Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Depressed, anxious, and stressed: What have healthcare workers on the
frontlines in Egypt and Saudi Arabia experienced during the COVID-19
pandemic?
Ahmed Arafaa,b,⁎, Zeinab Mohammedb, Omaima Mahmoudc, Momen Elshazleyd,e, Ashraf Ewisf,g
a Department of Public Health, Graduate School of Medicine, Osaka University, Osaka, Japan
b Department of Public Health, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
c Department of Psychiatric Nursing, Faculty of Nursing, Beni-Suef University, Beni-Suef, Egypt
d Department of Medicine, Taibah College of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Saudi Arabia
e Department of Occupational Medicine, Faculty of Medicine, Sohag University, Sohag, Egypt
f Department of Public Health, Faculty of Medicine, Minia University, El-Minia, Egypt
g Department of Public Health and Occupational Medicine, Faculty of Health Sciences – AlQunfudah, Umm AlQura University, Meccah, Saudi Arabia

A R T I C L E I N F O

Keywords:
Anxiety
COVID-19
Depression
Healthcare workers
Sleeping hours
Stress

A B S T R A C T

Introduction: As the Novel Corona Virus Disease (COVID-19) was declared by the world health organization a
pandemic in March 2020, thousands of healthcare workers (HCWs) worldwide were on the frontlines fighting
against the pandemic. Herein, we selected two Middle East countries; Egypt and Saudi Arabia to investigate the
psychological impacts of the COVID-19 pandemic on their HCWs.
Methods: In this cross-sectional study, a Google survey was used to access HCWs in many hospitals in Egypt and
Saudi Arabia between the 14th and 24th of April 2020. The survey assessed HCWs regarding their socio-
demographic and occupational features, sleeping hours, and psychological impacts of the COVID-19 pandemic
using the Depression Anxiety Stress Scale-21 (DASS-21).
Results: This study included 426 HCWs (48.4% physicians, 24.2% nurses, and 27.4% other HCWs). Of them,
69% had depression, 58.9% had anxiety, 55.9% had stress, and 37.3% had inadequate sleeping (<6 h/day).
Female sex, age ≤30 years, working in Egypt, attending emergency and night shifts, watching/reading COVID-
19 news ≥2 h/day, and not getting emotional support from family, society, and hospital were associated with a
high likelihood of depression, anxiety, stress, and inadequate sleeping.
Limitations: the cross-sectional design restricted our ability to distinguish between preexisting and emerging
psychological symptoms.
Conclusion: HCWs on the frontlines in Egypt and Saudi Arabia experienced depression, anxiety, stress, and in-
adequate sleeping during the COVID-19 pandemic.

1. Introduction

With more than 110 countries affected, the World Health
Organization (WHO) declared, on the 11th of March 2020, the Novel
Corona Virus Disease (COVID-19) a pandemic (WHO 2020a). As of the
1st of May 2020, 3175,207 confirmed COVID-19 cases and 224,172
related deaths have been reported worldwide (WHO, 2020b). In re-
sponse to the COVID-19 pandemic, a state of lockdown in several
countries has been set to prevent the spread of infection which resulted
in huge economic losses, breaks in the global supply chains, wide media
coverage, political division, disrupted travel plans, school closures, and

future uncertainty. These consequences led to a global atmosphere of
psychological distress (Ebrahim et al., 2020; Ho et al., 2020; Peng et al.,
2020).

Healthcare workers (HCWs) on the frontlines are, however, more
vulnerable to traumatization and psychological deficits during the
COVID-19 pandemic (Roy et al., 2020; Lai et al., 2020; Cai et al., 2020;
de Pablo et al., 2020). In addition to the previous factors, the fear of
getting infected or infecting family and friends, the hefty workload, the
intermittent shortage of personal protective equipment (PPE), and the
need to take stressful precautions during the medical examination and
in the operative fields can add enormous psychological burdens to

https://doi.org/10.1016/j.jad.2020.09.080
Received 3 May 2020; Received in revised form 18 August 2020; Accepted 17 September 2020

⁎ Corresponding author.
E-mail address: ahmed011172@med.bsu.edu.eg (A. Arafa).

Journal of Affective Disorders 278 (2021) 365–371

Available online 24 September 2020
0165-0327/ © 2020 Elsevier B.V. All rights reserved.

T

HCWs (Joob and Wiwanitkit, 2020; Montemurro, 2020). These burdens
do not only undermine the health-related quality of life of HCWs but
also diminish their caring behaviors and increase practice errors
leading to worse outcomes and additional costs (Sarafis et al., 2016;
Wagner et al., 2018).

Reports emerging from China, where the COVID-19 was first de-
tected, showed a high prevalence of depression, anxiety, and insomnia
among HCWs (Du et al., 2020; Lai et al., 2020; Zhang et al., 2020a,
2020b; Liu et al., 2020; Xiao et al., 2020). In Arab countries, where
surveillance and infection control programs, laboratory capacity, and
public health resources are limited (Jabbour, 2013; Asbu et al., 2017),
the response of HCWs to the COVID-19 pandemic would be challenging
and, as a result, the psychological impacts of the pandemic on HCWs in
Arab countries could be augmented. Egypt and Saudi Arabia, in parti-
cular, are among the most afflicted Arab countries on the human and
financial levels (WHO, 2020b; Al-Tawfiq and Memish, 2020). Living in
severely hit areas by the COVID-19 was shown to be associated with
psychological distress (Tang et al., 2020). Hence, we conducted this
cross-sectional study to evaluate psychological disturbances among
HCWs on the frontlines in Egypt and Saudi Arabia during the COVID-19
pandemic and to investigate the potential associations with these dis-
turbances. We hope that our study can help in detecting HCWs at high
risk of psychological disturbances and determining potential associa-
tions for possible interventions during this pandemic or future waves of
infection in both countries.

2. Methods

2.1. Subjects

HCWs in Egypt and Saudi Arabia were invited to participate in this
cross-sectional survey during the period between the 14th and 24th of
April 2020. Because of the lockdown in both countries, a non-prob-
ability snowball sampling technique was used. A Google survey was
created and the link to the survey was sent by e-mails to HCWs with
recorded contact details in Beni-Suef University Hospital and Beni-Suef
General Hospital in Egypt and Taibah Teaching Hospital in Al-Madinah
Al-Munawwarah in Saudi Arabia. The e-mails were sent on the 14th of
April 2020 and reminders were sent 5 days later. We also shared the
survey link to the social network groups that include HCWs from both
countries. HCWs were asked to forward the link to other HCWs from
their contact e-mail and social network lists. Social network use is
widespread among HCWs in Egypt (Abdel Wahed et al., 2020) and
Saudi Arabia (Almaiman et al., 2015). Our eligibility criteria included:
1) HCWs working in Egypt and Saudi Arabia, 2) aged ≥18 years old,
and 3) currently working in a hospital managing patients infected or
could be infected with COVID-19. HCWs included physicians, nurses,
pharmacists, technicians, and paramedics. HCWs who reported working
in academic and research but not in hospitals managing COVID-19 were
excluded.

