key: cord-0835575-wh29gvwi
authors: Pan, Xiao; Xiao, Ying; Ren, Ding; Xu, Zheng‐Mei; Zhang, Qian; Yang, Li‐Ying; Liu, Fen; Hao, Yu‐Shi; Zhao, Feng; Bai, Yong‐Hai
title: Prevalence of mental health problems and associated risk factors among military healthcare workers in specialized COVID‐19 hospitals in Wuhan, China: A cross‐sectional survey
date: 2020-10-21
journal: Asia Pac Psychiatry
DOI: 10.1111/appy.12427
sha: a56e2d8cbfa2e082d0f3e8af39254d4c05e1d9a3
doc_id: 835575
cord_uid: wh29gvwi

INTRODUCTION: China has been severely affected by coronavirus disease 2019 (COVID‐19) since December 2019. Military healthcare workers in China have experienced many pressures when combating COVID‐19. This study aimed to investigate the current psychological status and associated risk factors among military healthcare workers. METHODS: We collected data from 194 military healthcare workers from three inpatient wards in two specialized COVID‐19 hospitals using a web‐based cross‐sectional survey. The survey covered demographic information, the patient health questionnaire‐9, the Generalized Anxiety Disorder‐7, and the patient health questionnaire‐15. Hierarchical regression analysis was used to explore potential risk factors for mental health problems. RESULTS: The overall prevalence rates of depressive, generalized anxiety, and somatic symptoms were 37.6%, 32.5%, and 50%, respectively. Rates of severe depression, generalized anxiety, and somatic symptoms were 5.2%, 3.6%, and 15.5%, respectively. In 22.7% of cases, comorbidities existed between depression, generalized anxiety, and somatization. A junior‐grade professional title was associated with depression, older age was associated with generalized anxiety and somatization, and short sleep duration and poor sleep quality were associated with all three symptoms. DISCUSSION: The prevalence of depression, generalized anxiety, and somatic symptoms among military healthcare workers in specialized COVID‐19 hospitals is high during the current COVID‐19 outbreak. A junior‐grade professional title, older age, short sleep duration, and poor sleep quality significantly affect military healthcare workers' mental health. Continuous surveillance and monitoring of the psychological consequences of the COVID‐19 outbreak should be routine to promote mental health among military healthcare workers.

during the current COVID-19 outbreak. A junior-grade professional title, older age, short sleep duration, and poor sleep quality significantly affect military healthcare workers' mental health. Continuous surveillance and monitoring of the psychological consequences of the COVID-19 outbreak should be routine to promote mental health among military healthcare workers. First-line health workers carry an inconceivable workload and are at huge risk for COVID-19 infection while working to save lives.

According to Wang et al.'s (2020) research, infected healthcare workers accounted for 29% of all hospitalized COVID-19 patients in the early stage of COVID-19. In addition, Kang et al.'s (2020) research reported that these workers experienced psychological distress because of social isolation and possible discrimination. Mental health problems caused by such psychological distress tend to impair attention, cognitive function, and clinical decision-making (Panagioti et al., 2018) , all of which increase the possibility of medical negligence.

Consequently, it is necessary to pay more attention to the mental health of healthcare workers during the COVID-19 outbreak.

Healthcare workers from the military are a special group deployed by the central government to combat Therefore, it is necessary to focus on the mental health of this special population.

Depression, generalized anxiety, and somatic symptoms are common symptoms among medical staff and patients under stress, and the comorbidity rate exceeds 50% (Löwe et al., 2008) . Several studies have explored psychological effects during epidemics, such as SARS in 2003. Koh et al. (2005) reported 68% of first-line healthcare workers experienced severe work-related pressure and 57.0% experienced psychological disturbance during the SARS outbreak. Another study showed that 17.3% of healthcare workers experienced significant mental symptoms during the SARS epidemic (Lu, Shu, Chang, & Lung, 2006) . A survey that was conducted among 255 Chinese patients with breast cancer reported the percentage of high somatic symptoms was 43.5% (Leonhart et al., 2017) . Therefore, depression, general anxiety, and somatic symptoms should receive increased attention during the COVID-19 outbreak.

This study aimed to investigate the psychological status of firstline military healthcare workers and identify risk factors for developing depression, anxiety, and somatic symptoms to inform targeted mental health interventions for military healthcare workers during COVID-19 and future similar epidemic outbreaks.

