key: cord-0823467-xo7q4dqr
authors: Pappa, Sofia; Ntella, Vasiliki; Giannakas, Timoleon; Giannakoulis, Vassilis G.; Papoutsi, Eleni; Katsaounou, Paraskevi
title: Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis
date: 2020-05-08
journal: Brain Behav Immun
DOI: 10.1016/j.bbi.2020.05.026
sha: 5cf874db9f31821d128a78e7d0d2560f990a2ba0
doc_id: 823467
cord_uid: xo7q4dqr

Abstract Background COVID-19 pandemic has the potential to significantly affect the mental health of healthcare workers (HCWs), who stand in the frontline of this crisis. It is, therefore, an immediate priority to monitor rates of mood, sleep and other mental health issues in order to understand mediating factors and inform tailored interventions. The aim of this review is to synthesize and analyze existing evidence on the prevalence of depression, anxiety and insomnia among HCWs during the Covid-19 outbreak. Methods A systematic search of literature databases was conducted up to April 17th, 2020. Two reviewers independently assessed full-text articles according to predefined criteria. Risk of bias for each individual study was assessed and data pooled using random-effects meta-analyses to estimate the prevalence of specific mental health problems. The review protocol is registered in PROSPERO and is available online. Findings Thirteen studies were included in the analysis with a combined total of 33062 participants. Anxiety was assessed in 12 studies, with a pooled prevalence of 23·2% and depression in 10 studies, with a prevalence rate of 22·8%. A subgroup analysis revealed gender and occupational differences with female HCPs and nurses exhibiting higher rates of affective symptoms compared to male and medical staff respectively. Finally, insomnia prevalence was estimated at 38·9% across 4 studies. Interpretation Early evidence suggests that a considerable proportion of HCWs experience mood and sleep disturbances during this outbreak, stressing the need to establish ways to mitigate mental health risks and adjust interventions under pandemic conditions.

Lower respiratory infections remain the communicable disease with the highest mortality worldwide 1 . In December 2019, a highly infectious serious acute respiratory syndrome caused by a novel coronavirus (SARS-CoV-2) emerged in Wuhan, China. On March 11th 2020, the World Health Organization (WHO) declared COVID-19 a pandemic 2 .

According to previous studies from SARS or Ebola epidemics, the onset of a sudden and immediately life-threatening illness could lead to extraordinary amounts of pressure on healthcare workers (HCWs) 3 . Increased workload, physical exhaustion, inadequate personal equipment, nosocomial transmission, and the need to make ethically difficult decisions on the rationing of care may have dramatic effects on their physical and mental well-being. Their resilience can be further compromised by isolation and loss of social support, risk or infections of friends and relatives as well as drastic, often unsettling changes in the ways of working. HCWs are, therefore, especially vulnerable to mental health problems, including fear, anxiety, depression and insomnia 4, 5 .

Immediate interventions are essential in order to enhance psychological resilience and strengthen the healthcare systems' capacity 6 . Clear communication, limitation of shift hours, provision of rest areas as well as broad access and detailed rules on the use and management of protective equipment and specialized training on handling COVID-19 patients could reduce anxiety coming from the perceived unfamiliarity and uncontrollability of the hazards involved. Providing timely and appropriately tailored mental health support through hotline teams, media or multidisciplinary teams, including mental health professionals is also vital 7 .

Previous reviews have explored the prevalence and factors associated with psychological outcomes in HCWs during past infectious disease outbreaks 8 . However, to date, the impact of the current unprecedented crisis on the psychological well-being of medical and nursing staff is yet to be established. The aim of this rapid systematic review and meta-analysis is to examine the emerging evidence of the effects of the COVID-19 outbreak on the mental health of HCW and particularly in relation to the prevalence of anxiety, depression and insomnia.

The systematic review was conducted in accordance with the PRISMA statement 9 . The MOOSE (Meta-analyses Of Observational Studies in Epidemiology) Checklist was followed.

The review protocol is registered in PROSPERO and is available online (CRD42020180313).

Our search strategy was generated by consensus among all researchers in the group. Two authors independently identified records published until April 17 th 2020 that reported on the prevalence of depression, anxiety, and insomnia in HCWs during the coronavirus pandemic through systematically searching MEDLINE, PubMed and Google Scholar databases.

Moreover, due to the rapid dissemination of information during the current pandemic, preprint articles published on Medrxiv and SSRN servers were also included. "Snowball sampling" by searching reference lists and citation tracking was performed in each retrieved article. No language restrictions were applied. If there were queries regarding the methodology or results of the studies under consideration, we attempted to contact the corresponding authors for clarification. Following search terms were used: ("healthcare workers" OR "medical staff" OR "healthcare professionals") AND ("coronavirus" OR "SARS-COV-2" OR "COVID-19") AND ("depression" OR "anxiety" OR "insomnia" OR "mental health" OR "psychological").