2.2. Data collection

We designed an Arabic questionnaire composed of 4 sections to
collect the data. Section I included a detailed explanation of the steps,
aims, and eligibility criteria of the study. Section II included questions
about the sociodemographic and occupational features of HCWs in-
cluding age (18–30, 31–45, or >45 years), sex (man or woman),
country (Egypt or Saudi Arabia) and city where he/she works (type the
name), living with children (yes or no), living with older adults (yes or
no), profession (physician, nurse, pharmacist, technician, paramedic, or
others and specify), department (internal medicine: general and spe-
cialties, surgery: general and specialties, emergency, radiology, or
others and specify), and years of experience (1–5, 6–15, or >15 years).
Section III included questions related to occupation during the previous
month only and included the following: average daily working hours

(1–6, 7–12, or >12 h/day), average daily sleeping hours (<6, 6–9, or
>9 h/day), attending emergency shifts (never, 1–2, or >2 shifts/
week), attending night shifts (never, 1–2, or >2 shifts/week), watching
or reading news about COVID-19 (<1, 2–4, or >4 h/day), getting
enough emotional support from family (yes or no), getting enough
emotional support from the society (yes or no), and getting enough
emotional support from the hospital where he/she works (yes or no).
Section IV included the Arabic version of the Depression Anxiety Stress
Scale-21 (DASS-21). The DASS-21 is a quantitative measure of depres-
sion, anxiety, and stress symptomatology (7 statements each) during
the past week. The depression statements evaluate hopelessness, dys-
phoria, self-deprecation, devaluation of life, lack of interest and in-
volvement, anhedonia, and inertia. The anxiety statements evaluate
skeletal muscle effects, autonomic arousal, situational anxiety, and
subjective experience of anxious affect. The stress scale evaluates ner-
vous arousal, difficulties in relaxation, and being easily upset or over-
reactive. Participants should decide how much the statements apply for
them using a scale from 0 to 3 where 0 refers to “did not apply to me at
all”, 1 refers to “applied to me to some degree or some of the time”, 2
refers to “applied to me to a considerable degree or a good part of the
time”, and 3 refers to “applied to me very much or most of the time”.
The score of each axis is multiplied by 2 to lie within a 0 to 42 scale
where higher scores indicate worse outcomes (Lovibond and
Lovibond, 1995). The Arabic version of the DASS-21 was validated in a
previous study and the Cronbach’s alpha for its subscales was 0.81,
0.76, and 0.67, respectively (Ali et al., 2017). In this study, depression,
anxiety, stress, and sleeping <6 h/day were considered outcomes.
Sleeping <6 h/day was referred to in this article as “inadequate
sleeping”. We programed the Google survey to make all questions but
one (the name of the city where subject works) mandatory.

2.3. Statistical analyses

The adopted cut-off values for the DASS-21 scales were the fol-
lowing: 1) Depression: normal (0–9), mild to moderate (10–20), and
severe to extremely severe (≥21), 2) Anxiety: normal (0–7), mild to
moderate (8–14), and severe to extremely severe (≥15), and 3) Stress:
normal (0–14), mild to moderate (15–25), and severe to extremely se-
vere (≥26) (Lovibond and Lovibond, 1995).

The logistic regression analyses were used to calculate the un-
adjusted and adjusted odds ratios (ORs) and their 95% confidence in-
tervals (CIs) of different sociodemographic factors for HCWs with mild
to moderate and severe to very severe depression, anxiety, and stress,
and inadequate sleep compared with HCWs without the corresponding
psychological conditions. The following variables were included in the
regression models: age, sex, profession, and country. HCWs other than
physicians and nurses were assigned to one group referred to as “other
HCWs”. Data were analyzed using the Statistical Package for Social
Science (SPSS) released in 2013 (IBM SPSS Statistics for Windows,
Version 22.0, IBM Corporation, Armonk, New York).

2.4. Ethical considerations

We conducted the study in full accordance with the guidelines for
Good Clinical Practice and the Declaration of Helsinki. The conditions
and eligibility criteria of the study were described in section I and re-
spondents had to agree to proceed to the upcoming sections and to
submit their answers after filling out the survey which was considered
approval of participation.

3. Results

This study included 426 HCWs (275 from Egypt and 151 from Saudi
Arabia) distributed as follows: 206 (48.4%) physicians, 103 (24.2%)
nurses, and 117 (27.4%) other HCWs. Of them, 47.2% were aged ≤30
years, 50.2% were men, 65% were living with children, and 51.6%

A. Arafa, et al. Journal of Affective Disorders 278 (2021) 365–371

366

were living with older adults. More than half of HCWs reported at-
tending emergency shifts (55.6%) and night shifts (51.4%) and
watching or reading COVID-19 news ≥2 h/day (56.1%) during the
previous month. Getting enough emotional support from family during
the pandemic was higher than that from society and hospital; 78.9%,
44.6%, and 35.6%, respectively (Table 1).

Up to 69% of HCWs had depression (39.4% mild to moderate and
29.6% severe to very severe), 58.9% had anxiety (31.9% mild to
moderate and 27.0% severe to very severe), and 55.9% had stress
(36.6% mild to moderate and 19.3% severe to very severe). More than a
third (37.3%) of HCWs reported inadequate sleeping during the pre-
vious month (Table 2).

In the multivariable-adjusted regression model, several personal
and occupational factors were associated with depression, anxiety,
stress, and inadequate sleeping. Of these factors, age ≤30 years was
associated with severe to very severe forms of depression (OR 2.88,
95% CI: 1.25, 6.62) and stress (OR 2.49, 95% CI: 1.00, 6.18). Compared
with men, women had more severe to very severe depression (OR 2.57,
95% CI: 1.43, 4.61), anxiety (OR 2.68, 95% CI: 1.56, 4.62), and stress
(OR 2.39, 95% CI: 1.33, 4.32). HCWs in Egypt were more likely to
show, compared with their counterparts in Saudi Arabia, mild to
moderate depression (OR 2.19, 95% CI: 1.28, 3.74), anxiety (OR 2.27,
95% CI: 1.32, 3.88), and stress (OR 3.67, 95%CI: 2.13, 6.31) and severe
to very severe depression (OR 4.71, 95% CI: 2.45, 9.04), anxiety (OR
3.31, 95% CI: 1.78, 6.15), and stress (OR 2.81, 95% CI: 1.45, 5.45).
Also, attending emergency and night shifts was associated with various
forms of depression, anxiety, stress, and inadequate sleeping.
Watching/reading COVID-19 news ≥2 h/day was associated with a
high risk of depression, anxiety, stress, and inadequate sleeping.
Besides, lack of perceived emotional support from family, society, and

hospital was related to depression, anxiety, stress, and inadequate
sleeping. However, depression, anxiety, stress, and inadequate sleeping
did not differ between professions or departments (Table 3).

4. Discussion

This study indicated that, during the COVID-19 pandemic, 69% of
HCWs in Egypt and Saudi Arabia had depression (39.4% mild to
moderate and 29.6% severe to very severe), 58.9% had anxiety (31.9%
mild to moderate and 27.0% severe to very severe), 55.9% had stress
(36.6% mild to moderate and 19.3% severe to very severe), and 37.3%
experienced inadequate sleeping.

In line with our findings, a cross-sectional study reported a high
prevalence of depression (50.4%) and anxiety (44.6%) among 1257
Chinese HCWs on the frontlines during the COVID-19 pandemic
(Lai et al., 2020). Another study conducted on 134 HCWs from China
put the prevalence of anxiety at 20.1% (Du et al., 2020). Similar psy-
chological disturbances were recognized among HCWs during the se-
vere acute respiratory syndrome (SARS) epidemic (Chua et al., 2004;
Lee et al., 2005). In contrast, a study on 470 HCWs in Singapore put the
prevalence of depression, anxiety, and stress during the COVID-19
pandemic at 8.1%, 10.8%, and 6.4%, respectively. These relatively low
rates of psychological distress could be attributed to improved mental
health preparedness and rigorous infection control measures in Singa-
pore in the wake of the SARS outbreak epidemic (Tan et al., 2020). Still,
a meta-analysis of cross-sectional studies including 11 studies from
China in addition to the Singaporean study estimated the pooled pre-
valence of depression and anxiety among HCWs during the COVID-19
pandemic with 22.8% and 23.2%, respectively (Pappa et al., 2020).
However, we cannot claim that the prevalence of psychological dis-
turbances in the current study is higher than the Chinese studies be-
cause of the high heterogeneity between studies regarding the socio-
demographic characteristics of HCWs and the scales and cut-offs used
for psychological assessment.

However, the psychological disturbances among HCWs in Egypt
were significantly worse than those among HCWs in Saudi Arabia. This
finding may reflect the robustness of the healthcare system in Saudi
Arabia compared with the Egyptian one. During the past decade, the
Saudi government adopted a long-term plan to improve the healthcare
system which was translated into allocating about 15% of the govern-
ment budgetary expenditures for health services and social develop-
ment (Al-Hanawi et al., 2019). This plan resulted in significant signs of
progress in healthcare human and financial resources and striking im-
provements in key health indicators such as life expectancy and the
availability of health resources (Al-Hanawi et al., 2019). Moreover, the
circulation of the Middle East Respiratory Syndrome Coronavirus
(MERS-CoV) in Saudi Arabia in 2012 led to significant improvement in
infection control preparedness in healthcare institutions across the
country (Barry et al., 2020; Temsah et al., 2020). On the other hand, the
healthcare system in Egypt faces several challenges related to defective
spending and limitations in human resources and infrastructure
(Fakhouri, 2016).

