key: cord-0961835-o5330j95 authors: Al Hariri, Moustafa; Hamade, Bachar; Bizri, Maya; Salman, Oday; Tamim, Hani; Al Jalbout, Nour title: Psychological impact of COVID-19 on emergency department healthcare workers in a tertiary care center during a national economic crisis date: 2021-11-06 journal: Am J Emerg Med DOI: 10.1016/j.ajem.2021.10.055 sha: aa9956c0e3c5a5731db1992c32f94153a74280c6 doc_id: 961835 cord_uid: o5330j95 BACKGROUND: Since the declaration of the novel Corona Virus Disease (COVID-19) as a global pandemic by the World Health Organization, frontline healthcare workers (HCWs) and staff in the Emergency Departments (ED) started experiencing feelings of anxiety and fear from the projected exponential spread and the potential burden on the healthcare system and infrastructure. In Lebanon, major local factors contributing to this fear were the rapid escalation of COVID-19 cases across the country, the lack of preparedness, and the shortage of personal protective equipment, in addition to the evolving economic crisis and financial restrictions. This study aims to investigate the immediate psychological impact of the COVID-19 outbreak on ED staff working in a hospital environment in relation to their household income. METHODS: Self-reported cross-sectional survey was delivered to the frontline staff working at the Department of Emergency Medicine of AUBMC in Beirut, Lebanon. General demographic characteristics, scores of Generalized Anxiety Disorder 7 (GAD-7), scores of Patient Health Questionnaire 9 (PHQ-9), and scores of Burnout Measure-Short (BMS) version were collected. RESULTS: 74 HCWs (49.6%) participated in the study. The mean age for participants was (31.78 ± 9.49). More than half of the participants were nurses and more than 70% reported a monthly salary of less than 2000 USD. The household income was negatively associated with the participant's scores on the GAD-7 and PHQ-9, but not the BMS. Previous mental health diagnosis was positively associated with the PHQ-9 and BMS scores, while seeking mental health care was negatively associated with the PHQ-9 and BMS scores. CONCLUSION: At our tertiary care center in a low-income, low resource country amidst the COVID-19 pandemic, the HCWs reported marked psychological disturbances on different scales. In particular, the financial burden was associated with increased anxiety and clinical depression, but was not associated with burnout. In January 2020, the World Health Organization (WHO) declared a novel coronavirus outbreak causing Corona Virus Disease and considered it a public health emergency of international concern. With its exponential spread across countries, the WHO considered COVID-19 a global pandemic on March 11, 2020 [1] . To date (October 6, 2021), 235,673,032 confirmed cases of COVID- 19 have been reported globally. The total number of deaths secondary to COVID-19 has reached 4,814,651 cases [2] . In Lebanon, the first case of COVID-19 was diagnosed on February 21, 2020. Since then, there has been steep growth in the daily number of cases of COVID-19. To date (October 6, 2021), Lebanon has officially registered 627,722 confirmed cases and 8,997 deaths [3] . On March 10, 2020, the American University of Beirut Medical Center (AUBMC) started performing COVID-19 PCR testing, rendering the Emergency Department (ED) at AUBMC the frontline recipient of COVID-19 suspected cases, testing between 80-200 cases per day during the study period. Given the uncertainty of the mode of disease spread early on, conflicting data from WHO and Center for Disease Control (CDC), the global shortage of personal protective equipment (PPE), and the large number of infected healthcare workers (HCWs) internationally, frontline staff in the ED began experiencing feelings of anxiety from the projected spread and disease burden [1, 4] . Additional factors, such as the observed high lethality in neighboring countries, and the daily change of infection control protocols and public health recommendations, heightened the perception of personal danger and feelings of apprehension among staff. This is in addition to the fear of carrying the disease home, as well as the social stigmatization of HCWs as vectors for the disease. J o u r n a l P r e -p r o o f Journal Pre-proof Importantly, Lebanon was facing a challenging and unprecedented economic crisis. Amidst the COVID-19 pandemic, the Lebanese financial sector suffered from an exponential devaluation of the local currency [5] . Subsequently, the workers in the Lebanese industries lost between 61.5% to 84.7% of the value of their