key: cord-0990202-wtazcv6b authors: Luo, Dan; Liu, Qian; Chen, Qin; Huang, Run; Chen, Pan; Yang, Bing Xiang; Liu, Zhongchun title: Mental Health Status of the General Public, Frontline, and Non-frontline Healthcare Providers in the Early Stage of COVID-19 date: 2021-03-18 journal: Front Psychiatry DOI: 10.3389/fpsyt.2021.553021 sha: 7f9ada22341f10c3afdde9cd8a53fec251111596 doc_id: 990202 cord_uid: wtazcv6b Background: The outbreak of COVID-19 occurred in 2020 which resulted in high levels of psychological stress in both the general public and healthcare providers. Purpose: The study aimed to address the mental health status of people in China in the early stage of the COVID-19 outbreak, and to identify differences among the general public, frontline, and non-frontline healthcare providers. Method: A cross-sectional study was used to identify the mental health status of the general public and healthcare providers between Jan 29 and Feb 11, 2020. Data were collected using an online survey from a convenience sample. The instruments used included: Patient Health Questionnaire, Generalized Anxiety Disorder scale, Insomnia Severity Index, and Impact of Event Scale-Revised. Descriptive statistics were used to describe the data. Kruskal-Wallis H tests were performed to assess differences in measurements among the three groups; P < 0.05 (two-sided) was considered to be statistically significant. Results: Results showed that a majority of participants experienced post-traumatic stress (68.8%), depression (46.1%), anxiety (39.8%), and insomnia (31.4%). Significant changes in the mental health status of frontline providers was found as compared to those of the other groups (P < 0.001). Interestingly, the scores of the general public were significantly higher than those of the non-frontline healthcare providers (P < 0.001). Conclusion: These findings provide information to evaluate outbreak associated psychological stress for the general public and healthcare providers, and assist in providing professional support and actionable guidance to ease psychological stress and improve mental health. The outbreak of Coronavirus Disease (COVID-19) occurred in Hubei province in December 2019, resulting in more than 82,165 confirmed cases, and 3,298 deaths in China (1) . The pandemic then spread quickly world-wide as countries rolled out measures to curb the effects of the novel coronavirus (2) . In the face of this large-scale public health event, both healthcare providers and the public have been experiencing psychological pressure. The surge of confirmed cases and deaths stressed the entire healthcare system, and many healthcare providers were recruited from multiple departments to control the epidemic. About nine million residents of Wuhan (the provincial capital) were under home quarantine for 2 months because of the lock-down policy, and their life was significantly disrupted (3) . The development and implementation of mental health assessment, treatment and services are vital goal in the health response to the COVID-19 outbreak (4). Following the major outbreaks of severe respiratory syndrome (SARS) in 2003 and Middle East respiratory syndrome (MERS) in 2015, a series of mental health disorders of healthcare workers were reported, including depression, anxiety, delirium, posttraumatic stress disorder (PTSD), and even suicidality (5, 6) . The risk factors for these mental health disorders included exposure to trauma, such as witnessing and caring for patients who were severely ill, the deaths of healthcare professionals, substantial mortality and bereavement, perceived life threat, orphaning of children, food and resource insecurity, discrimination against affected families, and stigma (7) . Although the outbreaks of SARS and MERS stimulated related research, there has been minimal focus on the psychological impact of infectious diseases on persons in the initial stage of the outbreak. This study aims to understand the changes in the mental health status of the general public and healthcare providers in the early stage of the COVID-19 outbreak. The findings of this study will provide insight into the development of psychological interventions aimed to support people affected by a pandemic. Due to the strict lockdown and quarantine policy, this national, cross-sectional study was conducted between Jan 20 and February 11, 2020 using an online survey. Ethical approval for this study was received from the institutional review board at Renmin Hospital of Wuhan University (No. WDRY2020-K004). Eligibility criteria of participants included: (1) frontline healthcare providers: a licensed healthcare professional who worked in a hospital designated to care for COVID-19 patients; (2) non-frontline healthcare providers: a licensed health professional who worked in a health care facility that did not directly care for COVID-19 patients; (3) members of the general Abbreviations: PHQ-9, patient health questionnaire, GAD-7, generalized anxiety disorder; ISI, insomnia severity index; ISE-R, impact of event scale-revised. public: residents of the community who were >18 years of age. Staff from the COVID-19 designated hospitals were contacted by the research team and asked to invite members of their work group to complete an online survey. This survey was distributed via WeChat, a commonly used social media platform in China. Meanwhile, information about the study and the online survey link were posted on WeChat to recruit participants from the general public. In this way, the online survey was open to a large population of healthcare providers and the general public. Respondents were asked to complete an online informed consent, prior to completing the survey. A total of 915 frontline healthcare providers, 1,659 non-frontline healthcare providers and 490 members of the general public were recruited and completed the survey. Demographic questionnaires collected data on gender, age, marital status, educational background, profession, and professional