Prevalence and Factors Associated with Depression and Anxiety Among Health Care Personnel in the United States During Coronavirus Disease 2019 (COVID-19) Pandemic

Introduction: Healthcare personnel (HCP) are at risk of psychological and emotional distress during the coronavirus disease 2019 (COVID-19) pandemic. The aim of the study was to assess the prevalence and explore the factors associated with depression and anxiety among HCP taking care of patients with COVID-19 in the United States (US). Methods: The study is cross-sectional, anonymous, web-based survey of HCP distributed in the US via email and social media between April 14, 2020 and May 5, 2020. Participants were stratified based on their occupation (i.e., registered nurses, other first responders, physicians, respiratory therapists, and nurse practitioners or physician assistants) and specialty. Practice settings were stratified based on hospital type (academic or community-based) and location. Study outcomes were prevalence and factors associated with depression and anxiety using the 9-item Patient Health Questionnaire (PHQ-9; range: 0-27) and the 7-item Generalized Anxiety Disorder (GAD 7; range 0-21) questionnaires, respectively. Results: In all, 1426 HCP submitted surveys, predominantly females (81%), aged 31-40 years, and non-Hispanic white (78%). Overall, the prevalence of depression and anxiety was 57.4% and 56.7%, respectively. Factors associated with depression were HCP with COVID-19 risk factors (odds ratio [OR] = 1.46; 95% confidence interval [CI] = 1.1–1.94; P = .009), exposure (OR = 1.87; 95% CI = 1.44–2.44; P = <.001), and being uncomfortable with hospital infection control policies (OR = 1.87; 95% CI = 1.28–2.71; P = .001). Similarly, factors associated with anxiety included HCP with COVID-19 risk factors (OR = 1.36; CI = 1.03–1.81; P = .03), COVID-19 exposure (OR = 1.43; 95% CI = 1.09–1.86; P = .01), and not being comfortable with the healthcare facility infection control policies (OR = 1.66; 95% CI = 1.14–2.41; P = .008). Conclusion and Relevance: The majority of HCP surveyed had a high burden of depression and anxiety early in the COVID-19 pandemic in the US. Organizations and institutions will need to develop preventive and management strategies to optimize and sustain the mental health of HCP, particularly under pandemic conditions.


Introduction
Magnitude of problem: Coronavirus disease (COVID- 19), caused by the severe acute respiratory coronavirus-2 (SARS-COV-2), was declared a pandemic on March 11, 2020. [1] Since March 26, 2020, the United States (US) has recorded the highest number of cases in the world, surpassing 5 million by August 2020. [2,3] An estimated 16 million personnel employed in the health care industry in the US are involved directly or indirectly in the management of patients with COVID-19. [4] Pre-pandemic prevalence of burnout among health care personnel (HCP) ranged 35-54%; how the current pandemic may affect burnout and well-being moving forward is unknown. [5] HCP responding to a specific crisis event (e.g., trauma) often face increased work intensity and load, uncertainty due to unprecedented challenges, unpredictability, Personnel in the United States During Coronavirus Disease 2019 (COVID-19) Pandemic and pressure managing time-sensitive situations in addition to their usual work. A pandemic such as COVID-19 may present additional HCP considerations such as choosing between personal health versus providing the care for their patients, a lack of specific therapy, excessive media coverage, concerns surrounding personal protective equipment (PPE), lack of precise timing of when or if the pandemic will affect their community while viewing the effects on others. Prior observations among HCP during the 2003 SARS-CoV-1 outbreak showed significant anxiety, stress, and depression which persisted up to a year later. [6][7][8] As the US is in the initial stages of the pandemic, the well-being and emotional resilience of HCP are critical components of maintaining essential health care services during the COVID-19 outbreak.
Current Recommendations and study aim/ goal: To our knowledge, the impact of the COVID-19 pandemic on the mental health of HCP in the US is unknown. The study aim was to assess the mental health of HCP in the US by measuring and exploring the factors associated with depression and anxiety.