salaries compared to USD, thus reducing the workers' purchasing power. Specifically, the healthcare sector endured capital control and restrictions on utilizing their bank deposits for purchases of essential basic supplies. The SARS outbreak in 2003 revealed that HCWs are at risk of experiencing an immediate psychological impact, including feelings of anxiety and sometimes post-traumatic stress disorder, affecting occupational productivity [6] [7] [8] . On March 12, 2020, WHO initiated online education on the psychosocial considerations during the COVID-19 outbreak [9] , with a specific section dedicated to HCWs. With experience from SARS, and WHO's early awareness campaigns on mental health during COVID-19, there was a need to evaluate the current psychological burden of COVID-19 among ED HCWs and staff in order to identify areas for possible prevention and intervention, especially in a region of continuous conflict and economic uncertainties. This will be vital in planning for future outbreaks of emerging infectious diseases. The aim of this study was to investigate the immediate psychological impact on all ED staff working in a tertiary care hospital environment in Lebanon during the COVID-19 outbreak in conjunction with an ongoing national economic crisis, as related to their household income. The study population consisted of 149 HCWs who responded to the online survey questions via LimeSurvey between May and July 2020. HCWs included attending physicians, house staff physicians, residents, registered and practical nurses, registration personnel, and clerks working at the ED. All participants consented to participate in the study. We elected to adopt a convenience sampling technique by targeting all the HCWs in the department of emergency medicine at AUBMC. The institutional review Board at AUB approved the conduct of this study under the IRB ID SBS-2020-0169. The survey included basic demographic information of the participants: age, gender, marital status, presence of elderly or children at home, occupation, education, years in current occupation, working hours per week, and full-time vs. part-time. In addition, we surveyed participants for the outcome of psychological impact using the following assessment tools screening for anxiety, burnout, and depression, respectively: General Anxiety Disorder (GAD-7) questionnaire [10] , Burnout Measure-Short questionnaire (BMS) [11] , and Patient Health Questionnaire-9 (PHQ-9) questionnaire [12] . We used the English version of these assessment tools, as English is the primary language used at our institution. The questions of the GAD-7 and PHQ-9 tools have four responses. "Not at all" was assigned a score of "0", "Several days" was assigned a score of "1", "More than half of the days" was assigned a score of "2", and "Nearly every day" was assigned a score of "3" [10, 12] . The questions of the BMS tool have seven responses. "Never" was assigned a score of "1", "Almost never" was assigned a score of "2", "Rarely" was assigned a score of "3", "Sometimes" was assigned a score of "4", "Often" was assigned a score of "5", "Very often" was assigned a score of "6", and "Always" was assigned a score of "7" [11] . Cut-off scores of 10 or more were used to define cases at high risk for depression by PHQ-9 [13] , and generalized anxiety by GAD-7 [10] , while a cut-off score of 4 was used to indicate a high level of exposure to burnout by BMS [11] . The participant's monthly income was selected to stratify the population into two groups (<$2000 or ≥$2000). The minimum monthly wage in Lebanon was around $466 during the study period [14, 15] . The 2000$ income cut-off was selected based on the reported average wages of HCWs in Lebanon during 2020 and based on a previous study by Kassak et al. that surveyed the Lebanese physicians registered in the Lebanese Order of Physicians, showing an average salary of more than $1800 with a median around $1,300 [14, 16] . All statistical analyses were performed using IBM SPSS 24©. Characteristics and demographics were described and reported as mean ± standard deviation for continuous variables, and frequency and percentage for categorical variables. As applicable, Chi-Square and Fisher exact tests were used to assess the association between the categorical variables and the outcome at the bivariate level. T-test was used to assess the association between the continuous variables and the outcome at the bivariate level. Linear regression was used to assess the association of the J o u r n a l P r e -p r o o f predictors with the values of the scores