key: cord-1017970-mbe9dt3v authors: Sharif, Salman; Amin, Faridah; Hafiz, Mehak; Benzel, Edward; Peev, Nikolay Angelov; Dahlan, Rully Hanafi; Enchev, Yavor; Pereira, Paulo; Vaishya, Sandeep title: COVID 19-Depression and Neurosurgeons date: 2020-06-06 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.06.007 sha: c04b7d2d71fcd480e31f21ce74175a32b7482013 doc_id: 1017970 cord_uid: mbe9dt3v nan The novel coronavirus initially originated in China and has rapidly spread globally. The growing pandemic of severe acute respiratory syndrome coronavirus 2 diseases (COVID-19) has become a significant public health liability worldwide. The COVID-19 pandemic has grown into one of the central health crises of a generation. It has affected people irrespective of nation, race, caste, and socioeconomic groups. On 30 th Jan 2020, the WHO (World Health Organization) announced the emergence of the novel coronavirus. It declared a PHEIC (Public Health Emergency of International Concern), which is the sixth PHEIC under the IHR (International Health Regulations). The rapid increase in cases and evolving guidelines regarding protection and prevention of the spread of pandemic, with no confirmed treatment or approved vaccine has caused apprehension and anxiety among health care workers. Unpredictability in the biological behavior of the virus, erratic changing instructions from WHO, variable guidelines regarding quarantine and management of the pandemic have increased the uncertainty. As of the first week of May 2020, 2,227,191 COVID positive cases with 258,356 confirmed deaths have been reported worldwide and 212 countries are affected by the pandemic. 1 So far, more than 42,600 health-care providers have been infected with COVID-19 in China, and more than 124 doctors have died in Italy 2, 3 . In the United States, approximately 9,300 nurses, doctors, and other frontline health care workers have been infected by the disease, and dozens have died. 4 Across Western Europe, nearly 14 percent out of confirmed coronavirus cases are medical professionals which is the highest reported cases among doctors and nurses. 5 Moreover according to the report on 3 rd April 2020, at least 35 doctors have died,and more than 4,200 health workers have self-isolated in countries across Asia and Pacific region, therefore concerns among healthcare professionals are well-founded. 6 The pandemic is serious and disruptive 7 , yet despite the widespread infectivity and higher mortality than the common influenza virus, not much is known regarding management of critical cases, prevention and optimal measures to reduce its spread. Scarce resources and an often inadequate availability of personal protective equipment (PPE) and lack of knowledge about their optimal usage can further lead to apprehension, distress, panic and anxiety in health care workers. 9 The COVID associated health crisis has disrupted working of all medical communities around the world, including delivery of essential medical and neurosurgical services. The hasty outpouring numbers of COVID positive cases, not only presents a public health challenge but also have significant medical and ethical implications for the care of neurosurgical patients. Currently, there is a paucity of literature guiding neurosurgery practice. Neurosurgical societies have developed and published guidelinesto promote best practices for their patients. However, implementation of these guidelines is a challenge in many parts of the world where health care systems are not well established, but adjustments during an event like the COVID-19 pandemic have been made. It may provoke even more distress and depression within the neurosurgical fraternity. 8 A survey was developed to assess to stressors affecting neurosurgeons as a result of the pandemic. The goal of this survey was to determine the prevalence and factors associated with anxiety and depression among neurosurgeons during the COVID-19 pandemic. While the full impact of the pandemic remains to be seen, this survey aimed to determine the frequency of depression among neurosurgeons during the pandemic and explore any modifiable factors that could be addressed to reduce the incidence of distress and mental illness among neurosurgeons. This was a cross-sectional study design conducted through an anonymous online questionnaire with only information about the city and no contact information to address ethical implications of the survey. The study duration was 3 weeks (until the requisite sample sizewas achieved). The questionnaire was modified based on suggestions fromWorld Spinal Column Society (WSCS) executive board members. Majority of the members of the World Spinal Column Society are neurosurgeons, who also perform spinal surgery. The survey was designed on Google form and sent to neurosurgeons who were members of scientific societies globally through WSCS Executive Committee. The survey was circulated to members of WSCS on their social media, WhatsApp groups and emails, and through snowballing technique locally and internationally. The neurosurgeons identified through these media were asked to forward the survey to other neurosurgeons in their professional circle and so on. Out of total 800 neurosurgeons who were approached, 375 responded. A recent Chinese study showed a 40.77% (201/493) prevalence of mild to moderate depression among physicians during the COVID pandemic. 