Study Design
Our study is a cross-sectional, anonymous, web-based survey of HCP conducted in the US via a region stratified, cluster sampling from April 14, 2020 to May 5, 2020. The survey was broadly distributed via email and social media. During this period, the total number of confirmed COVID-19 cases in the world was 3.6 million, of which 1.2 million cases were in the US. Survey participation was voluntary, and could be terminated at any time. Informed consent was implied from all subjects by participation. Responses were anonymous, and all data gathered was confidential. The study (# 20-0071) was exempted from review by the Institutional Review Board of University of Texas Medical Branch.

Setting
Our sampling included both inpatient and outpatient clinical settings. Practice settings were stratified based on hospital affiliation (academic or community-based) and geographic location (by zip code).

Participants
Participants were stratified based on their job title (i.e., registered nurses, other first responders, physicians, respiratory therapists, and nurse practitioners or physician assistants) and their primary specialty.

Demographic Data
Demographic data were self-reported by the participants, including age, gender, race, relationship status (in a relationship or not), presence of any COVID-19 risk factors, and COVID-19 exposure. Participants were also asked whether they were on a dedicated COVID-19 care service (i.e., direct contact with at least one COVID-19 patient).

Outcomes and Covariates
The focus of our survey was to assess symptoms of depression and anxiety using previously validated measurement tools. The validated questionnaires used were the 9-item Patient Health Questionnaire (PHQ-9; range, 0-27) and a 7-item Generalized Anxiety Disorder questionnaire (GAD-7; range 0-21), with scores of five and higher for each considered a positive response for depression and anxiety, respectively. [9,10] Other questions included were the provision of PPE, comfort level with local infection control policy, personal consideration of a leave of absence, and feeling stigmatized by the community.

Statistical Analysis
We summarized each characteristic and general question responses by occupation. Univariate analysis utilizing summary statistics and Chi-square test were performed to show the association of covariates with outcomes. We performed a multivariate analysis with logistic regression for each outcome. A full model was evaluated using Akaike information criterion (AIC). We then developed our final model based on AIC and clinical knowledge. All analyses were conducting using SAS for Windows version 12.2 (SAS Inc., Cary, NC). Table 1 shows the characteristics of the surveyed HCP. Respondents were predominantly female (81%), with the majority aged 31-40 years (77%), non-Hispanic whites (78%), without comorbidity or COVID-19 risk factors (72%), and not having received a COVID-19 test (84%). The majority were registered nurses (41%), followed by other first responders (24%) and physicians (24%).

Results
Sixty-two percent were assigned to a dedicated COVID-19 service, and more than half reported exposure to COVID-19. One-third were not comfortable with the infection control policies in place, and one third reported that they were not provided adequate PPE. Two-thirds of those surveyed had concerns regarding their personal or their family health, and a quarter felt stigmatized by their community.
Overall, the prevalence of depression was 57.4% and anxiety was 56.7%. Depression and anxiety were more common in females, HCP younger than 30 years, and registered nurses. HCP with COVID-19 risk factors or exposure, those uncomfortable with infection control policies and those were not provided adequate PPE had a higher likelihood of depression and anxiety. Depression alone was more common among HCP who provided services in the emergency department and anxiety alone was more common in HCP assigned to a dedicated COVID-19 service ( Table 2).