of the three tools (GAD-7, PHQ-9, and BMS) used in this study. Out of the 149 HCWs at the AUBMC ED, 74 (49.6%) completed the study survey. The (Table 1) . When comparing the characteristics of the participants according to their average monthly income (<$2000 or ≥$2000), the participants' age, occupation, and employment status were significantly different between the two groups ( Table 1 ). The participants in the higher-income group were older (37.9 ± 12.44 vs. 29.36 ± 6.77 years, p=0.006), physicians (66.67%, p<0.0001), and were employed full time (71.43%, p<0.0001). J o u r n a l P r e -p r o o f Upon assessing the participants' responses to the GAD-7 tool, the higher-income group scored 2.65 points lower on the total score compared to the lower-income group (5.1 ± 2.36 vs. 7.75 ± 4.63, p=0.002) ( Table 2) . Additionally, the higher-income group scored significantly lower than the lower-income group on specific questions in GAD-7 such as "Being so restless that it's hard to sit still" (0.29 ± 0.56 vs. 0.68 ± 0.73, p=0.016), "Becoming easily annoyed or irritable" (0.76 ± 0.54 vs. 1.19 ± 1, p=0.021), and "Feeling afraid as if something awful might happen" (0.38 ± 0.5 vs. 1 ± 1, p=0.009). Moreover, our data showed that 32.08% of HCWs in the lower-income group scored more than 10 points on the GAD-7 tool (moderate to severe groups) compared to 4.76% of the HCWs in the higher-income group (p=0.015). Upon evaluating the responses of the participants to the PHQ-9 tool, the higher-income group scored 2.5 points lower on the total score compared to the lower-income group (5.24 ± 3.7 vs. 7.74 ± 4.95, p=0.022) ( Table 3) . Additionally, the higher-income group scored significantly lower than the lower-income group on specific questions in PHQ-9 such as "Trouble concentrating on things, such as reading the newspaper or watching television?" (0.33 ± 0.66 vs. 0.81 ± 0.96, p=0.018) and "Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?" (0.05 ± 0.22 vs. 0.26 ± 0.59, p=0.025). Moreover, our data showed that 32.08% of HCWs in the lower-income group scored more than 10 on the PHQ-9 tool (moderate to severe groups) compared to 9.52% of the HCWs in the higher-income group, though the difference was not statistically significant (p=0.074). Upon assessing the participants' responses to the BMS tool, the higher-income group scored 2.63 points lower on the total score compared to the lower-income group (32.33 ± 11.7 vs. 34.96 ± 11.95), though the difference was not statistically significant (Table 4) . Additionally, our data did not show any statistically significant difference in the participants' responses to any BMS question. Importantly, our data showed that 42.86% of HCWs in the lower-income group were categorized in the burnout category compared to 49.06% of the HCWs in the higher-income group, though the difference was not statistically significant (p=0.797). All ED HCWs at a tertiary care center in a low-resource country were surveyed to assess the direct psychological impact of COVID-19 on their wellbeing, during an unprecedented national economic crisis. The results of this survey showed a negative association between HCWs' psychological health and COVID-19 in relationship to the household income. The scores on the anxiety and depression scales (GAD-7 and PHQ-9) were statistically significantly higher among participants in the lower-income group working during the COVID-19 outbreak. During the 2020 COVID-19 pandemic, Lebanon faced a tragic economic crisis that led to the devaluation of the current currency (Lebanese pound-LBP) from 1505 LBP per dollar to a range of 3900 to 9800 LBP per dollar during the study period [5] . The majority of the workers in the Lebanese industries, including the majority of the surveyed participants, continued to receive their salaries in LBP. Therefore, the participants in this study had lost between 61.5% to 84.7% of the value of their salaries compared to USD, thus reducing their purchasing power. We investigated which of the participants' characteristics could predict the scores on the utilized tools (Table 5 ). Using GAD-7, our data showed that 24.32% of the HCWs displayed moderate to severe symptoms of anxiety due to COVID-19, which is comparable to the prevalence of COVID-19 related anxiety (23.21%) of HCWs (n=6,968) reported in a meta-analysis of 12 studies conducted in China and Singapore [17] . Our GAD-7 score linear regression results China who reported a high anxiety score that was associated with younger age (<35 years of age), our data did not show an association between age and