The study population group consisted of healthcare workers (medical and non-medical) in COVID-19 affected countries or areas. Only studies evaluating the prevalence rates of depression, anxiety and/or insomnia using validated assessment methods were eligible for inclusion. Broad terms such as 'psychological distress' were excluded as they can be difficult to quantify; PTSD was also not excluded as its onset can be delayed.

The following data were extracted from each article by two reviews independently: study type, total number of participants, participation rate, region, percentage of physicians, nurses and other HCWs screened in the survey, number of male and female participants, assessment methods used and their cut-offs as well as the total number and percentage of participants that screened positive for depression, anxiety or insomnia. If any of this information was not reported, the necessary calculations (e.g. from percentage to number of HCWs) were done, where possible. The accuracy of the extracted or calculated data was confirmed by comparing the collection forms of the two investigators.

In addition, two authors independently evaluated the risk of bias of the included crosssectional studies using a modified form of the Newcastle-Ottawa scale. Potential disagreements were resolved by a third author. Quality assessment criteria were the following: sample representativeness and size, comparability between respondents and nonrespondents, ascertainment of depression, anxiety and insomnia, and adequacy of descriptive statistics. Total quality score ranged between 0-5. Studies scoring ≥3 points were regarded as low risk of bias, compared to the studies assessed with <3 points that were regarded as high risk of bias.

For the purposes of the current study, MetaXL (www.epigear.com), an add-in for metaanalysis in Microsoft Excel for Windows was utilized. Due to the fact, that studies with prevalence close to 0 or 1 have affected variance which may lead to a large weight of the study in the meta-analysis, the proportions were transformed using the double arcsine method and then back-transformed for ease of interpretation 10 . Due to the different patient populations, regions, and assessment methods across studies, one true effect size cannot be assumed; therefore, a random effects model (DerSimonian & Laird) was used to extract the pooled prevalence. Substantial heterogeneity was defined as I 2 >75%. Subgroup analysis was done in the following categories: gender, rating scales, severity of depression and anxiety and professional group. Sensitivity analysis was done by subtracting each study and calculating the pooled prevalence of the remaining studies, in order to identify studies which may severely affect the pooled prevalence. Our main outcomes were prevalence (p), confidence intervals (CI) and percentage prevalence (p x 100%).

A PRISMA diagram detailing the study retrieval process is shown in Figure 1 

After de-duplication and screening, thirteen studies 11-23 with a total of 33062 participants were included in the analysis. All of the studies were cross-sectional and reported on the prevalence of depression, anxiety or insomnia among HCW during the Covid-19 pandemic.

Out of the 13 studies, 12 were undertaken in China, two of which were in Wuhan 15,23 , while one took place in Singapore 20 . Median number of individuals per study was 1563 (range 134, 11118) with a median male representation of 18% (281·5/1563) and a median questionnaire participation rate of 85·3% (range 43·2%, 94·88%).

A summary of the characteristics of each study, including the number of participants per study, participation rate, country or region, HCW distribution, male to female ratio and prevalence of each mental health condition are provided in Table 1 . The Newcastle-Ottawa score results for each study are shown in Table 2 . The resulting pooled prevalence of anxiety, depression and insomnia as well as the subgroup analyses are presented below. Notably, I 2 was over 75% in the vast majority of the results; if I 2 was close to 100% or 0% two decimals were used.

Anxiety was estimated in 12 studies 11-18,20-23 . The pooled prevalence was 23·20% (95% CI 17·77-29·12, I 2 =99%) as presented in Figure 2 . In sensitivity analysis, no study affected the pooled prevalence by over 2% when excluded. Furthermore, low risk of bias studies (n=9) revealed a total pooled anxiety prevalence of 24·05% (95% CI 16·84-32·07, I 2 =99%).

Regarding assessment methods, four studies 12,13,16,17 used the Zung Self-Rating Anxiety Scale (SAS) with a pooled prevalence of 16·47% (95% CI 14·66-18·63, I 2 =84%) and four studies 14,15,21,23 used the GAD-7 scale with a pooled prevalence of 36·90% (95% CI 26·06-48·19, I 2 =99%). Each of the four remaining studies used a different questionnaire. 

Insomnia prevalence was estimated in five 14,15,19,21,22 out of the 13 retrieved studies ( Figure   4 ). The pooled prevalence was calculated as 34·32% (95% CI 27·45-41·54, I 2 =98%). In sensitivity analysis, no study affected the pooled prevalence by over 3% when excluded. The risk of bias was deemed as low for all five studies. 

A subgroup analysis of the prevalence of anxiety and depression by gender, severity and professional group was further conducted and summarized in Table 3 .