8 Depression was assessed through a World Health Organization validated questionnaire (selfreporting questionnaire, SRQ-20). 10 A cut-off score of 8 or more was considered as positive for depression. Dependent variable: Depression graded on WHO SRQ -20 with a cut-off score of 8 or more for a positive case of anxiety/depression. Univariate binary logistic regression was applied to determine association of each independent variable with the outcome (anxiety/depression). Multivariate logistic regression was used to measure the association of multiple independent variables with the outcome (anxiety/depression) by computing adjusted odds ratios and their 95% confidence intervals. Variables with p-value < 0.25 in univariate analysis were subsequently included in the multivariate logistic regression model. Statistical significance was assumed for p-value<0.05 in the multivariate model. Consent was taken from all those who filled the online questionnaire. The participant's identity and name of the institution was not disclosed. All data were kept confidential in a password protected computer. There was no financial compensation for participation nor any penalty for not participating. A total of 375 neurosurgery trainees and consultants from 52 countries and 5 continents participated in the survey (figure 1). The majority of the respondents were from Asia (n=181, 48.5%) (Figure1). Table 1 shows the distribution of socio-demographic factors among participants. The majority of the participants were consultants (79%) from low to middle-income countries (66%). More than half were younger than 40. Among all participants, 84% worked in departments with 4 or more staff (83%), while more than half of the respondents reported having less than 10 trainees in their departments (53.3%). Table 2 shows the distribution of responses regarding the COVID-19 pandemic. Almost 69% reported basic to moderate knowledge about the pandemic. Sources of information are depicted in Figure 2 . The most common source of information was scientific publications, while almost half of them also used social media as a source for information. The majority (74%) of the participants thought that it would take more than two months for the pandemic to end. (Figure 3) Majority of the participants (68%) said that enough information had been provided by their institutions regarding the COVID pandemic. 31% reported that they had not been provided PPE by their Hospital, though more than half have attended training courses arranged by their institutions. Among consultants and trainees, 45.6 % reported that they did not feel safe during the pandemic. The majority (72%) had severe concerns regarding the safety of their families back home. 21% reported that they had been exposed to a COVID positive case among colleagues. Of these, 85% had been quarantined or self-isolated themselves, 8.8% got admitted for quarantine. Surprisingly, 5% continued work, while 1.3% took no action at all on being exposed. 41.6% of the respondents reported that their primary concern during this pandemic was the inadequate provision of PPE. The majority (n=328, 87.5%) of the neurosurgeons said that as a routine, their weekly surgery volumes were more than 10 cases. In comparison, during the pandemic, 270 (72%) said they were doing fewer than 10 surgeries /week (p<0.001). Similarly, the majority (n=336, 89.6 %) reported performing more than 75% elective surgeries before the pandemic, while 272 (72.5%) said that the number of elective surgeries during COVID-19 pandemic reduced to 25% or less (p<0.001). Families of 67% of neurosurgeons did not feel safe for them going to work. About 1/4 (28 %) of the participants were redeployed to a COVID affected area for work during the pandemic, and the majority (60%) thought that redeployment would not be useful considering their knowledge and expertise. A 13.9 % prevalence of anxiety/depression was found among neurosurgery trainees and consultants in this study. Among all participants, 34% felt tensed, 32.5% were unhappy, 25 % experienced insomnia, almost 20% had headaches, were easily fatigued or tired and thought that they were unable to play a useful part in their life, 10% had difficulty in decision making, 5% cried more than usual, while, 5% had suicidal ideation during the pandemic (Table 3) . Table 4 shows the univariate and multivariate analysis for the association of different factors with anxiety and depression among neurosurgical trainees and consultants. The likelihood of depression was higher among those who didn't receive information or self-protection from their institutions to combat the situation than those who got it (OR= 2.47, 95% CI: 1.37 -4.48). Those who reported that they didn't feel safe with provided PPE were also at a higher risk of depression (OR=3.13, 95% CI: 1.67 -5.88). Anxiety and depression were less likely among those who had minor (n=4, 10%) and moderate concerns (n=3, 4.7%) for the health of their families as compared to participants who were more concerned for their families during the current pandemic situation (n=45, 16.6%). Univariate odds ratios showed that the likelihood of depression was significantly lower in neurosurgeons who had minor concerns as compared to those with significant health concerns for their families (OR = 0.36, 95% CI 0.16 -0.83). The