A questionnaire survey was used for data collection. This crosssectional survey was conducted from February 7, 2020 to February 21, 2020. We used cluster sampling to recruit 200 military healthcare workers who had worked for 3 weeks rescuing patients with COVID-19 from three inpatient wards in two specialized COVID-19 hospitals. The exclusion criteria were: (a) an answer time for the 31 survey items of more than 30 minutes or less than 1 minute, and (b) having schizophrenia, severe mood disorders, or other mental disorders. The questionnaires were prepared using "Wen Juan Xing," which is an online research tool that converts a paper scale into an electronic version. This made the psychological assessment easily to access and conduct using cell phones or PC devices. Because of the high transmission risk associated with COVID-19, this tool has been widely applied in various studies , including among our team.

The nine-item patient health questionnaire (PHQ-9) from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was used to measure depression symptoms. The PHQ-9 evaluates the degree to which an individual has experienced depression symptoms over the past 2 weeks. Each item is rated from 0 (never) to 3 (nearly every day). The PHQ-9 total score ranges from 0 to 27, and a higher score indicates greater depression severity. Total scores of 5, 10, 15, and 20 represent cutoff points for low, medium, moderate-severe, and high depression symptom severity, respectively.

Based on a study by Teymoori et al. (2020) , a PHQ-9 score ≥5 was considered to represent the presence of depression symptoms. The Cronbach's alpha for the PHQ-9 was 0.815. Research using the Chinese version of the PHQ-9 showed satisfactory reliability and validity in the general population (Chen et al., 2010) .

The generalized anxiety disorder-7 (GAD-7) scale from the DSM-5 was used to measure anxiety symptoms. These seven items assess the frequency of anxiety symptoms over the past 2 weeks on a 4-point Likert-scale ranging from 0 (never) to 3 (nearly every day).

Higher scores indicate more severe functional impairment as a result of anxiety. Total scores of 5, 10, and 15 represent cutoff points for low, medium, and high anxiety symptom severity, respectively. Consistent with a study by Toussaint, a GAD-7 score ≥ 5 was considered to indicate the existence of anxiety symptoms (Toussaint et al., 2020) . In addition, background monitoring was conducted in real time to ensure data reliability.

Statistical analyses were performed with IBM SPSS Statistics version 21.0. Descriptive analyses were conducted to describe participants' demographic characteristics and the overall prevalence rates of depression, generalized anxiety, and somatic symptoms. We used t tests, one-way variance (ANOVA), and nonparametric analyses to compare the prevalence of depression, generalized anxiety, and somatic symptoms between different subgroups. Hierarchical regression analysis was applied to identify independent variables associated with depression, generalized anxiety, and somatic symptoms among military healthcare workers. P < .05 was considered statistically significant.

In total, 194 military healthcare workers were recruited for this study, among which 158 (81.4%) were females. Just over half (n = 102, 52.6%) were aged under 30 years, 87 (44.8%) were aged 30 to 50 years, and five (2.6%) were aged over 50 years. Forty-two (21.6%) participants were doctors, 148 (76.3%) were nurses, and four (2.1%) were command staff. A junior-grade professional title was held by 110 (56.7%) participants, 56 (28.9%) had a medium-grade professional title, and 28 (14.4%) had a senior-grade title. For doctors, nurses, and command staff, the terms "junior-grade," "medium-grade," and "senior-grade" reflect the grading system used in healthcare practice in China (also called professional titles). These designations comprehensively represent their professional years, performance, and academic level. Individuals must pass an examination and interview with the Professional Committee to achieve "medium" and "senior" professional grades.

In terms of the frequency of daily checking of COVID-19 news, 23 (11.9%) participants checked >10 times per day and 93 (47.9%) checked 3 to 10 times. Sixty-one (31.4%) participants worked ≥8 hours per day. The average daily sleep duration was <6 hours (n = 36, 18.6%), and 157 (80.9%) participants reported ordinary or bad sleep quality (Table 1) . Table 2 presents the average scores and overall prevalence rates of depression, generalized anxiety, and somatic symptoms as assessed by the PHQ-9, GAD-7, and PHQ-15, respectively. The average PHQ-9, GAD-7, and PHQ-15 scores were 3.79 ± 3.30, 3.09 ± 3.22, and 5.34 ± 4.44, respectively. With a cutoff score of 5, the overall prevalence of depression, generalized anxiety, and somatic symptoms was 37.6%, 32.5%, and 50%, respectively. Given that we defined a score ≥ 10 as severe symptoms, the prevalence of severe depression, severe generalized anxiety, and severe somatic symptoms was 5.2%, 3.6%, and 15.5%, respectively. In 22.7% of cases, comorbidities existed between depression, generalized anxiety, and somatization.

