personnel and medical students. Despite the numerous reports, few studies compare the aforementioned groups. The information obtained regarding this matter will establish J o u r n a l P r e -p r o o f better intervention policies to prioritize the most affected population groups, offering medical intervention, social and therapeutic support. To this end, the main objective of this study is to find out differences between medical students, COVID-19 frontline health personnel, health personnel not exposed to COVID-19, and the general population, regarding depression, anxiety, and distress scores. Participants younger than 18 years old, with insufficient knowledge of Spanish and medical difficulties that could restrict the participation (i.e., learning difficulties, especially illiteracy as well incomplete school studies, or blindness) in the online survey were not included in this study. All participants were fully informed of the study and gave their consent to participate. This study was approved by the ethics committee from the Faculty of Medicine of the Peruvian University Cayetano Heredia and carried out in accordance with the Helsinki Declaration and the ethical standards of the APA. [2] Data collection [3] Online survey The information of this study comes from a database of a study project that englobes emotional impact and COVID-19 pandemics. Part of this information was For the data collection, an online survey was carried out. Due to the restrictive policies for avoiding COVID-19 contagions, all instruments and questions were digitalized and programmed in using a free internet survey program (Google Forms). Afterwards, the online survey was distributed through different social media (i.e., Facebook, Twitter, Instagram, LinkedIn, etc.) and using the principles of the snowballing sampling for the data recollection. In case of the medical students, we distributed also the online survey by using the e-mail program of the university and to different social groups of the UPCH medical faculty. The questions included: informed consent, general information (i.e., age, gender, district, confession/faith, and occupation), previous medical diagnosis and medication intake, and the COVID-19 peritraumatic distress index (CPDI) for the COVID-19 pandemic, GAD-7, and PHQ-9 instruments. Before answering the questions, each participant must accept its participation through the informed consent and declare that the participant is full age (i.e., 18 years old). Finally, additional questions were asked, as follows: "In the last 14 days, did you have a cough, difficulty breathing, sore throat, and fever?" (COVID_1); "Do you have positive results for any COVID-19 test?" (COVID_2); "Have you been hospitalized (or are you hospitalized at the moment) due to COVID-19?" (COVID_3); "Do you have relatives with positive results for any COVID-19 test?" (COVID_4); "Do you have relatives who were hospitalized due to COVID-19?" (COVID_5), and "Do you have relatives who have passed away due to COVID-19?" (COVID_6). This instrument consists of 24 items, with a four-factor design: negative mood, cognition, behavioral change, somatization, and hyperarousal/exhaustion. Each item was evaluated by using Likert elements (from 0 to 4: never, occasionally, sometimes, often, and most of the time). 10 The sum of each value per question results in the raw score. The displayed score is obtained by adding 4 to the raw score and used to calculate the CPDI severity degrees. For this reason, this instrument defines different categories for peritraumatic stress due to the COVID-19 pandemic: normal (0 to 28 display points), mild (29 to 52 display points, and severe (53 to 100 display points). 10 [3] Depressive and anxiety symptoms The authors of this study followed the definition of depression and anxiety used in a recent study of Krüger-Malpartida et al., published elsewhere. 10 Some methodological aspects of this article were followed also in this study. The Peruvian version of the PHQ-9 23 The "block" that best explained the data was chosen by using the Akaike information criterion (AIC). The results of this statistical modeling are presented in "Results". The odds ratio (OR) was flagged as "significant" if the 2-tailed P-value was <.05. The 95% confidence intervals (95%CI) were calculated for this model. Descriptive data regarding anxiety scores, depression scores, and CPDI scores are presented in table 3. This study's objective was to find out differences between the 5 established groups (i.e., GP, MS-pre, MS-cli, HP and HP-COVID) regarding depression, anxiety, and distress scores. Variables were introduced stepwise in 4 different blocks. The block which best explained the data was chosen using a smaller AIC. In this case, Block 2 was chosen as the model that could best explain the data of the 5 groups (Block 1, χ 2 (df=12)=63.10, AIC=1139; Block 2, χ 2 (df=20)=408.40, AIC=809; Block 3, χ 2 (df=44)=442.40, AIC=823; Block 4, χ 2 (df=56)=462.10, AIC=828). Block 2 included the variables age, gender, CPDI scores, GAD-7 scores, PHQ-9 scores as predictors. Different correlations were found between the 5 groups. These are presented in To the best of our knowledge, there is information on this line of evidence that could be comparable to our results. For instance, Naser et al. published a cross-sectional study comparing the adverse effects of the COVID-19 pandemic in three different groups: university students, health care professionals, and the general population. They found that mental health problems (i.e., anxiety and depression) were more prevalent in university students. 28 In this study, the groups of medical students showed correlations with PHQ-9 values compared to the HP-COVID group. However, no correlations were seen for anxiety scores (table 4). These outcomes revealing higher depression values among medical students could be due to the social restrictions that obligate many medical students to abandon their studies. 