prevalence of depression was also significantly higher in participants whose families considered their workplace unsafe (OR=2.29, 95% CI: 1.11 -4.73). In multivariate analysis (Table 4) , effects of the following variables were controlled; age, selfrating of COVID-19 knowledge, information regarding protection provided by Hospital, feeling safe with provided protective equipment, degree of concern for family health, presence of positive COVID-19 colleagues and families considering the workplace safe. After controlling for the effects of other covariates, the odds of depression were significantly higher in individuals who did not feel safe with the PPEs provided to them than those were satisfied with provided PPEs (OR=2.43, 95% CI: 1.13 -5.22). Participants who had moderate concerns for their families had lesser odds of anxiety and depression than those with significant concerns (OR=0.28, 95% CI: 0.08 -0.99). Being exposed to a COVID-19 positive colleague significantly increased the likelihood of anxiety/depression, even after adjusting for other covariates (OR=2.54, 95% CI: 1.24 -5.19). The COVID-19 pandemic is spreading across the globe at an exponential rate, creating apprehension and distress among all healthcare professionals. 9 Neurosurgeons being an essential part of the healthcare community are also affected in a major way. Belonging to a fundamental surgical specialty, tackling emergencies and performing complex operations requiring significant dexterity, hypothetically enable them to deal with stressful situations, making them less prone to develop anxiety and depression 11 . This may only be an assumption as we did not find any study to determine the frequency of anxiety/depression among this specialty before the pandemic. It is for the first time that depression was found among 14% of neurosurgeons. It cannot be said with conviction if this frequency is higher than that before the pandemic but a study done in 2003 among surgeons, demonstrated a rise in prevalence of depression post SARS outbreak with a 30% increase in suicide. 12 Poor mental health is a social stigma 13 moreover, a fear of being judged may explain neurosurgeons having a lower depression score as was seen in another study assessing level of stress among surgeons. 11 This may be one of the reasons that despite mental health problems and psychosocial issues among health-care workers, most of them do not often seek mental health care. 14 Majority of the participants were consultants (79%), and almost half of them were 40 years of age and above. The senior neurosurgeons were less likely to be anxious and depressed, though the results were not statistically significant. In relation to this finding, a recent NHS survey also indicated that 70 % of young physicians suffered from mental health issues, while retired physicians and surgeons were more enthusiastic to volunteer for COVID duties. 15, 16 There was no difference in the frequency of depression among neurosurgeons working in private or government/ university hospitals. Though, a significant decrease in workload may be a potential risk factor leading to psychological distress, yet a non-differential change between workload of private and public sector explains our finding, as confirmed by a recent survey by Walter Jean. 17 The COVID-19 pandemic has a global impact, irrespective of race, caste, color or creed, with widespread xenophobia especially among the medical fraternity regarding their families' and their own health (unpublished data). Despite trying times, this survey showed no difference in depression among the neurosurgeons, whether they belonged to high-income (12.6%) or middle/lower-income countries (14.2%), European (10.4%) or non-European (15%) countries. Although, a recent Chinese study reported a much higher prevalence of depression (50.4%), anxiety (44.6%) and insomnia (34%) among frontline health care workers. 16 This translates to the fact that more than the income, specialty or region, the area of practice influences mental health, predisposing to an increased sense of insecurity and hence psychological distress. The requirement for quarantine, social distancing, and shelter-in-place orders have lead to an abrupt change in life styles and may be leading to increased apprehension among families especially of healthcare workers. Not only families of neurosurgeons felt unsafe for them to go to work but the surgeons themselves reported concerns for the safety of their families back home. Therefore a feeling of self-protection with provided PPE had a significant negative association with anxiety/depression while a positive COVID colleague increased the likelihood of depression among neurosurgeons. A recent survey in UK reported half of health workers suffering from stress due to inadequate availability of PPE. 15 This pandemic has disturbed functioning of all medical and surgical specialties. Selected emergency neurosurgery cases are being performed in special circumstances only such as trauma, severe acute functional impairment and tumors causing impending disability. Neurosurgical approaches through the nose and sinuses are being postponed due to high risk of viral transmission and updated neurosurgical guidelines for the treatment of positive or suspected COVID patients have been circulated. 