key: cord-0792926-f7pkpk6s authors: Thakur, B.; Pathak, M. title: Burden of predominant psychological reactions among the healthcare workers and general during COVID-19 pandemic phase: a systematic review and meta-analysis date: 2021-01-04 journal: nan DOI: 10.1101/2021.01.02.21249126 sha: c75c0f5b0cc93316e46a865a55cc3b465b6d9c6e doc_id: 792926 cord_uid: f7pkpk6s Aim: Present systematic review and meta-analysis examined the burden of psychological reactions predominantly anxiety, depression, stress and insomnia during novel COVID-19 pandemic phase among the frontline healthcare, non-frontline healthcare and general. Methodology: PubMed, EMBASE and SCOPUS were searched for studies between Jan 1, 2020 to May 25, 2020. Brief protocol of the systematic review was registered with the PROSPERO database, (CRD42020186229).Any study that reported the burden of at least one of psychological reactions including anxiety or depression or stress or insomnia was eligible. Heterogeneity was assessed using I2 statistic and results were synthesized using random effect meta-analysis. Results: Out of 52eligible studies, 43 reported anxiety, 43 reported depression, 20 reported stress and 11 reported insomnia. Overall prevalence for anxiety, depression, stress and insomnia were 26.6%, 26.2%,26.2% and 34.4% respectively. Anxiety and depression were found highest among the COVID-19 patients (43.3% and 51.75 respectively). Apart from COVID-19 patients, prevalence of anxiety, depression, stress and insomnia were found highest among the frontline healthcare (27.2%, 32.1%,55.6% and 34.4% respectively) as compared to general healthcare workers (26.9%, 15.7%, 7.0% and 34.0% respectively) and general population (25.9%, 25.9%,25.4% and 29.4% respectively). Conclusion: Anxiety and depression were found highest among the COVID-19 patients. Apart from COVID-19 patients, the anxiety, depression, stress and insomnia were more prevalent among frontline healthcare workers compared to general. Such increased prevalence is prompting towards the global mental health emergency. Therefore a call of urgent attention and pan-region effective mental-health intervention are required to mitigate these psychological reactions. The novel pneumonia caused by the coronavirus disease has emerged in the patients, healthcare personnel, medical students, and older as well as general population. (2, (4) (5) (6) Mental-illness was globally estimated around 32.4% of total year lived with disability and 13.0% of disability adjusted life years. (7) Depression was the first leading cause of disability and a prime contributor to the disease burden globally (8) whereas anxiety disorders reported as sixth leading causes of global disability. (9) Sudden declaration of public health emergency may further intensify the existing burdens of mental health outcomes. History has been witnessing to the mental health challenges during infectious outbreaks around the globe. (10) During Ebola outbreak in West Africa, greater number of healthy people was mentally traumatized compare to the number of infected people, and remained longer (11) . Such historical devastation prompts towards another global mental health challenges during COVID-19 pandemic. Therefore, it is important to understand the increased burdens of mental health outcomes as a consequence of COVID-19 pandemic. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint Several studies suggested that the new psychological reactions were uncovered during initial phase of COVID-19 pandemic. However, estimates of these burdens vary across the studies. Such variations might occur because these studies carried on different population, with varying sample sizes and dealt with different scale of mental-illness assessment. In this study, a systematic review and meta-analysis was conducted on the burden of mental health outcomes predominantly on the prevalence of anxiety, depression, stress and insomnia during COVID-19 global emergency. We focused to assess the burden among three group of population, i.e., frontline healthcare workers (FHW), non-frontline healthcare workers (NFHW) and general who are not healthcare workers. Prior to conducting this systematic review and meta-analysis, the study aims and methods (brief protocol) were registered with the PROSPERO database, University of York (Registration Number: CRD42020186229) (12) . The present systematic review manuscript is designed as per the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) (13). A systematic literature search in electronic databases including Embase, PubMed and Scopus between January 1, 2020 and May 25, 2020 was used in order to find the eligible studies. The used search term was"(COVID-19 OR SARS-CoV-2 OR 2019-nCoV OR corona virus) AND (Depression OR Anxiety OR stress OR insomnia OR "psychological distress" OR "Psychiatric illness" OR "Mental Health")". Additionally, a supplementary search was conducted using Google Scholar. All the published or unpublished studies were considered eligible if they met the following eligible criteria: (1) described the assessment of at least one of mental-illness including psychological anxiety or depression or stress or insomnia as an impact of COVID-19; (2) used . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint the scientific rating scale to assess the mental-illness; and (3) the scale based findings were reported in terms of overall prevalence and graded prevalence (mild, moderate and severe). All those studies published as letter to editor, editorial or commentaries and reported the required outcome were also included. All the retrieved articles first were screened on the basis of title and abstract and then reviewed for full text of potentially eligible articles independently and in duplicate by both authors (B.T. and M.P.). Data regarding study identification, population, sample size, prevalence of anxiety, Depression, Stress and Insomnia (or categorized on graded scale like normal, mild, moderate, and severe), scale for outcome measurement and quality related variables were extracted by both authors independently on pre-prepared form. All the discrepancies were resolved by discussion. The modified Newcastle-Ottawa Quality Assessment Scale (NOS) was used to assess the methodological quality for cross-sectional studies (14) (Supplementary Figure 1 ). Since present meta-analysis focused only prevalence of mental health outcomes, the quality of the studies was judged on the basis of four criteria only including representative sample, adequate sample size, low non-response rate and objective outcome measurement. So the range of quality score was 0 to 5. Quality scores were categorized as 4/5= Good, 3= Average, 2/0= Poor. Both the reviewer (BT and MP) independently assessed the quality of eligible studies. Proportion of psychological stress, anxiety, depression and insomnia as overall, as well as on the graded scale of mild, moderate and severe were pooled using fixed effect inverse variance method or DerSimonian& Liard random effect method (15, 16) depending on heterogeneity measured using I 2 statistic (17). Subgroup analysis was performed on the basis of type of population, i.e., FHW, NFHW and other general. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint Publication bias assessment method lays on the fact that likelihood of publication depends on the sample size and statistical significance (18) , but this was not the case with the current research conducted during Covid-19. Since conventional funnel plots are inaccurate to assess the publication bias in meta-analysis of proportion, especially in case of proportion (19) , we used egger's test (20) to assess publication bias. The quality of our evidence was graded using GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach(21). A total of 2337 unique studies were identified by searching the databases. Out of these, 111 studies qualified for full text review [ Figure 1 ]. Out of these 111 studies, 60 were excluded because of various reasons such as one study with children population, two studies found published in other than English language, incidence of actual outcome not reported in 36 studies, original investigation were not done in five studies, three studies were found duplicate, full text was not available for four studies, five studies found in chronic disease population, one . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint study was related to mental health service, one study found related to MERS-CoV and two were qualitative studies. Our search yielded a total of 51 studies for inclusion which comprised 59 datasets Patients (49, 70) and two datasets reported mental health of 2535 quarantined populations (49, 71) . Two studies (35, 52) reported mental health status of FHWs as well as general population while another two studies(28,39) reported among the healthcare workers other than frontline as well as general population. One study (49) reported mental health incidences independently among the COVID-19 patients, quarantined group and general population. One study (56) reported anxiety and depression among the FHWs with different sample sizes. Group-wise data in these studies were extracted to facilitate subgroup comparison. Majority of the studies (35 out of 52) were conducted in China. Among rest of the 17 studies, two (29,37) were conducted in Iran, one was in Israel (68) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint (5, 22, 27, 31, 41, 45, 47, 51, 56, 59, 64, 70, 71) ; five for stress (5, 27, 41, 45, 59) and four for insomnia (27, 45, 59, 62) . Details of study level characteristics are reported in supplementary Table 1 . Quality assessment: Out of the total 51 included studies, 32 studies had 'Good' quality (12 studies had score 5 and 20 studies had score 4), 18studies were grades as 'average' quality with score 3 and one study had poor quality with score 2.Details of quality assessment for these included studies are made available in supplementary . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint A total of 26.2% (95% CI: 21.8% -30.5%) were identified to have depression ( Figure 2 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. Figure 3 (C)]. Overall insomnia burden was found as 31. This Burden of anxiety and depression in COVID-19 patients was found the highest compared to general. However these results were based on only two available studies. Apart from COVID-19 patients, burden of anxiety, depression, stress and insomnia were found highest among the FHWs. We also found that after FHWs, burden of depression and stress was highest among the general population and burden of anxiety and insomnia was highest among the NFHWs. During this pandemic, a handful of reviews and meta-analysis on the prevalence of mental health outcomes were reported among the healthcare workers and general population. (44, 72, 73) However, all these reviews are based on small number of studies, majorly based on Chinese studies and focusing a particular population. In addition to the Chinese studies, our review attempted to include the most updated global studies targeting wide range of population. We also attempted the overall prevalence based on the graded scale of severity for all the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint outcomes. Burden of mild stage were observed as highest followed by moderate and severe stages for all the four outcomes. Similar exploration on graded scale was also attempted among the various subpopulations, i.e., FHWs, NFHWs, general population, COVID-19 infected patients and quarantine people. A meta-analysis reported that the global prevalence of anxiety disorder was 7.3% in general population after adjusting the methodological differences. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint vaccine really take to be available in the global market. Studies on the risk factors associated with the various mental health problems is need to be explored to manage with evidence based interventions. Some of the individual level risk factors may also get effected by the country level parameters such as countries' policies on virus prevention at community level, healthcare infrastructure, climatic condition, concurrent burden of COVID-19 and its spreading speed, government program and policies to control the psychological responses, facilities of educational and behavioral intervention, rehabilitation centers etc. These ongoing challenges vary from one country to another country and going to be a global devastating public health crisis. Policymakers need to make effective decisions about where to focus their efforts to mitigate such burden. Around 37% of the studies were average or poor in their quality. Data were not collected based on the appropriate sampling design from a well-defined population in majority of the studies as those were collected from online survey on social media platform. Only two studies depicted the calculation of representative sample size or power assessment. Further observation of a wide heterogeneity in the reported results provides clue of lower confidence in graded evidence. Included studies are the cross-sectional studies and hence it is hard to comment on the temporal trends of mental health problems during this continuing ongoing pandemic. Overall COVID-19 pandemic has been impacting on mental health of world-wide general population but frontline healthcare warriors had shown relatively having more stress, anxiety, depression and insomnia as compared to general healthcare workers and general. However, mostly these mental ailments are mild to moderate in severity. Our finding suggests that the new psychological reactions and sudden increment in burden of mental health outcomes during the COVID-19 pandemic is prompting towards the another global health emergency. Therefore a call of urgent attention and pan-region intervention are required to manage the current burden of mental health outcomes and further for future prevention. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. ; https://doi.org/10.1101/2021.01.02.21249126 doi: medRxiv preprint The authors do not declare any conflict of interests. Work on this publication was not supported by any internal and external fund. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 4, 2021. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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The Lancet We thank to the Department of Research, Kalinga institute of Medical Sciences, KIIT University to make available all the resources to conduct this study.