7, 9, 29 The switch to distance education and the suspension of clinical activities or night shifts could have negatively influenced this group's mental health, leading mostly to adverse mood effects. 7, 9, 29 Krishnamoorthy et al. published a meta-analysis indicating that during pandemic, health professionals have a higher prevalence of psychological morbidities than the general population, characterized mostly by psychological distress and poor sleep quality. 30 The results of this study indeed support that higher values of psychological distress are correlated to the COVID-19 frontline health personnel group. However, being part of the general population is mostly correlated with higher depression scores. Frontline professionals are faced most of the time with fears of getting infected or infecting others. 30 Other concerns, like personal protection, death of their own colleagues, or excess working hours, could have influenced the obtained results. On the other hand, the general population is exposed to isolation due to the sanitary restrictions. 10,29,31 People belonging to the general population are confined in their homes and have their transit restricted. 10,29,31 This could lead to higher values of depression, poor sleep quality, hopeless feelings, and suicidal thoughts. 32, 33 Also remarkable are the results between HP and HP-COVID (table 4). In this case, being a COVID-19 frontline health professional is correlated with higher values of psychological distress due to COVID-19 (CPDI). Our results could be comparable with the findings of Cai et al. 34 In this mentioned study, COVID-19 frontline medical workers have higher rates of mental health problems of any kind compared to nonfrontline medical workers. 34 (table 4 and table 5 ). This could mean that age and gender could also have influenced in the correlations found by this multinomial logistic regression. In this case, younger age or female gender correlated with higher scores of the aforementioned psychological instruments (i.e., PHQ-9 and CPDI). These obtained results coincided with other studies that have found associations with female gender and age of the participant. 21, 28, 35, 36 Although these results contribute to the actual COVID-19 pandemic's panorama, concerning mostly adverse effects on mental health as an emotional impact, the reader must consider some limitations. Firstly, the sampling procedure (in this case the snowballing method) could contravene the principle of randomization. However, the social restrictions due to COVID-19 pandemic made it difficult to have direct contact with other persons, making the online distribution of the survey one of the most suitable methods for recruiting participants and recollecting data. Moreover, the sample size could be larger to generalize the results beyond the study's scope. However, the power obtained from this study with 375 participants and 5 groups was 1-β=.93, a value that overcame the 1-β=.80 threshold. Therefore, the sample size for the study design should be sufficient to examine the expected effects. Also, the higher total of women compared to men could have influenced the results. However, studies related to COVID-19 lockdown distress have also reported a higher proportion of female participants, which is also reflected in this study. As expected, there were many very low CPDI, PHQ-9 and GAD-7 scores in the evaluated participants, which led to skewed distributions. Multinomial logistic regression was computed to overcome this limitation because there is no consideration regarding skewed statistical distributions. Finally, medication intake, previous medical conditions, and district of residence could affect COVID-19 distress scores. All these variables were included in the model. However, these variables did not appear to affect the results of the current study. In conclusion, being a COVID-19 frontline health personnel is associated with more psychological distress, involving harmful behavioral and emotional components. This could be related to the fact that frontline health professionals confront excess working hours, their colleagues' death, fear of being infected, among others. On the other hand, higher depression scores were associated mostly with other groups not Helped with the data recollection and contributed with the proofreading. [1] Conflict of interests J o u r n a l P r e -p r o o f Mental health of front-line staff in prevention of coronavirus disease 2019. Zhong nan da xue xue bao. 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Association of self-perceptions of aging, personal and family resources and loneliness with psychological distress during the lock-down period of COVID-19 GP: general population; HP: health personnel (not COVID-19 frontline health personnel) COVID-19 frontline health personnel; MS-cli: medical students, clinical studies; MS-pre: medical students, pre-clinical studies COVID_1: in the last 14 days, did you have cough, difficulty breathing, sore throat and fever?; COVID_2: do you have positive results for any sort of COVID-19 test? the moment) due to COVID-19?; COVID_4: do you have relatives with positive results for any sort of COVID-19 test?; COVID_5: do you have relatives who were hospitalized due to COVID-19?; COVID_6: do you have relatives who have passed away? Data shown as n (%), mean ± standard deviation, or median PHQ-9 values, correlations with gender and age Gender Age GP vs. HP-COVID rs= HP-COVID rs=-.26, P=.004* rs=-.29, P=.001* CPDI values, correlations with gender and age Gender Age GP vs. HP-COVID rs= HP-COVID rs=-.30, P=.001* rs=-.19 HP vs. HP-COVID rs= CPDI: COVID-19 peritraumatic distress index; GAD-7: general anxiety disorder questionnaire 7; GP: general population; HP: health personnel COVID-19 frontline health personnel; MS-cli: medical students, clinical studies; MS-pre: medical students, pre-clinical studies PHQ-9: patient health questionnaire 9 The authors declare no conflict of interests.