9 The COVID crisis has hence led to a considerable decrease in elective cases (p<0.001). Walter Jean also showed a drop of more than 50% operative volume during the present pandemic. 17 Though our study did not find a significant association between this drop in elective cases and anxiety/depression among neurosurgeons, yet if this status quo is further extended, it may lead to impending depression as one third of our participants were unhappy, felt tensed, experienced insomnia, headaches and felt fatigued and tired. Moreover, one in 20 respondents cried more than usual and had suicidal ideation. This hypothesis is confirmed by another study conducted at Liaquat National Hospital on frontline physicians (unpublished data) which found that there was more depression in physicians who were working < 20 hours a week compared to those who are working > 20 hours during the pandemic. Although the potential shortage of ventilators and ICU beds necessary to care for the surge of critically ill patients has been well described, additional supplies and beds will not be helpful unless there is an adequate workforce. According to our data, about 28 % of the participants were redeployed to a COVID affected area, during the pandemic. Nevertheless, 60 % of neurosurgeons believed that their knowledge and expertise in an unknown environment would not be useful, and their work will not be meaningful if redeployed out of their specialty. To our knowledge, this is the first study ever to determine the frequency and factors associated with anxiety and depression among 375 neurosurgeons from 52 countries. The prevalence of depression and anxiety among neurosurgeons was found to be lower than the frequency reported among other frontline workers during the COVID pandemic. Yet, it is difficult to conclude the magnitude of the problem attributable to the pandemic, as there is a paucity of data regarding mental illness among neurosurgeons before the catastrophe. In a recent survey among neurosurgery residents, the risk of burnout was found to be 20.7% and higher working hours was one of the drivers for burnout (1) while another survey found a 56.7% burnout among neurosurgeons (2) . As both these surveys did not explore depression or anxiety, results of our study are not comparable, yet, as the working hours during the pandemic have considerably reduced, it can be extrapolated that the frequency of burn out would be consequentially less. 17, 18 Mental illness is a social stigma around the globe and this may be more of an issue among fraternities who are considered as the "resilient lot" such as the neurosurgical specialty, hence leading to an underreporting of symptoms. Only one scale (SRQ-20) was used to screen for anxiety /depression, as asking too many questions on an online survey was inconvenient and would have lead to missing data. Moreover in online surveys, there is always a high probability of participation bias because the participants, based on their state of mind at the time of the study, may or may not choose to participate in the study. Though, it may lead to non-differential participation bias. With the evolving pandemic, the situation is still dynamic in various countries around the globe. Circumstances have varied from day to day, and hence the response of participants may be different according to their changing situation. Therefore, the survey being filled readily by participants having more concerns regarding the ongoing pandemic may have introduced a bias. Although we tried to control for confounders during recruitment as well as analysis stage through multivariate analysis, yet there is a possibility that we may have missed potential confounders which may have exaggerated or masked the associations. Yet, the factors associated with anxiety/depression among neurosurgeons in the multivariate analysis are all biologically plausible. The world is going through an unprecedented crisis, which caused turmoil in all the countries in the world. The health system in decades has not dealt with such a disaster. Neurosurgeons, like all other specialties, are affected and experiencing challenges in their work and daily living. Colleagues getting infected, feeling of being unprotected and concerns for the health of their families were factors found to be associated with anxiety/depression. We therefore recommended that the safety of the health-care workers be ensured by providing standard PPE and having optimum safety measures for them to regain confidence and hence reduce the incidence of mental ailments. Less than 4 weeks 4 to 8 weeks 2 to 6 months More than 6 months Don't know Never Death from Covid-19 of 23 health care workers in China Doctors and healthcare workers at frontline of COVID 19 epidemic: Admiration, a pat on the back, and need for extreme caution Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 Validation of the WHO self-reporting questionnaire SRQ-20) item in primary health care settings in Eritrea Stress in surgeons. The British journal of surgery UK military doctors; stigma, mental health and help-seeking: a comparative cohort study Mental health and a novel coronavirus (2019-nCoV) in China Clinical depression: surgeons and mental illness The impact of COVID-19 on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey We thank Ms. Noureen Durrani for statistical analysis of the Data and Mr. Imad Ullah for helping throughout the study.