Further, this study showed a gender gap of psychological dis-
turbances with a higher prevalence of depression, anxiety, and stress
among women than men. In agreement, the Pappa et al. (2020) meta-
analysis showed that female HCWs were more likely to suffer depres-
sion and anxiety during the COVID-19 pandemic compared with male
HCWs.

Moreover, our results showed that watching/reading COVID-19
news ≥2 h/day was associated with depression, anxiety, stress, and
inadequate sleeping. The COVID-19 pandemic is characterized by wide
media coverage with plenty of untrustworthy sources of information.
For example, 27% of HCWs in Egypt reported retrieving their in-
formation on COVID-19 from the social network, newspapers, and tel-
evision (Abdel Wahed et al., 2020). Social media can be a source of
misinformation of COVID-19 that may result in panic (Cuan-

Table 1
Sociodemographic and occupational characteristics of HCWs deployed in facing
COVID-19 pandemic in Egypt and Saudi Arabia.

Characteristics Study population
n = 426 (%)

Age (years) 18–30 201 (47.2)
31–45 172 (40.4)
>45 53 (12.4)

Sex Men 214 (50.2)
Women 212 (49.8)

Country Egypt 275 (64.6)
Saudi Arabia 151 (35.4)

Profession Physician 206 (48.4)
Nurse 103 (24.2)
Others 117 (27.4)

Department Internal & ICU 84 (19.7)
Emergency 84 (19.7)
Others 258 (60.6)

Years of experience 1–5 189 (44.4)
6–15 153 (35.9)
>15 84 (19.7)

Working hours per day 1–6 153 (35.9)
7–12 211 (49.5)
>12 62 (14.6)

Emergency shifts per week Never 189 (44.4)
≤2 90 (21.1)
>2 147 (34.5)

Night shifts per week Never 207 (48.6)
≤2 96 (22.5)
>2 123 (28.9)

Watching/reading COVID-19 news
hours per day

<2 187 (43.9)

2–4 159 (37.3)
>4 80 (18.8)

Living with children 277 (65.0)
Living with older adults 220 (51.6)
Emotional support from family 336 (78.9)
Emotional support from society 190 (44.6)
Emotional support from hospital 150 (35.6)

A. Arafa, et al. Journal of Affective Disorders 278 (2021) 365–371

367

Baltazar et al., 2020). Dong and Zheng (2020) described “headline
stress disorder” among the general public due to COVID‐19 news.
Therefore, HCWs should be advised to cautiously select their sources of
health information during public health crises. The WHO and govern-
ments should exert more efforts to provide reliable sources of in-
formation and force the social network platforms, newspapers, and
television channels to take down misinformation of the COVID-19.
However, it is worth pointing out that the cross-sectional design of this
study cannot imply a temporal association between watching/reading
COVID-19 news and psychological disturbances. It could be suggested
that depressed, anxious, and stressed HCWs have resorted to COVID-19
news to look for hopeful news of COVID-19 medications and vaccines to
alleviate their psychological distress. One study, for instance, showed
that COVID-19 anxiety could lead to excessive internet use (Elhai et al.,
2020).

Furthermore, we could detect that HCWs who lacked emotional
support from family, society, and hospital showed worse psychological
disturbances compared with their counterparts who were offered
emotional support. A study on medical students from China showed
that social support correlated negatively with their level of anxiety
(Cao et al., 2020). One study discussed the need for providing mental
healthcare services to HCWs on the frontlines to alleviate their psy-
chological distress and improve their physical health (Kang et al.,
2020). These findings, therefore, highlight the importance of psycho-
logical counseling.

Also, attending night shifts was associated with psychological

distress and inadequate sleeping. Previous research conducted on HCWs
under normal circumstances reached also the same conclusion
(Jehan et al., 2017), thus, we cannot assume that working the night
shifts during the COVID-19 pandemic, per se, increased the psycholo-
gical distress. However, increased psychological distress and disturbed
sleep during the COVID-19 pandemic alongside attending night shifts
could have worsened the situation.

It should be noted that this study had several strengths such as in-
cluding HCWs representing different professions of healthcare, limiting
the inclusion criteria to HCWs currently serving on the frontlines during
the COVID-19 pandemic, using a validated assessment tool to measure
the outcomes, and avoiding the chronic problems of online surveying
such as lurking, dropping out, and item non-response by making the
questions mandatory.

However, some limitations should be addressed. First, the cross-
sectional design restricted our ability to distinguish between preexisting
and new symptoms and to study whether the psychological symptoms
of HCWs have been worsening or not, therefore, a longitudinal study is
warranted. Second, because of the lockdown, we had to solely rely on
the online survey to access HCWs. This method of data collection can be
accompanied by non-response bias that could undermine the general-
izability of the study because non-respondents might carry different
characteristics compared with the respondents (Arafa et al., 2019). To
avoid this bias, we did not ask the respondents to unveil their identities
or include any sensitive questions related to income or availability of
PPE. We also forwarded the link to the Google survey via different

Table 2
Prevalence of depression, anxiety, stress, and inadequate sleeping among HCWs deployed in facing COVID-19 pandemic in Egypt and Saudi Arabia.

Characteristics Depression Anxiety Stress Sleeping hours/day
Normal Mild to

moderate
Severe to
very severe

Normal Mild to
moderate

Severe to
very severe

Normal Mild to
moderate

Severe to
very severe

≥6 <6

Overall 31.0 39.4 29.6 41.1 31.9 27.0 44.1 36.6 19.3 62.7 37.3
Age (years) 18–30 29.2 39.9 30.9 39.4 23.7 27.9 42.4 37.5 20.1 63.5 36.5

>30 43.4 35.8 20.8 52.8 26.4 20.8 56.6 30.2 13.2 56.6 43.4
Sex Men 40.6 36.0 23.4 51.4 30.4 18.2 54.7 30.8 14.5 65.9 34.1

Women 21.2 42.9 35.9 30.7 33.5 35.8 33.5 42.5 24.0 59.4 40.6
Profession Physicians 26.2 35.4 38.4 39.3 31.6 29.1 39.8 37.4 22.8 67.5 32.5

Nurses 35.0 46.6 18.4 40.8 35.0 24.3 46.6 37.9 15.5 57.3 42.7
Others 35.9 40.2 23.9 44.4 29.9 25.7 49.6 34.2 16.2 59.0 41.0

Country Egypt 21.5 40.7 37.8 31.6 34.9 33.5 23.7 44.4 22.9 63.3 36.7
Saudi Arabia 48.3 37.1 14.6 58.3 26.5 15.2 64.9 22.5 12.6 61.6 38.4

Department Internal, ICU &
Emergency

34.5 38.1 27.4 41.1 34.5 24.4 47.0 38.1 14.9 62.5 37.5

Others 28.7 40.3 31.0 41.1 30.2 28.7 42.2 35.7 22.1 62.8 37.2
Experience (years) 1–5 33.3 36.0 30.7 45.5 30.2 24.3 49.7 36.5 13.8 61.9 38.1

>5 29.1 42.2 28.7 37.6 33.3 29.1 39.7 36.7 23.6 63.3 36.7
Working hours/day 1–6 21.6 44.4 34.0 39.9 32.0 28.1 39.9 42.5 17.6 70.6 29.4

>6 36.3 36.6 27.1 41.8 31.9 26.3 46.5 33.3 20.2 58.2 41.8
Emergency shifts Yes 28.3 40.5 31.2 34.6 36.3 29.1 40.9 38.8 20.3 59.9 40.1

No 34.4 38.1 27.5 49.2 26.5 24.3 48.1 33.9 18.0 66.1 33.9
Night shifts Yes 32.9 36.5 30.6 37.0 33.8 29.2 42.9 35.6 21.5 58.0 42.0

No 29.0 42.5 28.5 45.4 30.0 24.6 45.4 37.7 16.9 67.6 32.4
Watching/reading

COVID-19 news
(hours/day)

