Factors associated with mental health outcomes in emergency department healthcare workers on the frontlines of the COVID-19 pandemic.

INTRODUCTION The World Health Organization (WHO) declared the novel coronavirus disease 2019 (COVID-19) outbreak a Public Health Emergency of International Concern on 30 January 2020. Pandemics can inflict a broad spectrum of psychological effects on healthcare workers (HCWs).[1,2] These mental health problems can lead to long-term psychological implications such as major depressive disorder and post-traumatic symptoms, as seen during the outbreaks of the severe acute respiratory syndrome (SARS) and Ebola virus disease.[3,4] A survey of mental disorders in Singapore published in 2012 highlighted that age, gender, ethnicity and marital status are all significantly associated with major depressive disorders, generalised anxiety disorders and dysthymia.[5] Studies carried out in China during the COVID-19 pandemic[6,7] showed that nurses have poorer mental health outcomes as compared to physicians. Being in social isolation during a pandemic has been shown to increase adverse psychological outcomes amongst HCWs[8]; conversely, having family support reduces the risk of adverse psychological outcomes.[9] However, the fear of infecting loved ones at home, especially the elderly, can influence mental health outcomes.[10] The emergency department (ED) of Khoo Teck Puat Hospital employs a large number of foreign staff; at the time of this study (June 2020), overseas leave had been curtailed for four months. Travel restrictions on this scale have never been implemented in previous outbreaks, and the effect of being physically separated from loved ones over a prolonged period is unknown. METHODS This is a cross-sectional single-centre study. An anonymous paper-based survey was administered to all HCWs working in the ED from 1 June to 9 June 2020. At the time of this study, Singapore had just exited an eight-week-long, nation-wide, partial lockdown with closure of schools and workplaces, as well as prohibition of social gatherings in both private and public spaces.[11] Our ED sees an average of 135,000 patients a year. All doctors, nurses and nursing aides in the ED who had direct patient contact were invited to participate. Participation was voluntary. The survey was handed to the staff during department nurse roll calls and doctor handover rounds. The completed questionnaires were collected at the end of the roll call or shift. Respondents could also slip the forms into a collection box at the ED office. This study was approved by the National Healthcare Group Domain Specific Review Board (DSRB 2020/00653). Mental health outcomes surveyed depression, anxiety, stress and post-traumatic stress disorder (PTSD), as measured by the validated Depression Anxiety and Stress Scale 21-item (DASS-21)[12] and Impact of Events Scale-Revised (IES-R).[13] Demographic characteristics of the HCWs and information related to their family situation were collected. The DASS-21 was developed in 1995[12] to measure three emotional states, namely depression, anxiety and stress. It is a reliable tool that has been widely used in different ethnic groups and is available in many translations. We defined a positive screen for depression, anxiety or stress as a depression subscale score >9, anxiety subscale score >7, and stress subscale score >14, respectively. Although the DASS-21 has no direct implications for the allocation of patients to discrete diagnostic categories, unlike the Diagnostic and Statistical Manual of Mental Disorders, it gives a good gauge of negative emotional symptoms. The original IES was developed in 1979 as a measure of psychological stress reactions after trauma.[14] The revised version (IES-R) has 22 questions. A cut-off score ≥24 is used to define PTSD symptoms of clinical concern,[15] although it is not diagnostic for PTSD and may be used to gauge stress response at various points in time. Measurements can be obtained and compared during both early and late ‘post-event’. While it may not be considered ‘post-COVID’ when the survey was administered in June 2020, the situation (in terms of the load and stress on the healthcare system based on the number of COVID-related attendances at the ED) had already improved by then. Both the DASS-21 and IES-R have been validated for use in a population study investigating the psychological impact of COVID-19 in China[7] and in a multicentre study on psychological outcomes among HCWs during COVID-19 in Singapore and India.