The scores for depression, generalized anxiety, and somatic symptoms by different subgroups are presented in Table 3 . In terms of depression, participants with junior (P = .003) and medium (P = .012) grade professional titles had significantly higher scores than those with senior titles. Military healthcare workers that checked the daily news more than 10 times had significantly higher depression scores than those who checked 3 to 10 times (P = .009). Participants who had sleep duration per day of ≥6 hours (P < .001) and good sleep quality (P < .001) were less likely to report depression symptoms.

In terms of anxiety, participants with junior (P = .049) and medium (P = .006) grade professional titles had significantly higher scores than those with senior titles. Military healthcare workers that checked the news more than 10 times per day had significantly higher anxiety scores than those who checked 3-10 times (P = .017) and <3 times (P = .014) per day. There were significant differences in the daily working hours (P = .019), daily sleep duration (P = .003), and sleep quality (P < .001) among the subgroups.

In terms of somatic symptoms, the scores of females and doctors were significantly higher than those of males (P = .008) and nurses (P = .011). Participants with junior (P = .004) and medium (P = .001) grade professional titles had significantly higher somatic symptoms scores than those with senior titles. There were significant differences in the daily sleep duration (P = .001) and sleep quality (P < .001) among the subgroups. Table 4 presents the results of the hierarchical logistic regression analysis. Professional title (P = .010), daily sleep duration (P = .004), and sleep quality (P < .0001) were significantly associated with PHQ-9 score. Age (P = .013) and sleep quality (P = .001) were associated with GAD-7 scores. Age (P = .017), daily sleep duration (P = .018), and sleep quality (P < .0001) were significantly associated with PHQ-15 scores.

The COVID-19 outbreak was regarded as a public health emergency. It raised public health concerns and caused tremendous psychological distress. Although the increase of confirmed and suspected COVID-19 noting that the prevalence of mental health problems in this group was lower than that of healthcare workers in local hospitals during the COVID-19 outbreak. Huang and Zhao revealed that the prevalence of depression and anxiety among healthcare workers in local hospitals was as high as 50.7% and 44.7%, respectively (Huang & Zhao, 2020) . Our study showed that 22.7% of military health workers with depression symptoms had comorbid anxiety and somatization, which was lower than that among primary care clinic patients in the United States (Löwe et al., 2008) . However, military healthcare workers may have specific characteristics related to their military training that may act as mechanisms to protect their mental health to some extent.

Military healthcare workers with lower grade professional titles showed more depression symptoms, which was consistent with a previous study (Huang & Zhao, 2020) , and may be related to the following reasons. People with junior-grade professional titles face more challenges, such as economic pressure and limited societal resources.

In addition, to secure promotion, they need to consider other issues while treating patients with COVID-19 (eg, scientific research, publishing papers, and teaching tasks). Our study also showed that with the increase of age, more symptoms of anxiety and somatization appeared in military healthcare workers. This result indicated that older military healthcare workers may experience more occupational exhaustion and other pressures (eg, family responsibilities).

The present study found depression, generalized anxiety, and somatic symptoms were more prevalent among military health workers with short sleep duration and poor sleep quality. This was consistent with a previous study that showed poor sleep was strongly associated with symptoms of depression, anxiety, and posttraumatic stress disorder (Kobayashi, Boarts, & Delahanty, 2007 

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We acknowledge all project participants and the investigators for collecting data. This work was supported by Changzheng Hospital Pyramid Talent Project (2020) 

The authors declare no conflicts of interest. All authors participated in discussion of the outcomes and offered their unique contribution to this research.

This survey was approved by the ethics panel of the Medical Association Changzheng Hospital (No. 2020SL010). All participants in this study provided informed consent to participate.

https://orcid.org/0000-0001-5818-7216