For anxiety, gender data were available in six studies, with a pooled prevalence of 20.92% for males and 29·06% for females 11 For insomnia, a subgroup analysis was not performed due to the limited data available.

A recent position paper in The Lancet 24 , called for high-quality data on the mental health effects of the COVID-19 pandemic across the whole population and vulnerable groups such as health care professionals.

This timely rapid systematic review and meta-analyses of 13 cross-sectional studies and a total of 33062 participants provides early evidence that a high proportion of healthcare professionals experience significant levels of anxiety, depression and insomnia during COVID-19 pandemic. We are mindful that mental health research in times of crisis, such as COVID-19 outbreak, is a sensitive topic and would like to believe that all the studies included were given due ethical consideration 25 .

The prevalence rates of anxiety and depression (23·2% and 22·8% respectively) of HCWs during COVID-19 are broadly comparable to the respective rates, ranging between 22·6%-36·3% for anxiety and 16·5%-48·3% for depression, reported for the general population in China during the same period, which shows the considerable effect of the crisis on the whole of the population 26-28 . Our results are also at the lower end of the outcomes previously reported among HCWs during and after the MERS and SARS epidemics where high rates of depression and anxiety as well as post-traumatic stress disorder (PTSD) and moral injury were observed [29] [30] [31] [32] . Potential differences, however, between these outbreaks and the COVID-19 pandemic could be explained on the basis of the extremely high infectious potential and mortality rate of the former but also the experience acquired in the interim in these areas.

Although, the different scales and cut-off scores adopted by each survey possibly introduced great between-study heterogeneity, it appears that the majority of the HCWs experienced mild symptoms both for depression and anxiety, while moderate and severe symptoms were less common among the participants. In our view this emphasizes the need for early detection and the importance of picking up and effectively treating the milder clinical mood symptoms or sub-threshold syndromes before they evolve to more complex and enduring psychological responses.

Furthermore, our sub-analysis revealed potentially important gender and occupational differences. The prevalence rate of anxiety and depression appeared to be higher in females, which probably reflects the already established gender gap for anxious and depressive symptoms 33 . Again, nursing staff exhibited higher prevalence estimates both for anxiety and depression compared to doctors. These results may be partly confounded by the fact that nurses are mostly female but could be also attributed to the fact they may face a greater risk of exposure to COVID-19 patients as they spend more time on wards, provide direct care to patients and are responsible for the collection of sputum for virus detection 17 . Moreover, due to their closer contact with patients they may be more exposed to moral injury pertaining to suffering, death and ethical dilemmas. To this end, early, targeted interventions should be considered. Of relevance, another study performed in the original center of the epidemic, Wuhan, showed that a large proportion of HCW in Wuhan were affected and that mental health support was necessary even for mild psychological reactions 43 . Indeed, much can be offered in the current context, such as virtual clinics, remotely delivered psychological therapies and psycho-education, chat lines, digital phenotyping and technologies monitoring risk. Finally, alongside infected patients and HCWs, suspected cases, who are home isolated, and families and friends of affected people have to be supported, too 44 .

Nevertheless, there are several strenghts and key limitations to our review. To our knowledge, this is the first systematic review and meta-analysis to examine the pooled prevalence of depression, anxiety and insomnia on HCW during the COVID-19 outbreak.

Although, the number of studies per se included in our meta-analysis was as expected in the early stages of the pandemic still relatively low, the majority of studies comprised a considerable number of participants. Furthermore, our subgroup analysis of anxiety and depression based on gender, professional group and severity provided additional valuable insights of potential particular vulnerabilities.

One major drawback that merits consideration is the inherent heterogeneity across studies.

Different assessment scales were utilized for population screening and different cut offs set even though several studies used the same tests. Thus, threshold criteria for case definition varied with some investigators intentionally using more lenient criteria in order to capture milder or subsyndromal cases; hence our subgroup analysis by severity. Another limitation is

that several studies might have included the same population as they were broadly conducted in the same region/country. Again, as the majority of studies were conducted in China, the generalizability of our findings may be limited. Having said that, generalizing this type of results could pose severe flaws as healthcare systems vary greatly between countries.

Nevertheless, considering the fact that China was severely affected, they provide a reliable indication of the potential of COVID-19 pandemic to affect the mental health of HCWs.

Furthermore, the studies included in our meta-analysis were all cross-sectional, thus the longterm implications of COVID-19 pandemic on HCW's mental health warrant further research.

In conclusion, our systematic review and meta-analysis provide a timely and comprehensive synthesis of the existing evidence highlighting the high prevalence rates of depression, anxiety and insomnia of healthcare professionals. Findings can help to quantify staff support needs and inform tiered and tailored interventions under pandemic conditions that enhance resilience and mitigate vulnerability. 

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