key: cord-1046717-8ypafd3h
authors: da Silva, Flaviane Cristine Troglio; Neto, Modesto Leite Rolim
title: Psychiatric symptomatology associated with depression, anxiety, distress, and insomnia in health professionals working in patients affected by COVID-19: A systematic review with meta-analysis
date: 2020-08-07
journal: Prog Neuropsychopharmacol Biol Psychiatry
DOI: 10.1016/j.pnpbp.2020.110057
sha: 6408b02b836e9ce793efeb368ba897f8a34c2c00
doc_id: 1046717
cord_uid: 8ypafd3h

BACKGROUND: Health professionals are key personnel to containing infectious diseases like COVID-19. In the face of long work shifts (that reach 16 h per day on average), the risk of getting infected by a high-infectious disease and the lack of enough biological protection measures, mental suffering among health professionals suddenly became evident. METHOD: We carried out an updated meta-analysis to investigate the psychiatric impacts on health professionals in the face of the physical and psychological conditions to which they are subjected due to the high demands of the COVID-19 pandemic. Papers were researched in four databases from December 2019 to April 2020. In total, eight papers were included in the study. RESULTS: Health professionals working to fight COVID-19 are being more severely affected by psychiatric disorders associated with depression, anxiety, distress and insomnia, stress, and indirect traumatization than other occupational groups. No significant differences were observed in the publication bias. CONCLUSION: There is a strong association between health professionals and COVID-19 in terms of psychiatric repercussions. Our meta-analysis showed that health professionals have a higher level of indirect traumatization, in which the level of damage exceeds psychological and emotional tolerance and indirectly results in psychological abnormalities. The incidence of obsessive-compulsive traces and somatizations was higher in situations involving front-line professionals.

At the end of December 2019, the first cases of pneumonia etiologically associated with a new virus, which was later identified as SARS-CoV-2, were registered in the city of Wuhan, province of Hubei, China. The new coronavirus disease (COVID-19) may create a variable clinical spectrum of symptoms and signs, which varies from asymptomatic conditions to the occurrence of a Severe Acute Respiratory Syndrome (SARS). Its spread has increased quickly. On January 20, China confirmed the transmission of COVID-19 from human to human. On January 23, the city of Wuhan closed all its access paths to decrease disease spread, but this was not enough. On January 30, 2020, during an emergency meeting convened by the World Health Organization (WHO), COVID-19 was pointed out as a public health emergency of international interest, and it was declared a pandemic on March 11, 2020 (Lai et al., 2020; Zhang et al., 2020) . 2,719,897 cases of COVID-19 and 187,705 deaths have been confirmed in the world until April 25, 2020, according to an information report from the Pan American Health Organization -PAHO (2020) and WHO (2020) .

China disclosed the adoption of active measures to help control the quick spread of COVID-19 in its territory. More than 30,000 health professionals moved to the province of Hubei and city of Wuhan. This professional category was soon affected by the SARS-CoV-2 spread. Since the beginning of the pandemic, more than 3,000 health professionals were infected in China (Li et al., 2020; Huang and Zhao, 2020a) . In the face of long work shifts (that reach 16 hours per day on average), the risk of getting infected by a high-infectious disease and the lack of enough biological protection measures, mental suffering among health professionals suddenly became evident and, as a consequence, it brought sleep, anxiety, and depression disorders. Thus, not only the physical health, but also the mental health of these workers became more vulnerable during the COVID-19 outbreak (Huang and Zhao, 2020a,b; Dai et al., 2020) .

Hence, health professionals are key personnel to containing infectious diseases like COVID-19. They perform their activities in a full and assertive way when in a calm environment where the risks they are exposed to are dully controlled. Thus, more should J o u r n a l P r e -p r o o f be understood about the mental health condition of these workers and the negative psychological repercussions when facing a prolonged source of distress to plan actions that promote and protect their mental and physical health (Mo et al., 2020; Lai et al., 2020) .