anxiety scores [20] . With respect to the PHQ-9 score, 25.68% of the HCWs in our study exhibited moderate to severe symptoms of depression due to COVID-19, which is higher than the prevalence of depression the adolescent years of a subject is associated with depression in adulthood years [23, 24] . In parallel, a systematic review and meta-analysis showed that mental health illnesses are among the risk factors for developing depression [25] . Our results revealed that prior seeking of mental care is associated with a lower score of PHQ-9. This can be explained by the fact that seeking mental health evaluation and treatment ensures control of symptoms and disease and lowers the scores. This is in line with a study by Schwenk et al. that assessed the responses of 1,154 physicians. Participants in this study reported a delay J o u r n a l P r e -p r o o f in seeking mental care for physicians with minimal to mild depressions and their preference to self-care [26] . With respect to the BMS scores, 47.3% of our participants experienced burnout symptoms, which was comparable to the burnout levels of HCWs (between 44 to 45%) reported in a systematic review and meta-analysis of 15 RCTs and 37 cohort studies (3630 physicians) by West et al. but higher than the burnout levels of HCWs (40.1%) reported in a cross-sectional study by Macía-Rodríguez et al. [27, 28] . The latter study pinpointed the association between burnout scores and PPE availability and overtime work compensation [27] . Our linear regression results indicated that a history of mental health diagnosis (β= 25.69, p=0.049, 95%CI [0.09, 51.29]) and prior seeking of mental health care (β= -25.69, p=0.03, 95%CI [-48.76, -2.62]) were significant predictors of burnout scores. Similarly, the association between mental health illness and higher burnout was discussed by Baigent and Baigent [29] . Additionally, Dobson et al. investigated the predictors of burnout among HCWs in one of the major tertiary care centers in Melbourne, Australia. The results of their cross-sectional study showed that burnout was associated with "Past psychiatric history" of the participants [30] . As for seeking mental health care, our findings could be explained by the fact that previously seeking mental health care could help HCWs cope better with psychological stressors and subsequently lower their burnout score. Our study has some limitations. The study was a self-reported survey in a single center in Beirut, Lebanon. We elected to use this design to preserve the participants' social distancing and avoid J o u r n a l P r e -p r o o f exposure and virus spread, especially prior to the vaccine availability. Moreover, during our study period, multiple groups in the institution were sending various surveys to the AUBMC community, which might have caused survey fatigue resulting in a low response rate. Additionally, half of the participants were nurses, which is proportional to their representation in our department, and the majority of the participants were in the lower-income group which could have potentially skewed the results of our study. Finally, mental health is a culturally sensitive topic among the Lebanese population, which could have reduced the reporting rate on the various psychological scores. While Lebanon was facing one of its most complex economic crisis, and amidst the COVID-19 pandemic, HCWs surveyed in a tertiary care center reported major psychological disturbances on multiple levels. The pandemic, faced with the additional financial burden, was a primary determinant of anxiety and depression scores, but not burnout scores. 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Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists Marital status, Occupation, Presence of Elderly (≥ 65 years) at home, Presence of Children at home, Years in Current Occupation, Employment Status, Working hours per week, History of mental health diagnosis, and Prior seeking any mental health care Marital status, Occupation, Presence of Elderly (≥ 65 years) at home, Presence of Children at home, Years in Current Occupation, Employment Status, and Working hours per week †Accounting for: Gender, Education, Marital status, Occupation, Household income, Presence of Elderly (≥ 65 years) at home, Presence of Children at home, Years in Current Occupation Not Applicable. All contributing parties were eligible for authorship status J o u r n a l P r e -p r o o f Journal Pre-proof Conflict of Interest Disclosure: MAH, BH, MB, OS, HT and NA report no conflict of interest with the original work presented below.