[16] Pearson’s Chi-square test was used to evaluate categorical variables and the Mann-Whitney U test was used for continuous variables that were not normally distributed. All statistical analyses were based on a two-sided test with significance level set at 0.1. Multivariate logistic regression was used to adjust for confounders to determine independent association for binary outcomes. RESULTS Of the 363 eligible HCWs, 327 (90.0%) participated in the study. Nurses and nursing aides comprised 72.2% (n = 236) of the participants. The majority were female (n = 235, 71.9%), in the 21–40 years age group (n = 275, 84.1%) and of Chinese ethnicity (n = 126, 38.5%). An overwhelming majority (n = 313, 95.7%) had no past medical or psychiatric history. 52 (15.6%) HCWs lived with elderly relative (s) at home, 25 (7.6%) had a family member or close friend who had contracted COVID-19 and 255 (77.5%) had family living overseas. From the DASS-21, we found positive screens for depression in 90 (27.5%), anxiety in 112 (34.3%) and stress in 40 (12.2%) of the participants. There were significant differences in the median scores of the DASS-21 subscales for occupation, gender, ethnicity and living with elderly relative (s). DASS-21 median depression scores (interquartile range [IQR]) were as follows: nurses 6 (2–10) vs. physicians 2 (0–8), P = 0.007; female 6 (2–16.8) vs. male 2 (2–8), P = 0.003; Chinese 4 (2–10) vs. Malay 6 (4–12) vs. Indian 4 (0–9.5) vs. Filipino/others 4 (0–10), P = 0.039. DASS-21 median anxiety scores (IQR) were: nurses 6 (2–10) vs. physicians 4 (0–6), P = 0.005; female 6 (2–10) vs. male 2 (2–10), P = 0.001; Chinese 4 (2–8) vs. Malay 8 (3–12) vs. Indian 5 (0–13) vs. Filipino/others 3 (2–8), P = 0.027; lives with elderly relative (s) 6 (2–12) vs. does not live with elderly relative (s) 4 (2–8), P = 0.034. DASS-21 median stress scores (IQR) were: female 6 (2–12) vs. male 4 (2–8), P = 0.002. Multivariate logistic regression [Table 1] showed that HCWs who were female (adjusted odds ratio [AOR] 2.24, 95% confidence interval [CI] 1.20–4.31, P = 0.013) and of Malay ethnicity (AOR 2.610, 95% CI 1.179–5.841, P = 0.018) had significantly higher odds of developing symptoms of anxiety. There were also significantly higher odds of developing symptoms of stress if a HCW was of Malay ethnicity (AOR 3.09, 95% CI 1.055–9.126, P = 0.039) and had family members living overseas (AOR 4.35, 95% CI 1.36–1.98, P = 0.026).Table 1: Risk factors for mental health outcomes identified by multivariate logistic regression analysis.53 (16.2%) participants had clinically concerning PTSD symptoms. HCWs who were female, worked as nurses and had family living overseas had significantly higher median IES-R scores (IQR): female 9 (2–20) vs. male 3.5 (1–10.8), P = 0.001; nurses 9 (2–20) vs. physicians 5 (1–11), P = 0.004; with family overseas 7 (2–19) vs. no family overseas 4 (1–13.8), P = 0.013. Additionally, multivariate logistic regression [Table 1] showed that HCWs of Malay ethnicity demonstrated a significantly higher AOR of 5.428 (95% CI 2.128–14.372, P < 0.001) for PTSD symptoms. A subgroup analysis revealed no significant differences in mental health outcomes between senior and junior doctors. Nursing aides scored poorer on all counts of mental health outcomes: depression (OR 3.155, 95% CI 1.294–7.874, P = 0.012), anxiety (OR 3.891, 95% CI 1.570–10.526, P = 0.005), stress (OR 4.132, 95%CI 1.524–10.638, P = 0.004) and PTSD symptoms (OR 3.546 95%CI 1.368–8.850, P = 0.007) when compared to nurses. DISCUSSION Our study found significant associations between some subgroups of HCWs and their risk of developing worse mental health outcomes in the midst of a pandemic. A review of 44 studies examining psychological stressors during previous outbreaks such as SARS and Middle East respiratory syndrome coronavirus found that sociodemographic factors (e.g. gender, age and marital status) demonstrated mixed results as risk factors.[17] Our findings that HCWs living with elderly relatives or having family overseas were risk factors for worse mental health outcomes during a pandemic have not been reported previously. Having family overseas could lead to emotional distress in HCWS due to concerns for the safety of their loved ones and the inability to be physically present with them due to travel restrictions. However, when we analysed the mental health outcomes of Singaporeans vs. migrant workers, we did not find any significantly higher odds of worse mental health outcomes in migrant workers. This could be due to the fact that migrant HCWs are not a homogeneous group. The Filipinos, who comprised the largest proportion of our migrant HCWs, had better mental health outcomes as an ethnic group than the other ethnic groups. HCWs who live with elderly relatives are another vulnerable group. As it has been widely reported[18] that the elderly are the most vulnerable cohort in this pandemic, the fear of them getting infected, whether directly or indirectly due to the HCW’s occupation, may add to the psychological distress of this group of HCWs. A targeted workplace support group for caregivers of the elderly may help reduce caregiver stress and increase caregivers’ coping ability.