key: cord-1034209-10n335qy authors: Tao, Jiang; Lin, Yueting; Jiang, Long; Zhou, Zhuojun; Zhao, Junjun; Qu, Donglin; Li, Wei; Zhu, Yaqin title: Psychological Impact of the COVID-19 Pandemic on Emergency Dental Care Providers on the Frontlines in China date: 2020-12-09 journal: Int Dent J DOI: 10.1016/j.identj.2020.12.001 sha: 28713f109bfb62f4bf85c1ff5b2647bdeab99921 doc_id: 1034209 cord_uid: 10n335qy COVID-19 is an infectious disease emerged at the end of 2019. On 30 January 2020, the WHO classified it as a pandemic. To examine the psychological effects on dental care providers in China in the midst of the COVID-19 outbreak and factors closely associated with those effects, we conducted a cross-sectional study online with four widely used self-administered questionnaires: the Patient Health Questionnaire-9, the General Anxiety Disorder-7, the Perceived Stress Scale-10, and the Acute Stress Disorder Scale. Univariate and multivariate analyses were performed to evaluate the variables that potentially affected the mental health of emergency dental care providers. As a result, 969 out of 1035 questionnaires were included in the analysis, with 642 respondents reporting more than one symptom (66.3%). The symptom of perceived stress was reported by the largest proportion of the respondents (66.2%, n=641), while anxiety the least (7.1%, n=69). After adjustment for confounders, it is found that dental practitioners with pre-existing physical health conditions were at higher risk of depression (OR, 1.972; 95%CI, 1.128∼3.448; p=0.017), and perceived stress (OR, 2.397 95%CI, 1.283∼4.478; p=0.006). Additionally, feelings of fear, helplessness, or terror resulting from the possibility of being contracted were significantly associated with the prevalence of all the four psychological symptoms observed (p<0.05). In the present study, we revealed the psychological depression, stress, anxiety, and posttraumatic stress disorder (PTSD) suffered by dental care providers during COVID-19, which indicates the importance of psychological support at times of major epidemic outbreaks. Clinical trial registration number: ChiCTR2000031538 Registry: Chinese Clinical Trial Registry Appearing at the end of 2019, COVID-19 overwhelmed medical systems in countries and regions worldwide. It is of the highest priority to contain the outbreak; however, its psychological effects on healthcare workers should not be ignored. As ordinary people, there is no doubt that healthcare workers who provide care for and treat patients on the frontlines bear enormous psychological burden. To prevent psychological problems from developing into secondary traumatization, attention to and knowledge of the psychological effects of the outbreak should be enhanced. According to previous research on infectious diseases, including Severe Acute Respiratory Syndrome (SARS)，Middle East Respiratory Syndrome (MERS)，H1N1, Ebola Viral Disease (EVD), and COVID-19, medical staff showed physical symptoms of insomnia, exhaustion, decreased appetite, and suffered from psychological symptoms of stress, depression, anxiety [1] [2] [3] [4] [5] . The symptoms could even persist for a long time, which possibly contributed to chronic psychological and physical health problems 6, 7 . Dental practitioners in many countries also reported similar psychological distress following disaster exposure 8 , which is of continuing concern. Jun Shigemura et al. evaluated the psychological responses in dentists who conducted disaster victim identification after the 2011 Fukushima Disaster, claimed that the dentist's psychological burden was associated with disaster 9 . Similarly, it was concluded that the COVID-19 emergency was having a highly negative impact on dental practitioners in two of the northern Italy districts, Israel, and some other parts of the world 8, 10, 11 . Since SARS-CoV-2 is transmitted through oral and nasal discharge exuded from virus carriers 12 , the droplets generated in the course of coughing and exhaling are risk factors for disease transmission. Dental care providers are inevitably in close contact with patients during dental procedures when aerosols or droplets can settle on different surfaces, which makes dental clinics a high-risk place in an epidemic of respiratory infectious diseases. During the COVID-19 outbreak, dental care workers in China have remained in their posts out of a sense of duty despite uncertain dangers. However, there is little literature on the mental health status of emergency dental care providers in China. We aim to clarify the psychological impact of COVID-19 and to accelerate the development of the psychological support system for dental practitioners. This is a cross-sectional survey that was conducted from 3 April 2020 to 10 April 2020 using web-based anonymous questionnaires. Volunteers were recruited by around 100 medical institutions under the Emergency Committee of the Chinese Stomatological Association through snowball sampling 13 . The inclusion criteria are: (1) informed consent and participation on a voluntary basis; (2) Chinese citizenship. Participants are excluded if they: (1) are of ages below 18 or over 65; (2) have a history of mental illness; (3) answered the series of questions in the questionnaire identically or in a clear pattern (e.g, choosing the same options). The protocol and informed consent documents were submitted to and approved by the Medical Ethics Committee of Shanghai Ninth People's Hospital (SH9H-2020-T55-2) and Chinese Clinical Trial Registry (ChiCTR2000031538). Based on previously documented studies in a similar population 14 , we estimated that no more than 70% would manifest psychological symptoms. After controlling for type 1 error at 0.05 with a tolerance of 3%, a target sample size of 896 was calculated using the formula = 1− 2 2 ⁄ (1 − )/ 2 15 . Suppose the response rate was above 90%. Then at least 996 participants should be recruited. The questionnaire was comprised of two parts: demographic information and Chinese version self-rating scales. Data on respondents' gender, hospital type, age, marital status, level of education, parental status, history of mental illness, and physical health status were all collected. The scales part, which consists of PHQ-9, GAD-7, PSS-10, and ASDS evaluating depression, anxiety, perceived stress, and PTSD symptoms reported satisfying psychometric properties among many different Chinese populations [16] [17] [18] [19] . Patient Health Questionnaire-9 (PHQ-9) is one of the most commonly used depression screening tools in primary healthcare settings 20 , which had shown good validity and internal consistency (Cronbach's α: 0.56-0.94) in previous study 21 . The performance characteristics are acceptable when the cutoff value is at or above 10 22 . The 7-item scale General Anxiety Disorder-7 (GAD-7) is a brief and convenient measure for identifying probable cases of anxiety. After validity and reliability analysis, prior study had supported its application in the general population 23 . A summary score of 10 for cutoff is recommended 24 The data were analyzed with the software Statistical Package for Social Sciences (IBM SPSS Statistics 25). Based on the univariate analysis, we entered specific variables (p<0.10) as independents in binary logistic regression models to further assess the impact of potential stressors. Dummy variables such as hospital types were defined. Confounding factors (ie, hospital types, gender, marital status, parental status, educational level, pre-existing physical diseases, COVID-19 related experiences or thoughts) were adjusted when appropriate. The statistical significance level was set at 0.05 with a two-tailed test. A total of 1035 questionnaires were returned, of which 66 with invalid data were were unmarried, and the rest was unspecified (n=16, 1.7%). 64.8% had a child or children (n=628). In terms of educational levels, 391 participants had a master's degree or above, 468 participants had a bachelor's degree, and 110 had an associate degree or below. In total, 802 respondents worked in the initial stage of the outbreak. Of all psychological symptoms, the most frequently reported was perceived stress, with a proportion of 66.2% (n=641), followed by depression (n=134, 13.8%), then PTSD (n=82, 8.5%), and at last anxiety (n=69, 7.1%).. Overall, 327 respondents (33.7%) reported no symptom, while 25 reported four symptoms (2.6%). After adjusting for the confounding variables, pre-existing physical diseases, having to face the possibility of treating a patient who later turned out to be a suspected or confirmed case, and the feelings of fear, helplessness or terror resulting from the possibility of being contracted were significantly associated with depression. Dental care providers who experienced these factors were at 1 p<0.001) times greater risk, respectively, than those who didn't ( Table 1) . As shown in Table 1 , feelings of fear, helplessness, or terror resulting from the possibility of being contracted (OR, 3.421; 95%CI, 2.026~5.776; p<0.001) was a factor associated with more anxiety symptoms. Likewise, respondents that were subjected to the feelings of fear, helplessness, or terror resulting from the possibility of being contracted were at higher risk of developing PTSD (OR, 4.856; 95%CI, 2.904~8.120, p<0.001) ( Table 2) . (Table 2 ). In this cross-sectional study, we revealed the psychological responses of dental care providers to the COVID-19 outbreak. Marital status, gender, educational levels, history of physical diseases, etc., were assumed to be factors associated with the prevalence of psychological symptoms. Of all the variables observed above, gender, marital status, and whether or not being on duty at the initial stage of the outbreak displayed no statistical differences, while the rest of the variables exhibited significant association with psychological symptoms. The gender, marital status showed no differences between the observed symptoms, which is consistent with a study on the psychological effect of SARS on emergency department staff 30 . It might because dental workers exposed to similar risk despite their gender and had family responsibility despite their marital status. However, some other studies on health care workers found that female gender and singles were more vulnerable to psychological problems, and attribute it to their most nurses' identification for longer contact time when cared for patients and younger age with less work experience 31, 32 . Concerning the variable of whether or not being on duty at the initial stage of the outbreak, adequate protections and prompt action might be played a role. In agreement with the research regarding immediate psychological responses during the initial stage of COVID-19 among the general population in China 32 , our survey identified the pre-existing physical disease as a factor associated with a higher risk of depression, anxiety. Previous studies on the psychological impact of SARS among frontline healthcare workers 31 also supported the variable of pre-existing physical disease as a significant indicator of psychological morbidity. Significantly, having or not having the feelings of fear, helplessness, or terror resulting from the possibility of being contracted presented statistically significant differences in the psychological outcomes of depression, anxiety, perceived stress, and posttraumatic stress disorder. In a similar vein, several psychological studies on past outbreaks 1,33 showed the adverse effect of exposure to infected patients. Moreover, it is reported that fear for one's health mediated the relationship between outbreaks and psychological distress 34 . Strengths of our study are as follows: we complemented the literature on the psychological impact of COVID-19 among Chinese dental care providers; the survey was conducted within a month from the initial stage, in which constant vigilance and response efforts remained; the sample was geographically representative with participants across provinces and cities in China. However, there are several limitations to the present study. Firstly, due to the nature of the cross-sectional study and the lack of normative data, causal inference cannot be made. Secondly, the self-reported data may be less accurate than clinical interviews. Thirdly, other contributing factors such as workload 3 were not surveyed. Further research on the long-term psychological effects of infectious diseases 35 , psychological resilience 36 and altruism 37 exhibited during an outbreak, and posttraumatic growth 38, 39 induced by the outbreak remains to be conducted. In conclusion，the emergence of the COVID-19 outbreak affected dental care providers to a varying degree. In particular, poor physical health conditions and feelings of fear, helplessness, or terror resulting from the possibility of being The authors declare no conflict of interest. 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