On February 2, 2020, the China State Council announced the adoption of direct lines of psychological support in the entire country to offer help during the pandemic (Lai et al., 2020) . Such action was based on studies indicating that the authorities should provide effective information and guidance regarding personal protection and also psychological interventions that may safeguard the mental health of the entire population (Wang et al., 2020) . Another study found that health education should be combined with psychological counseling for vulnerable subjects, such as the health professionals that are in the frontline fighting COVID-19 (Mo et al., 2020) .

Based on a scenario of increasing pandemic threat and a global atmosphere of anxiety, along with depression caused by the social distancing measures recommended to reduce disease transmission and an overload of information disclosed by different media outlets, information collection on the behavior and mental condition of health workers may help establish effective measures that stimulate and protect their health during the war against the pandemic (Wang et al., 2020) . Due to this situation, we have aimed to formulate a systematic review of literature regarding the psychiatric repercussions in health professionals that work in health systems to fight the clinical implications caused by J o u r n a l P r e -p r o o f 2. METHOD

A systematic research of all published papers was made in PubMed, Embase, ISI (Web of Science) and Scopus databases using the following combination of keywords:

"COVID-19" OR "Coronavirus Infections" (Medical Subject Headings -[MeSH term]; "Health Personnel" OR "Health Care Provider" [MeSH] term); and "Mental Health" (MeSH term), from December 2019 to April 2020.

The reason for limiting time to 2019-2020 was because during this period there was an increase in the number of research studies about health professionals as populations that are vulnerable to being contaminated by a highly virulent disease. Therefore, concern for health professionals has been associated not only with anxiety but also with other multiple clinical manifestations, like depression (having to face a large number of deaths, long work shifts and their association as an important indicator of psychic distress due to multiple uncertainties and demands associated with the treatment of COVID-19 patients.

The following searches were carried out: 1 and 2 and 3. The search strategy and retrieved papers were reviewed in two separate occasions to ensure proper sampling.

Then, each paper from the sample was read and data were extracted and added to a matrix that authors, journal, study sample description and main conclusions.

This study is based on the following research question: What are the psychiatric impacts on health professionals in the face of physical and psychological conditions to which they are subjected due to the high demands of the COVID-19 pandemic?

This question had obtained a larger impact in 2020 due to situations that involve health professionals directly in the diagnosis, treatment and support to patients, in the development of psychic spaces for pain installation and psychic J o u r n a l P r e -p r o o f suffering and other mental health symptoms. Thus, this systematic review aims to present the causes, psychiatric disorders per se, consequences and potential interventions.

The eligible studies should meet the following inclusion criteria: original studies about the psychiatric repercussions in health professionals involved in the fight against COVID-19; observational studies that measured the behavioral actions of health professionals involved in the fight against COVID-19. We excluded review studies and Controlled Randomized Trials, case reports, studies with methodological bias and conflicting results; there were no restrictions regarding language.

Data were collected independently by two reviewers (MLRN and FCTS) and any divergences between reviewers were solved by a mediator until a consensus was reached. The remaining papers were researched in full to determine if they met the inclusion criteria or not. The necessary information was collected from published papers ( Figure 1 ).

Stata, version 14.0 (Stata Corp), was used to collect data and perform relevant analyses in this meta-analysis. Each numerical value of the result was presented with a 95% confidence interval (95%CI). The publication bias was found through the Egger and Begg tests, p<0.05 was considered a significant publication bias. In addition, a sensitivity analysis was performed to test result stability using Stata 12.0 software. J o u r n a l P r e -p r o o f 3. RESULTS

The detailed steps of the literature research flow and screening process were described in Figure 1 . A total of 90 papers were found. Two independent researchers analyzed the title and abstract of the paper, 78 studies were removed because they did not meet the inclusion criteria and 12 potentially related papers were eligible. In the end, eight papers were considered relevant for a systematic review with meta-analysis. Table 1 .