[19,20] We also found female HCWs to be at a higher risk of developing symptoms of anxiety. Similarly, a study on the psychological impact of COVID-19 on HCWs in Wuhan found a higher prevalence of anxiety in the female HCWs as compared to symptoms of depression.[21] Interestingly, we found ethnicity to be a significant factor in mental health outcomes. In our study, we found that Malay HCWs had higher odds of anxiety, stress and PTSD compared to the reference group (the Filipinos). This is comparable to data found in studies conducted in Singapore and Malaysia,[22,23] where ethnic Chinese were found to have lower risks of major depressive disorders as compared to those of Malay and Indian ethnicities. The precise reason for this is unknown, although a previous study has found that the Chinese tend to somaticise rather than psychologise their complaints.[24] Within the nursing subgroup, our analysis showed that nursing aides had significantly higher odds of developing depression, anxiety, stress and PTSD symptoms as compared to nurses. We postulate some reasons for this observation. Firstly, all 22 nursing aides had family living overseas. Secondly, the difference in their educational level (high-school equivalent vs. minimum diploma level for nurses) might have influenced their understanding of the outbreak and negatively impacted their stress coping mechanisms. Finally, as the most junior level staff within the nursing group, they may have feelings of disempowerment from not having much say in the development of protocols. Overall, our study found higher levels of depression (27.5% vs. 8.1%), anxiety (34.3% vs. 10.8%), stress (12.2% vs. 6.4%) and PTSD symptoms (16.2% vs. 5.7%) among HCWs than another study carried out in Singapore.[25] Hence, our study adds to the pool of knowledge from similar studies conducted during this and other pandemics,[7,8] namely that frontline HCWs directly handling high-risk patients as the first point-of-contact are most vulnerable to suffering the psychological consequences of an outbreak. To promote good mental health in the workplace, WHO has laid out guidelines on occupational risks in the Mental Health Action Plan (2013–2030). Unfortunately, we were unable to retrospectively identify the HCWs that were unwell in the study, as our survey was anonymous. Hence, instead of identifying these HCWs individually, we have addressed the vulnerable demographics as a group. We have also disclosed the results of the survey to the hospital administrators, including the heads of department and nursing leads, so that they could further encourage this vulnerable group to attend the mental health outreach programmes that are available hospital-wide. This study had some limitations. First, this was an exploratory single-centre study conducted in the ED, and hence, the generalisability of the findings may be limited. Second, as this was a cross-sectional study, the progression of mental health outcomes in ED HCWs during this pandemic was not assessed. Third, our study did not assess any socioeconomic factors, which could be significant confounders. While we recognise that socioeconomic factors are important and that job grade (with income difference) could be one of the surrogate markers of socioeconomic status, our analysis of outcomes between physicians and nurses did not yield any statistically significant results. The strengths of this study are the high response rate from ED HCWs of diverse demographic backgrounds, the use of previously validated instruments and the completeness of our data. In conclusion, frontline ED HCWs as a group needs special focus in the COVID-19 pandemic. Those at risk of poorer mental health outcomes include female HCWs, nursing aides, HCWs of Malay ethnicity, and HCWs who live with elderly relative (s) or have family living overseas. Protective workplace interventions should be directed toward at-risk groups through proper screening, timely referral and early targeted intervention. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.