<2 20.5 43.5 36.0 30.1 35.1 34.8 33.5 41.0 25.5 59.0 41.0

≥2 44.4 34.2 21.4 55.1 27.8 17.1 57.8 31.0 11.2 67.4 32.6
Living with children Yes 27.8 40.4 31.8 39.4 31.0 29.6 41.2 37.2 21.6 61.4 38.6

No 36.9 37.6 25.5 44.3 33.6 22.1 49.7 35.6 14.7 65.1 34.9
Living with older

adults
Yes 21.8 39.5 38.7 35.0 33.6 31.4 39.1 39.1 21.8 58.2 41.8

No 40.8 39.3 19.9 47.6 30.1 22.3 49.5 34.0 16.5 67.5 32.5
Emotional support

from family
Yes 34.8 40.2 25.0 45.2 30.7 24.1 48.2 35.7 16.1 64.9 35.1

No 16.7 36.7 46.6 25.6 36.7 37.7 28.9 40.0 31.1 54.4 45.6
Emotional support

from society
Yes 51.1 37.9 11.0 59.5 26.3 14.2 61.6 28.9 9.5 67.4 32.6

No 14.8 40.7 44.5 26.3 36.4 37.3 30.1 42.8 27.1 58.9 41.1
Emotional support

from hospital
Yes 49.3 36.7 14.0 58.7 28.7 12.6 64.7 27.3 8.0 69.3 30.7

No 20.3 41.3 38.4 31.4 33.2 35.4 32.1 42.1 25.8 59.0 41.0

A. Arafa, et al. Journal of Affective Disorders 278 (2021) 365–371

368

T
ab
le

3
O
dd

s
ra
ti
os

an
d
co
nfi

de
nc
e
in
te
rv
al
s
of

th
e
as
so
ci
at
io
ns

w
it
h
de

pr
es
si
on

,
an

xi
et
y,

st
re
ss
,
an

d
in
ad

eq
ua

te
sl
ee
pi
ng

am
on

g
H
C
W
s
de

pl
oy

ed
in

fa
ci
ng

C
O
V
ID
-1
9
pa

nd
em

ic
in

Eg
yp

t
an

d
Sa
ud

i
A
ra
bi
a.

C
ha

ra
ct
er
is
ti
cs

R
eg
re
ss
io
n
m
od

el
s

D
ep
re
ss
io
n

A
nx

ie
ty

St
re
ss

Sl
ee
pi
ng

ho
ur
s/
da

y
N
or
m
al

M
ild

to
m
od

er
at
e

Se
ve
re

to
ve
ry

se
ve
re

N
or
m
al

M
ild

to
m
od

er
at
e

Se
ve
re

to
ve
ry

se
ve
re

N
or
m
al

M
ild

to
m
od

er
at
e

Se
ve
re

to
ve
ry

se
ve
re

≥
6

<
6

A
ge
:
18

–3
0
vs
.
>
30

ye
ar
s
(r
ef
)

M
od

el
I

1
1.
66

(0
.8
6,

3.
19

)
2.
21

(1
.0
3,

4.
74

)
1

1.
66

(0
.8
4,

3.
29

)
1.
80

(0
.8
6,

3.
78

)
1

1.
66

(0
.8
7,

3.
18

)
2.
03

(0
.8
6,

4.
84

)
1

0.
75

(0
.4
2,

1.
34

)
M
od

el
II

1
1.
95

(0
.9
7,

3.
93

)
2.
88

(1
.2
5,

6.
62

)
1

1.
81

(0
.8
8,

3.
71

)
2.
03

(0
.9
2,

4.
48

)
1

1.
90

(0
.9
5,

3.
81

)
2.
49

(1
.0
0,

6.
18

)
1

0.
68

(0
.3
7,

1.
24

)
Se
x:

W
om

en
vs
.
m
en

(r
ef
)

M
od

el
I

1
2.
29

(1
.4
3,

3.
66

)
2.
94

(1
.7
7,

4.
88

)
1

1.
85

(1
.1
7,

2.
91

)
3.
30

(2
.0
1,

5.
40

)
1

2.
25

(1
.4
6,

3.
47

)
2.
71

(1
.5
9,

4.
63

)
1

1.
32

(0
.8
9,

1.
95

)
M
od

el
II

1
2.
05

(1
.2
1,

3.
48

)
2.
57

(1
.4
3,

4.
61

)
1

1.
54

(0
.9
3,

2.
54

)
2.
68

(1
.5
6,

4.
62

)
1

1.
74

(1
.0
7,

2.
83

)
2.
39

(1
.3
3,

4.
32

)
1

1.
30

(0
.8
4,

2.
01

)
C
ou

nt
ry
:
Eg

yp
t
vs
.
Sa
ud

i
A
ra
bi
a
(r
ef
)

M
od

el
I

1
2.
48

(1
.5
5,

3.
96

)
5.
85

(3
.3
0,

10
.3
8)

1
2.
43

(1
.5
1,

3.
90

)
4.
05

(2
.3
5,

6.
98

)
1

3.
91

(2
.4
3,

6.
29

)
3.
61

(2
.0
1,

6.
50

)
1

0.
93

(0
.6
2,

1.
40

)
M
od

el
II

1
2.
19

(1
.2
8,

3.
74

)
4.
71

(2
.4
5,

9.
04

)
1

2.
27

(1
.3
2,

3.
88

)
3.
31

(1
.7
8,

6.
15

)
1

3.
67

(2
.1
3,

6.
31

)
2.
81

(1
.4
5,

5.
45

)
1

0.
92

(0
.5
7,

1.
47

)
Pr
of
es
si
on

😛
hy

si
ci
an

s
vs
.o

th
er
s
(n
on

-p
hy

si
ci
an

s,
no

n-
nu

rs
es
)
(r
ef
)

M
od

el
I

1
1.
21

(0
.7
0,

2.
08

)
2.
19

(1
.2
2,

3.
96

)
1

1.
19

(0
.7
0,

2.
04

)
1.
28

(0
.7
3,

2.
25

)
1

1.
36

(0
.8
2,

2.
27

)
1.
75

(0
.9
3,

3.
29

)
1

0.
69

(0
.4
3,

1.
11

)
M
od

el
II

1
1.
00

(0
.5
4,

1.
86

)
1.
50

(0
.7
5,

3.
00

)
1

0.
93

(0
.5
1,

1.
70

)
0.
89

(0
.4
6,

1.
70

)
1

0.
91

(0
.5
0,

1.
65

)
1.
32

(0
.6
5,

2.
69

)
1

0.
66

(0
.4
0,

1.
11

)
Pr
of
es
si
on

:
N
ur
se
s
vs
.
ot
he

rs
(n
on

-p
hy

si
ci
an

s,
no

n-
nu

rs
es
)
(r
ef
)

M
od

el
I

1
1.
19

(0
.6
5,

2.
17

)
0.
79

(0
.3
8,

1.
65

)
1

1.
27

(0
.6
9,

2.
36

)
1.
03

(0
.5
3,

2.
01

)
1

1.
18

(0
.6
6,

2.
11

)
1.
02

(0
.4
7,

2.
19

)
1

1.
07

(0
.6
3,

1.
83

)
M
od

el
II

1
0.
70

(0
.3
5,

1.
38

)
0.
36

(0
.1
6,

0.
82

)
1

0.
83

(0
.4
2,

1.
63

)
0.
53

(0
.2
5,

1.
12

Psychological Impact and Coping Strategies
of Frontline Medical Staff in Hunan Between
January and March 2020 During the Outbreak
of Coronavirus Disease 2019 (COVID‑19)
in Hubei, China

BEF 1 Haozheng Cai*
EF 1,2,3 Baoren Tu*
B 4 Jing Ma
B 5 Limin Chen
B 6 Lei Fu
AG 4 Yongfang Jiang
ACDG 1,2 Quan Zhuang

* Haozheng Cai and Baoren Tu contributed to this paper equally
Corresponding Authors: Yongfang Jiang, e-mail: jiangyongfang@csu.edu.cn, Quan Zhuang, e-mail: zhuangquansteven@163.com
Source of support: Grants from the National Natural Science Foundation of China (No. 81700658 and 81974079), the National Science and

Technology Major Project (No. 2017ZX10202203), the Natural Science Foundation of Hunan Province (No. 2016JJ4105), and the
New Xiangya Talent Project of the Third Xiangya Hospital of Central South University (No. JY201629)

Background: Throughout China, during the recent epidemic in Hubei province, frontline medical staff have been
responsible for tracing contacts of patients infected with coronavirus disease 2019 (COVID-19). This
study aimed to investigate the psychological impact and coping strategies of frontline medical staff
in Hunan province, adjacent to Hubei province, during the COVID-19 outbreak between January and
March 2020.