As shown in Table 1 , we found that the psychiatric repercussions among health professionals in the fight against COVID-19 was significant in studies developed in European and non-European countries. Results of a sensitivity analysis revealed that the studies significantly showed a posttraumatic stress concentration among professionals, which indicated statistically robust results. The publication bias was examined both in a qualitative (funnel plot asymmetry) and quantitative manner ( Li et al. (2020) have observed that the indirect traumatization scores for front-line nurses, including psychological scores and responses, were significantly lower (p<0.001). Mo et al. (2020) pointed out that the multiple regression analysis showed that children, work hours per week and anxiety were the main factors affecting the level of stress of nurses (p=0.000, 0.048, 0.000, respectively). For Qi et al. (2020) , a total of 1,306 subjects were enrolled. A group of subjects had significantly higher scores of PSQI (p 0.0001), AIS (p<0.0001), anxiety (p<0.0001), and depression (p=0.0010) and a higher prevalence of sleep disorders with PSQI>7 points (p<0.0001) and AIS>6 points (p=0.0001). Huang and Zhao. (2020a) pointed out that health professionals have a higher rate of sleep disorders in comparison with other occupations. Younger health workers and people that spent longer periods of time (≥ 3 hours/day) had a higher prevalence of anxiety symptoms than those that spent less time (<1 hour/day and 1-2 hours/day) in the outbreak. Huang and Zhao (2020a,b) observed that medical support workers were more prone to poor quality of sleep compared with other occupational groups. The multivariate logistic regression showed that age (<35 years) and time spent focused on COVID-19 (≥ 3 hours per day) were associated with GAD and with medical support to workers that had a higher risk of poor sleep quality. Dai et al. (2020) 

Health professionals that work to fight COVID-19 are being more severely affected by psychiatric disorders (Lai et al., 2020; Zhang et al., 2020; Dai et al., 2020) , sleep disorders (Huang and Zhao 2020a, b; Qi et al., 2020) , stress (Mo et al., 2020) , and indirect traumatization (Li et al., 2020) than other occupational groups. After studying physiological and molecular reasons of psychiatric disorders more profoundly, we observed that somatic symptomatology culminates in psychoneuroimmunology bias analysis (PNI) of COVID-19 (Wang et al., 2020) . The release of proinflammatory cytokines, including interleukin (IL) -1β and IL-6 of the respiratory tract, may be stimulated by the Severe Acute Respiratory Syndrome (SARS) caused by COVID-19 (Conti et al., 2020) . In parallel, the increase of cytokines was also seen in major depression disorders and in functional somatic syndromes (Wang et al., 2020) . Thus, COVID-19 and such psychiatric disorders have a similar psychoneuroimmunology (PNI) structure.

In this clinical scenario, the studies carried out by Lai et al. (2020) and Zhang et al. (2020) present higher statistically significant risks of a psychiatric symptomatology associated with depression, anxiety, distress, and insomnia in health professionals working in patients affected by COVID-19 in Wuhan, China. The results were obtained, respectively, through scales regarding the Patient Health Questionnaire (PHQ), the Generalized Anxiety Disorder (GAD), the Insomnia Severity Index (ISI), and the Impact of Events Scale-Revised (IES-R) (Lai et al., 2020) .

The studies conducted by Zhang et al. (2020) and Lai et al. (2020) observed a higher statistically relevant prevalence in health professionals who are not doctors of symptoms of depression, anxiety, and insomnia; however, a new symptomatology associated with obsessive-compulsive traces and somatization was also reported. The organic presence of disease was an independent factor for insomnia, anxiety, depression, somatization, and obsessive-compulsive symptoms in doctors, but it was a risk factor for non-doctors (Zhang et al., 2020) . Regarding a higher predisposition or vulnerability to disorders among health professionals, the profiles of female nurses were significantly reported with more severe levels of all the measures of mental disorders (Lai et al., 2020) . Being at risk of contact with patients, being a woman and living in rural areas were the most common risk factors for insomnia, anxiety, obsessive-compulsive symptoms, and depression (Zhang et al., 2020) . In the analysis of subgroups of front-line medical workers, compared to the male gender, women also had a significantly higher prevalence of sleep disorders (p<0.0001) (Qi et al., 2020) . A multiple regression analysis also showed that anxiety J o u r n a l P r e -p r o o f was significantly associated with stress developed by nurses whose fight against the COVID-19 pandemic makes them constantly under pressure.