Discussion
This cross-sectional survey of 1426 healthcare personnel (HCP) in the US during the early phase of the COVID-19 pandemic found that the majority had symptoms of depression and anxiety, especially those with COVID-19 risk factors and exposure. Discomfort with infection control policies increased the odds of both depression and anxiety.
Overall, the prevalence of depression was 57.4%, and anxiety was 56.7% among HCP in the US, results consistent with a survey conducted in China among COVID-19 HCP showing a prevalence of 50.4% and 44.6%, respectively. [11] Results of similar surveys revealed not only a high prevalence of depression and anxiety, but also of stress and insomnia among HCP during the current pandemic (Table 4). [12][13][14][15][16][17][18][19][20] Together, these findings suggest a psychological pandemic among HCP which parallels the infectious pandemic. Abbreviations: PHQ-9, 9-item Patient Health Questionnaire-9; HCW, Healthcare workers; GAD-7, 7-item General Anxiety Disorder; ISS, Insomnia severity index; IES-R, The Impact of Event Scale-Revised; PTSD, Post-traumatic stress disorder COVID-19 morbidity and mortality is associated with increasing age and the presence of comorbidity (chronic lung disease, serious heart conditions, immunocompromise, severe obesity, diabetes, chronic kidney disease, and liver disease) [21][22][23]. In our study, the presence of COVID-19 risk factors among HCP was associated with increased odds of depression and anxiety. The Centers for Disease Control and Prevention (CDC) suggests limiting the participation of HCP with risk factors in higher risk aerosol-generating procedures involving COVID-19 patients. [24] Other measures include having organizational policies that allow these HCP to work in low-risk exposure areas, such as telemedicine services and patient advice lines. [25] HCP directly caring for patients with COVID-19 and working for long hours have an increased risk of acquiring the virus. [12,26] Our survey revealed higher odds of depression and anxiety among respondents with exposure to patients with COVID-19 and in those not comfortable with their facility's infection control policies. Strict adherence to the CDC recommended guidelines to prevent transmission and manage exposures are required to ensure the safety of HCP [27]. HCP must be provided with adequate PPE and information and resources to help them avoid taking the infection home to family members. They should be educated on infection control policies, which should include basic knowledge of epidemiology and viral transmission, preventive strategies for infections, and training in the use of PPE. [28,29] HCP should have rapid access to occupational health resources, with efficient evaluation and testing, and work restrictions if they develop symptoms or have exposure to infected persons [30]. HCP themselves must self-monitor, report signs of illness, and not engage in patient care while exhibiting infectious symptoms [25]. A shortcoming in any one of these areas can lead adverse effects in personal and physical well-being.
During the COVID-19 pandemic, various organizations like the CDC, the American Medical Association, and the National Center for Post-traumatic stress disorder (PTSD) have published guidelines for HCP on how to cope with stress. [30][31][32] HCP should be educated to recognize the symptoms of stress, which may include feelings of irritation, anger, denial, nervousness, anxiety, helplessness, lack of motivation, tiredness, being overwhelmed, sadness, or trouble sleeping or concentrating. [30] Communication with the coworkers, supervisors, and employees about work factors that cause stress and how to access mental health resources should be promoted. [30] HCP should be encouraged to increase their sense of control by keeping a consistent daily routine when possible, with adequate sleep, healthy meals, and exercise. [30] At work, HCP should be able to take breaks during work shifts to rest, stretch, and check-in with supportive colleagues, friends, and family. [32] HCP should avoid negative coping strategies such as the use of alcohol, illicit drugs, or excessive amounts of prescription drugs. If stress persists they should consider seeking out formal mental health treatment. [32] Organizational support is required for HCP to successfully navigate the challenges of the pandemic and effectively care for their patients [31]. HCP may be affected by the stigma of voicing their concerns and the fear of contact of others. Employers should provide an encouraging and supportive atmosphere free of stigma, coercion, and fear of negative consequences. [32] Health care facilities must include plans to support the physical, emotional, and psychosocial needs of the workforce [31]. Regular screening for stress, depression, and anxiety should be performed among medical personnel involved in the treatment and diagnosis of patients with COVID-19. [32]

Strengths and Limitations
To our knowledge, this is the first survey among US HCP to assess mental health outcomes during the COVID-19 pandemic. There are several limitations to our study.
First, the survey was voluntary, and thus, there is the possibility of selection bias (i.e., respondents may have been different from non-respondents). Second, the questionnaires used, PHQ-9 and GAD-7, are not specifically validated for use in HCP or during exceptional situations like a pandemic. Third, the response rate is unknown, and there is a possibility that HCP from the areas most affected may not have completed the survey due to time restraints or competing interests; however, we found that 73% of respondents were from areas with the highest prevalence of COVID-19 cases at that time. Fourth, the survey did not distinguish HCP with baseline anxiety, depression, or other mental health disorder(s). Therefore, it is unknown if results were consistent with the development of new mental health symptoms or worsening of a preexisting condition.

Conclusion
A high burden of depression and anxiety was observed among US HCP early in the COVID-19 pandemic. These conditions were associated with COVID-19 risk factors, exposure, and discomfort with local infection control policies. Since the pandemic has continued with increasing numbers of infected individuals and deaths related to COVID-19, the mental health problems and distress may increase as well. Continued monitoring of HCP and the allocation of resources, along with the implementation of preventive and management strategies are needed to optimize the mental health during this stressful time.