Material/Methods: A cross-sectional observational study included doctors, nurses, and other hospital staff throughout
Hunan province between January and March 2020. The study questionnaire included five sections
and 67 questions (scores, 0 – 3). The chi-squared χ² test was used to compare the responses between
professional groups, age-groups, and gender.

Results: Study questionnaires were completed by 534 frontline medical staff. The responses showed that
they believed they had a social and professional obligation to continue working long hours. Medical
staff were anxious regarding their safety and the safety of their families and reported psychologi-
cal effects from reports of mortality from COVID-19 infection. The availability of strict infection con-
trol guidelines, specialized equipment, recognition of their efforts by hospital management and the
government, and reduction in reported cases of COVID-19 provided psychological benefit.

Conclusions: The COVID-19 outbreak in Hubei resulted in increased stress for medical staff in adjacent Hunan prov-
ince. Continued acknowledgment of the medical staff by hospital management and the government,
provision of infection control guidelines, specialized equipment and facilities for the management
of COVID-19 infection should be recognized as factors that may encourage medical staff to work dur-
ing future epidemics.

MeSH Keywords: Coronavirus Infections • Emotions • Medical Staff • Stress, Psychological • COVID-19

Full‑text PDF: https://www.medscimonit.com/abstract/index/idArt/924171

1 Transplantation Center, The 3rd Xiangya Hospital, Central South University,
Changsha, Hunan, P.R. China

2 Engineering and Technology Research Center of National Health Ministry
for Transplantation Medicine, Changsha, Hunan, P.R. China

3 The Center on Behavior Health, The Faculty of Social Science,
The University of Hong Kong, Hong Kong, P.R. China

4 Department of Infectious Diseases, The 2nd Xiangya Hospital, Central South
University, Changsha, Hunan, P.R. China

5 Department of Infectious Diseases, The 3rd Xiangya Hospital, Central South
University, Changsha, Hunan, P.R. China

6 Department of Infectious Diseases, Xiangya Hospital, Central South
University, Changsha, Hunan, P.R. China

3178 6 1 24

e-ISSN 1643–3750
© Med Sci Monit, 2020; 26: e924171

DOI: 10.12659/MSM.924171

e924171-1
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System]
[ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica]
[Chemical Abstracts/CAS]

CLINICAL RESEARCH

This work is licensed under Creative Common Attribution-
NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

924171
Cai H. et al.:

Frontline medical staff in Hunan during COVID-19

© Med Sci Monit, 2020; 26: e

CLR CLINICAL RESEARCH
SRT SHORT COMMUNICATIONS
DCS DRUG CONTROLLED STUDIES
PHE PHARMACOECONOMICS
DIA DIAGNOSTIC TECHNIQUES
MET MEDICAL TECHNOLOGY
PUB PUBLIC HEALTH
SPR SPECIAL REPORTS
EPI EPIDEMIOLOGY
REV REVIEW ARTICLES
LET LETTER TO THE EDITOR
HYP HYPOTHESIS
PIN PRODUCT INVESTIGATIONS
PRE PRELIMINARY REPORT
MHI MEDICAL HISTORY
LBR LAB/IN VITRO RESEARCH
ANS ANIMAL STUDY
HAN HUMAN ANATOMY
MOL MOLECULAR BIOLOGY
MTA META-ANALYSIS
BCH MEDICAL BIOCHEMISTRY
EDT EDITORIAL
DBA DATABASE ANALYSIS

Authors’ Contribution:
Study Design A

Data Collection B
Statistical Analysis C
Data Interpretation D

Manuscript Preparation E
Literature Search F
Funds Collection G

Received: 2020.03.10
Accepted: 2020.03.13

Available online: 2020.03.23
Published: 2020.04.15

Background

Since the beginning of the coronavirus disease 2019
(COVID-19) outbreak began in Hubei province from November
2019, frontline medical staff throughout China have experi-
enced an increase in workload, increased working hours, and
increased psychological stress. According to previous stud-
ies, during the outbreaks of severe acute respiratory syn-
drome (SARS) and Middle East respiratory syndrome (MERS),
frontline medical staff had reported high levels of stress
that resulted in posttraumatic stress disorder (PTSD) [1,2].
The risk factors of psychological stress in medical staff had
been previously investigated during the SARS and MERS ep-
idemics. In 2008, Styra et al., in Toronto, identified four ma-
jor risk factors for stress in medical staff during the SARS
outbreak, including the perception of the medical of their
risk of infection, the impact of SARS on their work, feelings
of depression, and working in high-risk medical units [3].
The perception of infection risk by medical staff was previ-
ously reported by Tam et al. in 2003 to be significantly asso-
ciated with their risk of developing PTSD [1]. Other factors,
including social stigmatization and contact with infected
patients, has previously been shown to be associated with
increased levels of stress and anxiety in medical staff [2].

Although recent reports have shown that 80% of patients
with COVID-19 have mild symptoms and will recover and the
mortality rate is low at up to 2%, because of the high trans-
mission rate, total mortality from COVID-19 is greater than
SARS and MRES combined [4]. Recently, Peeri et al. report-
ed that the infection rate of medical staff during the SARS
and MERS outbreaks reached 21% and 18.6%, respectively,
which resulted in adverse psychological effects, including
anxiety and depression [5]. Medical staff have been infect-
ed and have died during the COVID-19 epidemic in China,
there are no treatments for this infection, and no vaccines
have been developed [6]. All these factors contribute to in-
creased psychological stress of frontline medical staff in
China, which may have immediate or long-psychological
consequences that may have acute or chronic somatic ef-
fects that result in conditions such as cardiac arrhythmia
and myocardial infarction [7]. However, there have been few
studies that have investigated the coping strategies that
frontline medical staff can use during disease epidemics.
Personality traits, such as optimism, resilience, and altru-
ism, have previously been shown to have positive effects
on reducing psychological stress [6,8]. Objective measures
may reduce psychological stress, including effective infec-
tion control, personal protective measures, clear institution-
al policies and protocols, which may help to reduce stress in
medical staff [9]. Recognition and appreciation of the work
and efforts by the medical profession, hospital manage-
ment, government, and society have a positive impact on

stress experienced by medical staff during epidemics [10].
Therefore, this study aimed to investigate the psychologi-
cal impact and coping strategies of frontline medical staff
in Hunan province, adjacent to Hubei province, during the
COVID-19 outbreak between January and March 2020.

Material and Methods

Ethical approval

A cross-sectional observational study included doctors,
nurses, and other hospital staff throughout Hunan province
between January and March 2020. The Institutional Review
Board of the 3rd Xiangya Hospital of Central South University
provided ethical approval for this study.

Study participants

Questionnaires were sent to frontline medical staff who
were working during the outbreak of coronavirus disease
2019 (COVID-19). The participants included doctors and nurs-
es from departments of infectious diseases, emergency
medicine, fever clinics, and intensive care units, and in-
cluded technicians from radiology and laboratory medicine,
and hospital staff from the section of infection prevention.
A questionnaire was used that was previously designed by
Lee et al. [11], which was used to evaluate medical staff dur-
ing the 2003 severe acute respiratory syndrome (SARS) ep-
idemic. The questionnaire was modified for this study and
included five sections with 67 questions. All participants
were required to understand the meaning of the question
and to answer the questions on their own.