Factors that stimulate the psychic conditions mentioned include work conditions to which health professionals are subjected to, such as performing tasks under great pressure, irregular work schedule, and long shifts, contributing to the development of psychological and sleep disorders (Sveinsdottir, 2006) . Besides the general stressors to which these professionals are exposed to, the COVID-19 pandemic context brings specific stressors, such as the risk of infecting yourself and others, the care of relatives socially isolated at home and worries about mental and physical health conditions among coworkers (IASC, 2020) . This prolonged exposure to stressors may exceed the mechanisms individuals have to fight back and this results in psychological repercussions for these subjects (Fava et al., 2019) .

One of the causes of psychological stress among health professionals working in the pandemic may be associated with the difficulties found to ensure personal safety related to the high risk of being exposed to infected patients and the scarcity of protection equipment (Zhang et al., 2020) . In addition, these professionals are seeing significant changes in their work environment, such as the increase of occupational responsibilities, strict measures of safety and reduced self-care due to lack of time and energy (IASC, 2020; WHO, 2020). In a cross-sectional study including 1,306 health professionals in the province of Hubei, China, frequent work hours and occupational stress, besides COVID-19 severity, were mentioned by subjects as the main factors influencing sleep quality (Qi et al., 2020) .

In turn, reduced social support received by these subjects due to long work hours and stigmatization of workers in contact with COVID-19 patients may also contribute to the professional stress of workers directly involved with the pandemic (IASC, 2020; WHO, 2020) . This evidence is corroborated in the analysis of 4,357 health professionals in China, which found that "being isolated" among many other factors was a factor associated with poor prognosis of psychological disorders (Dai et al., 2020) . Similarly, working in rural areas was also associated with a higher risk of insomnia, anxiety, depression, and obsessive-compulsive disorder (OCD) among health professionals. This fact may also be associated with higher concerns about the risk of infection due to the J o u r n a l P r e -p r o o f need of working at a service that often has poorer work conditions in comparison with those from the urban area (Zhang et al., 2020) .

Besides the psychiatric symptomatology analyses, some interventionist measures may contribute to reduce the stress suffered by health professionals and promote mental health improvement, even during the pandemic. At first, it is important to acknowledge violent emotions, under these circumstances, including anger, irritability or mood alterations. They should be seen as regular and comprehensible stress reactions and, therefore, should not be processed as guilty. Ensuring basic needs are duly satisfied is also especially important, besides having sufficient breaks, keeping a healthy diet and remaining physically active. The use of substances, like alcohol and tobacco, as a coping strategy may bring psychological and physical damage in the long term and should be avoided. Sharing experiences and feelings with colleagues experiencing similar problems may help reduce psychological stress. Telephone calls and message services can be used to keep social contacts in the private sphere, which is a great contributor to maintaining good mental health (WHO, 2020; IASC, 2020; Petzold and Ströhle, 2020) .

The studies analyzed have limitations due to the limited scope, because most of the subjects belong to Wuhan, China, and due to the short period of the analysis. In addition, another limitation was the psychological assessments in online research and self-report tools. Therefore, large-sized longitudinal studies that include other health professionals, in addition to doctors and nurses, are necessary to further explore the pathogenesis, therapeutic strategies and use of clinical interviews to elaborate a wider assessment of the problem. 

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The authors would like to thank the researchs groups: Suicidology Research Group, 

 MLRN and FCTS designed the review, developed the inclusion criteria, screened titles and abstracts, appraised the quality of included papers, and drafted the manuscript.MLRN and FCTS reviewed the study protocol and inclusion criteria and provided substantial input to the manuscript.MLRN and FCTS reviewed the study protocol. MLRN read and screened articles for inclusion. All authors critically reviewed drafts and approved the final manuscript.

The authors declare that they have no competing interests.J o u r n a l P r e -p r o o f