titles. Depression was evaluated by the Patient Health Questionnaire (PHQ-9), which has nine items measuring self-assessed depressive symptoms experienced during the previous 2 weeks. It uses a 4-point Likert-type scale (0 = never, 1 = sometimes, 2 = more than once a week, and 3 = almost every day). The total score ranges from zero to 27, and higher scores indicate more depressive symptoms. Scores of 5, 10, and 15 represent cutpoints for mild, moderate, and moderately severe depression, respectively. The PHQ-9 has shown good psychometric properties (8, 9) . Anxiety was measured by the Generalized Anxiety Disorder scale (GAD-7), a self-report tool developed by Spitzer et al. (10) that follows the criteria from the Diagnostic and Statistical Manual-IV (DSM-IV). The seven items included continuous variables and verification questions. These items describe the typical symptoms of generalized anxiety disorder (GAD) and are rated on a 4-point scale, from "not at all" to "nearly every day". The scores on the nine items are summed for total scores that range from zero to 27; a higher score represents higher anxiety severity. Scores of 5, 10, and 15 represent cutpoints for mild, moderate, and moderately severe anxiety, respectively. Psychometric evaluations of the GAD-7 suggest that it is a reliable and valid measure of GAD symptoms in the psychiatric patient (11, 12) . The Insomnia Severity Index (ISI) is a brief instrument that assesses insomnia according to the criteria from the DSM-IV and the International Classification of Sleep Disorders (13) . The ISI is a 7-item self-report questionnaire assessing the nature, severity, and impact of insomnia in the past month. A 5-point Likert scale (0 = none; 4 = very severe) is used to rate each item, with total scores ranging from zero to 28. A higher total score indicates more severe sleep difficulties. Scores of 8, 15, and 22 represent cutpoints for subthreshold, moderate, and moderately severe insomnia, respectively. Adequate psychometric properties for both the English and Chinese versions have been reported in previous studies (14, 15) . The Impact of Event Scale (IES), a self-report questionnaire, is the most widely used measure of PTSD symptoms in critical care outcomes research (16) . The IES-R which is the revised version of the scale measures reexperiencing (intrusion) symptoms, avoidance/numbing symptoms, and hyperarousal symptoms of PTSD (17) . With the IES-R, respondents are asked to report how distressed or bothered they have been by particular difficulties in the past seven days: "not at all" (item score 0), "a little bit" (score, 1), "moderately" (score, 2), "quite a bit" (score, 3), or "extremely" (score, 4), with total scores ranging from zero to 88 for the 22 items of the scale. Scores of 9, 26, and 44 represent cutpoints for mild, moderate, and moderately severe PTSD symptoms, respectively. The IES-R has good reliability and validity in both the English and Chinese versions (18) (19) (20) . Descriptive statistics including frequency and percentages were used to describe the demographic characteristics of the participants. Since the data were not fit the normal distribution, Kruskal-Walls H tests were performed to assess differences in the characteristics and severity of mental health distress between frontline, non-frontline healthcare providers and the general public and P < 0.05 (two-sided) was considered to be statistically significant. Furthermore, Kruskal-Walls H tests were performed to assess the differences in the total score of the mental health measurements between the three groups of participants. Dunn-Bonferroni post-hoc tests were utilized to compare the group differences when the result of the Kruskal-Walls H tests indicated a statistical significance. Characteristics Between the General Public, Non-frontline, and Frontline Healthcare Providers A total of 3,064 participants (915 frontline healthcare providers, 1,659 non-frontline healthcare providers, and 490 members of the general public) completed the online survey. Most were female (75.8%) and the majority (76.1%) were <40 years of age. Significant statistical differences were found in gender, age, marital status, and educational background between the general public, non-frontline, and frontline healthcare providers. Additionally, there was a significant difference in professional titles between non-frontline and frontline healthcare providers (see Table 1 ). Comparison of Depression, Anxiety, Insomnia, and Impact of Event Scores Between the General Public, Non-frontline, and Frontline Healthcare Providers In this study, a majority (68.8%) of participants experienced post-traumatic stress and some reported symptoms of depression (46.1%), anxiety (39.8%), and insomnia (31.4%). When comparing participants in the three groups, more frontline healthcare workers had depression (58.8%), anxiety (52.6%), insomnia (42.2%), and post-traumatic stress (76.1%) than participants in the other groups. The results showed significant differences in the occurrence of depression, anxiety, insomnia, and post-traumatic stress in these groups (P <0.001) (see Table 1 ). Results in Table 2 show that a statistically significant difference was found among the three groups of participants (general public, non-frontline health professionals, and frontline health professionals) in regard to four aspects of mental health status. The frontline healthcare providers had significantly higher median scores for depression, anxiety, insomnia, and posttraumatic stress than the general public and non-frontline healthcare providers (P <0.001). The general public had significantly higher median scores for depression, anxiety, and insomnia than non-frontline healthcare providers (P <0.001). Most of the participants were under 40 years of age. This might be due to the fact that the social media platform used to distribute the survey is more often accessed by young adults. The results indicated that the frontline healthcare team is younger (