Study questionnaire

The first section of the questionnaire included 14 questions
that examined the feelings of the medical staff during the
COVID-19 outbreak. Each question had four choices on a four-
point scale (0=not at all; 1=slightly; 2=moderately; 3=very
much). The second section investigated 19 possible factors
that could induce stress for the medical staff (0=not at all;
1=slightly; 2=moderately; 3=very much). The third section in-
cluded 14 questions to identify factors that might reduce their
stress (0=never; 1=sometimes; 2=often; 3=always). The fourth
section included 11 questions, which aimed to identify per-
sonal coping strategies in response to the stress of the out-
break, with four choices with responses that ranged from not
important to most important (scores, 0 – 3). The fifth section
included questions on what would encourage medical staff
to be more confident in future outbreaks and included nine
questions, consisting of four choices with responses that
ranged from not important to most important (scores, 0 – 3).

e924171-2
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System]
[ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica]
[Chemical Abstracts/CAS]

CLINICAL RESEARCHCLINICAL RESEARCH

This work is licensed under Creative Common Attribution-
NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

Cai H. et al.:
Frontline medical staff in Hunan during COVID-19

© Med Sci Monit, 2020; 26: e924171

Statistical analysis

Statistical analysis of the data was performed with GraphPad
Prism version 7.0 (GraphPad Software Inc., La Jolla, CA, USA).
The chi-squared χ² test was used to compare the responses
between professional groups, age-groups, and gender for the
first four sections of the questionnaire. Descriptive statis-
tics were used to present the data collected from the survey
and included the mean, standard deviation (SD), and medi-
an of the data collected for all the sections. A P-value<0.05
was considered to be statistically significant.

Results

Characteristics of the study participants

A total of 534 questionnaires were completed from 167 men
and 367 women. The majority of participants were between
the ages of 18 – 30 years (42.4%) and 31 – 40 years (60.7%). All
the participants were working in hospitals in Hunan prov-
ince. Doctors and nurses together accounted for 90% of
the total participants. Most of the study participants were
married (79%) and had children (76.6%). The average clini-
cal experience was 14.5 years. Medical staff with a postgrad-
uate degree represented the majority of the study partici-
pants (64.4%). The demographic characteristics of the study

participants was shown in Table 1. All of the study partic-
ipants were Chinese citizens and worked in different lev-
els of hospital in Hunan, an adjacent province to Hubei.
The questionnaires were evenly distributed to all adminis-
trative districts in Hunan. The top three participating dis-
tricts were Changsha, Hengyang, and Yueyang (Figure 1),

Table 1. Medical staff demographics (n=534).

Characteristic Value

Age (years), mean (SD) 36.4 (16.18)

Gender, N (%)
Female
Male

367 (68.7)
167 (31.3)

Professional, N (%)
Nurse
Doctor
Medical Technician
Hospital staff

248 (46.4)
233 (43.6)
48 (9.0)
5 (1.0)

Married, N (%) 422 (79.0)

Having children, N (%) 409 (76.6)

Education degree, N (%)
Undergraduate
Master
Doctor
Others

344 (64.4)
96 (18.0)
56 (10.5)
38 (7.1)

Figure 1. The distribution of the study participants from Hunan province, China, during the epidemic of coronavirus disease 2019
(COVID-19) between January and March 2020. (1) Hunan province is located in the central southern area of China, adjacent
to Hubei province. (2) There were 534 completed questionnaires that included medical staff from 13 administrative districts
of Hunan province, including Changsha (317), Hengyang (79), Yueyang (27), Chenzhou (23), Shaoyang (23), Zhangjiajie (16),
Huaihua (15), Xiangtan (13), Zhuzhou (5), Changde (5), Yongzhou (3), Loudi (2), and Jishou (2).

e924171-3
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System]
[ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica]
[Chemical Abstracts/CAS]

CLINICAL RESEARCHCLINICAL RESEARCH

This work is licensed under Creative Common Attribution-
NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

Cai H. et al.:
Frontline medical staff in Hunan during COVID-19
© Med Sci Monit, 2020; 26: e924171

which were adjacent to the Jing-Guang Line, the most im-
portant railway and highway combining Hunan and Hubei.

The emotions of the medical staff in Hunan during the
coronavirus disease 2019 (COVID‑19) outbreak in Hubei

The emotions of the medical staff from the different med-
ical professionals are shown in Table 2. The chi-squared
χ² test showed that differences in responses from eight of
the 14 questions were statistically significant. The most im-
portant element was their social and moral responsibility,
which drove them to continue working during the outbreak
(P=0.03), and doctors had the highest mean score (2.47 ± 0.66).
Medical staff also expected to receive recognition from hos-
pital authorities (P<0.001), and nurses had more concerns
regarding extra financial compensation during or after the
outbreak when compared with other healthcare workers
(P=0.002). However, nursing staff also felt more nervous
and anxious when on the ward when compared with other
groups (P=0.02). Doctors were more unhappy about working
overtime during the COVID-19 outbreak than other health-
care workers (P=0.02). There was no significant difference
between the medical professionals for regarding stopping
work, and work overload.

Factors that caused stress, according to the age of the
medical staff

The study population was divided into four age-groups
(Table 3). The main factors associated with stress were con-
cerns for personal safety (P<0.001), concerns for their fami-
lies (P<0.001), and concerns for patient mortality (P=0.001).
Medical staff in the 31 – 40 year age-group were more wor-
ried about infecting their families compared with other
groups (2.46 ± 0.72). Staff>50 years of age felt greater stress
when seeing their patients die. Worry about their own safe-
ty were also an important factor in anxiety in medical staff,
particularly in the group aged 41 – 50 years. Lack of protec-
tive clothing (P=0.0195) and exhaustion due to increased du-
ration of working (P=0.03) were also significantly increased
in older staff. Stress from other colleagues affected staff
>50 years old when compared with other groups (P=0.0034).
The safety of their colleagues and the lack of treatment for
COVID-19 were considered to be important factors that in-
ducd stress in all medical staff, with no significant differ-
ences between the study groups.

Factors that helped to reduce stress of medical staff
during the COVID-19 outbreak, according to gender

Section 3 of the study questionnaire aimed to identify could
directly or indirectly help to reduce stress for a COVID-19
outbreak according to the previous severe acute respiratory

syndrome (SARS) and Middle East respiratory syndrome
(MERS) outbreaks, and these were evaluated in Section 3
(Table 4). In this section, we would like to look for differ-
ences from the sexual perspective. The safety of family was
the biggest impact in reducing staff stress (P=0.37>0.05),
though there are no significant difference in different gen-
ders. However, factors like correct guidance and effective
safeguards for prevention from disease transmission eased
more female staff anxiety (P<0.001). The positive attitude
from their colleagues was also important factor to reduce
staff distress during the outbreak (P=0.04). In general, fac-
tors of reducing stress had larger impact on female staff
than male ones.

Personal coping strategies used by the medical staff to
reduce stress among professionals

Section 4 of the study questionnaire was designed to pro-
vide insights into the personal coping strategies used by the
different professional groups of the medical staff (Table 5).
Strategies, such as strict protective measures, knowledge of
virus prevention and transmission, social isolation measures,
and positive self-attitude resulted in the highest scores
(mean scores <2.5), with nurses giving the highest scores in
every question. Seeking help from family and friends was a
significant supportive measure (P<0.001). Medical staff did
not express a significant wish to reduce stress by consulting
a psychologist to discuss their emotions, especially in the
populations of doctors and medical technicians.

Motivational factors to encourage continuation of work in
future outbreaks of infection

Section 5 of the study questionnaire included questions
for the medical staff about motivators to continue working
during any future COVID-19 or other epidemic outbreaks
(Table 6). Adequate protective equipment provided by the
hospitals was considered to be the most important moti-
vational factor to encourage continuation of work in future
outbreaks. The availability of strict infection control guide-
lines, specialized equipment, recognition of their efforts by
hospital management and the government, and reduction in
reported cases of COVID-19 provided psychological benefit.

Discussion

Frontline medical staff during epidemics of infectious dis-
ease include doctors and nurses from departments of in-
fectious disease, emergency medicine, fever clinics, and in-
tensive care units, and technicians mainly from radiology
and laboratory medicine, and hospital staff from infec-
tion control [11]. Previous studies during the severe acute

e924171-4
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System]
[ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica]
[Chemical Abstracts/CAS]

CLINICAL RESEARCHCLINICAL RESEARCH

This work is licensed under Creative Common Attribution-
NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

Cai H. et al.:
Frontline medical staff in Hunan during COVID-19

© Med Sci Monit, 2020; 26: e924171

Table 2. Staff feeling during COVID-19 outbreak among different position.

Question Condition

Groups

χ² PNurses
N=248

Doctors
N=233

Medical
Technician

N=48

Hospital staff
N=5

Total
N=534

1. You think that your current front-
line job comes from your social
and moral responsibility

Not at all 13 (5.2) 3 (1.3) 2 (4.2) 0 (0) 18 (3.4)

13.59 0.03*

Slight 11 (4.4) 13 (5.6) 5 (10.4) 0 (0) 29 (5.4)

Moderate 114 (50.0) 89 (38.2) 16 (33.3) 0 (0) 219 (41.0)

Very Much 110 (44.4) 128 (54.9) 25 (52.1) 5 (100) 268 (50.2)

Mean±SD 2.29±0.78 2.47±0.66 2.33±0.83 3.00±0.00 2.38±0.74

2. You have felt nervous or frighten
in the ward

Not at all 40 (16.2) 46 (19.7) 10 (20.8) 2 (40) 98 (18.4)

15.02 0.02*

Slight 88 (35.5) 108 (46.4) 22 (45.8) 1 (20) 219 (41.0)

Moderate 96 (38.7) 71 (30.5) 13 (27.1) 1 (20) 181 (33.9)

Very Much 24 (10.0) 8 (3.4) 3 (6.3) 1 (20) 36 (6.7)

Mean±SD 1.42±0.87 1.18±0.78 1.19±0.84 1.20±1.30 1.29±0.84

3. You were unhappy about working
overtime during the outbreak.

Not at all 133 (53.6) 96 (41.2) 31 (64.6) 2 (40) 262 (49.1)

15.08 0.02*

Slight 66 (26.6) 85 (36.5) 12 (25) 1 (20) 164 (30.7)

Moderate 43 (17.4) 42 (18.0) 5 (10.4) 1 (20) 91 (17.0)

Very Much 6 (2.4) 10 (4.3) 0 (0) 1 (20) 17 (3.2)

Mean±SD 0.69±0.84 0.85±0.86 0.46±0.68 1.20±1.30 0.74±0.85

4. You expect recognition of your
work from the hospital authorities

Not at all 12 (4.8) 2 (0.9) 8 (16.7) 0 (0) 22 (4.1)

98.12 <0.001***

Slight 21 (8.5) 33 (14.1) 24 (50) 1 (20) 79 (14.8)

Moderate 103 (41.5) 105 (45.1) 16 (33.3) 2 (40) 226 (42.3)

Very Much 112 (45.2) 93 (39.9) 0 (0) 2 (40) 207 (38.8)

Mean±SD 2.27±0.81 2.24±0.72 2.17±0.69 2.20±0.84 2.25±0.76

5. You expect to receive bonus
compensation during or after the
outbreak

Not at all 22 (8.9) 18 (7.7) 8 (16.7) 2 (40) 50 (9.4)

20.67 0.002**

Slight 38 (15.3) 66 (28.3) 15 (31.3) 0 (0) 119 (22.3)

Moderate 94 (37.9) 84 (36.1) 15 (31.3) 0 (0) 193 (36.1)

Very Much 94 (37.9) 65 (27.9) 10 (20.7) 3 (60) 172 (32.2)

Mean±SD 2.05±0.94 1.84±0.92 1.56±1.01 1.80±1.64 1.91±0.96

6. You try to reduce exposure to
patients diagnosed with COVID-19

Not at all 66 (26.5) 54 (23.2) 9 (18.8) 2 (40) 131 (24.5)

11.74 0.07

Slight 78 (31.5) 77 (33.0) 19 (39.6) 0 (0) 174 (32.6)

Moderate 82 (33.1) 72 (30.9) 9 (18.8) 2 (40) 165 (30.9)

Very Much 22 (8.9) 30 (12.9) 11 (22.8) 1 (20) 64 (20.0)

Mean±SD 1.24±0.95 1.33±0.97 1.46±1.05 1.40±1.34 1.30±0.97

7. You want to stop your present job

Not at all 156 (62.9) 142 (60.9) 45 (93.8) 4 (80) 347 (65.0)

20.83 0.02**

Slight 53 (21.4) 57 (24.5) 2 (4.2) 1 (20) 113 (21.2)

Moderate 23 (9.3) 23 (9.9) 1 (2.0) 0 (0) 47 (8.8)

Very Much 16 (6.4) 11 (4.7) 0 (0) 0 (0) 27 (5.0)

Mean±SD 0.59±0.90 0.58±0.85 0.08±0.35 0.20±0.45 0.54±0.85

e924171-5
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System]
[ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica]
[Chemical Abstracts/CAS]

CLINICAL RESEARCHCLINICAL RESEARCH

This work is licensed under Creative Common Attribution-
NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

Cai H. et al.:
Frontline medical staff in Hunan during COVID-19
© Med Sci Monit, 2020; 26: e924171

Question Condition

Groups

χ² PNurses
N=248

Doctors
N=233

Medical
Technician

N=48

Hospital staff
N=5

Total
N=534

8. You think HCWs who have not
been exposed to COVID-19 should
reduce their contact with you

Not at all 53 (21.4) 40 (17.2) 14 (29.2) 2 (40) 109 (20.4)

90.4 <0.001***

Slight 41 (16.5) 45 (19.3) 14 (29.2) 0 (0) 100 (18.7)

Moderate 70 (28.2) 89 (38.2) 12 (25.0) 2 (40) 173 (32.4)

Very Much 84 (33.9) 59 (25.3) 8 (16.6) 1 (20) 152 (28.5)

Mean±SD 1.75±1.14 1.72±1.03 1.29±1.07 1.40±1.34 1.69±1.09

9. You want to be able to work in a
unit where you don’t have to deal
with patients with COVID-19

Not at all 96 (38.7) 79 (33.9) 23 (47.9) 1 (20) 199 (37.2)

10.79 0.09

Slight 60 (24.2) 69 (29.6) 15 (31.3) 2 (40) 146 (27.3)

Moderate 59 (23.8) 47 (20.2) 9 (18.7) 0 (0) 115 (21.5)

Very Much 33 (13.3) 38 (16.3) 1 (2.1) 2 (40) 74 (14.0)

Mean±SD 1.12±1.07 1.19±1.08 0.75±0.84 1.60±1.34 1.12±1.06

10. You notice that other HCWs
outside your department are
avoiding contact with infected
patients

Not at all 47 (19.0) 27 (11.6) 12 (25.0) 3 (60) 89 (16.7)

22.17 0.01**

Slight 47 (19.0) 47 (20.2) 17 (35.4) 1 (20) 112 (21.0)

Moderate 78 (31.5) 83 (35.6) 16 (33.3) 0 (0) 177 (33.1)

Very Much 76 (30.5) 76 (32.6) 3 (6.3) 1 (20) 156 (29.2)

Mean±SD 1.74±1.09 1.89±0.99 1.21±0.90 0.80±1.30 1.75±1.05

11. If the epidemic suddenly gets
worse, you will have to stop
your job

Not at all 166 (66.9) 142 (610) 41 (85.4) 3 (60) 352 (65.9)

11.22 0.08

Slight 49 (20.0) 56 (24.0) 3 (6.3) 2 (40) 110 (20.6)

Moderate 25 (10.1) 27 (11.6) 3 (6.3) 0 (0) 55 (10.3)

Very Much 8 (3.0) 8 (3.4) 1 (2.0) 0 (0) 17 (3.2)

Mean±SD 0.50±0.80 0.58±0.83 0.25±0.67 0.40±0.55 0.51±0.81

12. You feel angry because your
workload is greater and more
dangerous than other doctors
who have not been exposed to
COVID-19

Not at all 134 (54.0) 124 (53.0) 29 (60.4) 3 (60) 290 (54.3)

8.303 0.22

Slight 53 (21.4) 61 (26.0) 15 (31.3) 2 (40) 131 (24.5)

Moderate 44 (17.7) 34 (15.0) 4 (8.3) 0 (0) 82 (15.4)

Very Much 17 (6.9) 14 (6.0) 0 (0) 0 (0) 31 (5.8)

Mean±SD 0.77±0.97 0.73±0.92 0.48±0.65 0.40±0.55 0.73±0.93

13. You want to call in sick

Not at all 207 (82.5) 195 (83.7) 46 (95.8) 5 (100) 453 (84.8)

9.17 0.16

Slight 22 (8.9) 28 (12.0) 2 (40) 0 (0) 52 (9.7)

Moderate 16 (6.5) 8 (3.4) 0 (0) 0 (0) 24 (4.5)

Very Much 3 (12.1) 2 (0.9) 0 (0) 0 (0) 5 (0.9)

Mean±SD 0.25±0.63 0.21±0.54 0.04±0.20 0.00±0.00 0.22±0.56

14. You’ve been off work at least
once

Not at all 228 (92.0) 219 (94.0) 48 (100) 5 (100) 500 (93.6)

8.555 0.2

Slight 10 (4.0) 10 (4.3) 0 (0) 0 (0) 20 (3.7)

Moderate 10 (4.0) 3 (1.3) 0 (0) 0 (0) 13 (2.4)

Very Much 0 (0) 1 (0.4) 0 (0) 0 (0) 1 (0.3)

Mean±SD 0.12±0.43 0.08±0.36 0.00±0.00 0.00±0.00 0.09±0.38

*<0.05; **<0.01; ***<0.001. χ² test was only performed among the groups of nurse, doctor and medical technician because of pretty small sample size in
the group of hospital staff.

Table 2 continued. Staff feeling during COVID-19 outbreak among different position.

e924171-6
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System]
[ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica]
[Chemical Abstracts/CAS]

CLINICAL RESEARCHCLINICAL RESEARCH

This work is licensed under Creative Common Attribution-
NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

Cai H. et al.:
Frontline medical staff in Hunan during COVID-19

© Med Sci Monit, 2020; 26: e924171

Question Condition
Groups (years old)

Total
N=534

χ² P18–30
N=150

31–40
N=215

41–50
N=117

50+
N=52

1. See your colleagues were
infected

Not at all 23 (15.3) 24 (11.2) 16 (13.7) 9 (17.3) 72 (13.5)

8.109 0.52

Slight 26 (17.3) 33 (15.3) 20 (17.1) 9 (17.3) 88 (16.5)

Moderate 45 (30.0) 75 (34.9) 31 (26.5) 21 (40.4) 172 (32.2)

Very Much 56 (37.4) 83 (38.6) 50 (42.7) 13 (25.0) 202 (37.8)

Mean±SD 1.89±1.08 2.01±1.00 1.98±1.07 1.73±1.03 1.94±1.04

2. You’re worried about infecting
your family

Not at all 8 (5.33) 3 (1.4) 2 (1.7) 3 (5.8) 16 (3.0)

137 <0.001***

Slight 19 (12.7) 20 (9.3) 24 (20.5) 5 (9.6) 68 (12.7)

Moderate 47 (31.3) 68 (31.6) 28 (24.0) 20 (38.5) 163 (30.6)

Very Much 76 (50.7) 124 (57.7) 64 (53.8) 24 (46.1) 287 (53.7)

Mean±SD 2.27±0.88 2.46±0.72 2.30±0.85 2.25±0.86 2.35±0.81

3. Small mistakes or inattentions
can make you or others infected

Not at all 6 (4.0) 8 (3.7) 0 (0.0) 7 (13.5) 21 (3.9)

37.69 <0.001***

Slight 37 (25.0) 41 (19.1) 25 (21.4) 3 (5.8) 106 (19.9)

Moderate 56 (37.0) 93 (43.3) 34 (29.1) 25 (48.0) 208 (39.0)

Very Much 41 (34.0) 73 (34.0) 58 (49.5) 17 (32.7) 199 (37.2)

Mean±SD 2.01±0.87 2.07±0.82 2.28±0.80 2.00±0.97 2.10±0.85

4. Take care of your infected
colleagues

Not at all 35 (23.3) 44 (20.5) 17 (14.5) 9 (17.3) 105 (19.7)

12.88 0.17

Slight 37 (24.7) 42 (19.5) 33 (28.2) 11 (21.1) 123 (23.0)

Moderate 50 (33.3) 83 (38.6) 32 (27.4) 21 (40.4) 186 (34.8)

Very Much 28 (18.7) 46 (21.4) 35 (29.9) 11 (21.2) 120 (22.5)

Mean±SD 1.47±1.05 1.61±1.04 1.73±1.05 1.65±1.01 1.60±1.04

5. See your infected patient die in
front of you

Not at all 16 (10.7) 25 (11.6) 9 (7.7) 2 (3.9) 52 (9.7)

27.06 0.001**

Slight 19 (12.7) 30 (14.0) 35 (29.9) 6 (11.5) 70 (13.1)

Moderate 57 (38.0) 64 (29.8) 40 (34.1) 18 (34.6) 168 (31.5)

Very Much 58 (38.6) 96 (44.7) 33 (28.3) 26 (50.0) 244 (45.7)

Mean±SD 2.05±0.97 2.07±1.02 2.26±0.96 2.31±0.83 2.13±0.98

6. You don’t know when the
outbreak will be contained

Not at all 7 (4.6) 6 (2.8) 9 (7.7) 2 (3.9) 24 (4.5)

11.41 0.25

Slight 39 (26.0) 69 (32.1) 35 (29.9) 18 (34.6) 161 (30.1)

Moderate 73 (48.7) 94 (43.7) 40 (34.2) 19 (36.5) 226 (42.3)

Very Much 31 (20.7) 46 (21.4) 33 (28.2) 13 (25.0) 123 (23.1)

Mean±SD 1.85±0.80 1.84±0.79 1.83±0.93 1.83±0.86 1.84±0.83

7. New infections or suspected
cases ask for your help.

Not at all 12 (8.0) 17 (7.9) 15 (12.8) 4 (7.7) 48 (9.0)

8.36 0.5

Slight 45 (30.0) 73 (34.0) 40 (34.2) 20 (38.5) 178 (33.3)

Moderate 61 (40.7) 89 (41.4) 35 (29.9) 19 (36.5) 204 (38.2)

Very Much 32 (21.3) 36 (16.7) 27 (23.1) 9 (17.3) 104 (19.5)

Mean±SD 1.75±0.88 1.67±0.85 1.63±0.98 1.63±0.86 1.68±0.89

Table 3. Factors that caused stress among staff with different ages.

e924171-7
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System]
[ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica]
[Chemical Abstracts/CAS]

CLINICAL RESEARCHCLINICAL RESEARCH

This work is licensed under Creative Common Attribution-
NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

Cai H. et al.:
Frontline medical staff in Hunan during COVID-19
© Med Sci Monit, 2020; 26: e924171

Question Condition
Groups (ye

OBSERVATIONS: BRIEF RESEARCH REPORTS

Psychological Impact of the COVID-19 Pandemic on Health
Care Workers in Singapore

Background: In response to the coronavirus disease 2019
(COVID-19) pandemic, Singapore raised its Disease Outbreak
Response System Condition alert to “orange,” the second
highest level. Between 19 February and 13 March 2020, con-
firmed cases rose from 84 to 200 (34.2 per 1 000 000 popu-
lation), with an increase in patients in critical condition from 4
to 11 (5.5%) and no reported deaths in Singapore (1). Under-
standing the psychological impact of the COVID-19 outbreak
among health care workers is crucial in guiding policies and
interventions to maintain their psychological well-being.

Objective: To examine the psychological distress, de-
pression, anxiety, and stress experienced by health care
workers in Singapore in the midst of the outbreak, and to
compare these between medically and non–medically
trained hospital personnel.

Methods and Findings: From 19 February to 13 March
2020, health care workers from 2 major tertiary institutions in
Singapore who were caring for patients with COVID-19 were
invited to participate with a self-administered questionnaire.

LETTERS

Annals.org Annals of Internal Medicine • Vol. 173 No. 4 • 18 August 2020 317

In addition to information on demographic characteristics and
medical history (Table 1), the questionnaire included the val-
idated Depression, Anxiety, and Stress Scales (DASS-21) and
the Impact of Events Scale–Revised (IES-R) instrument (2, 3).
Health care workers included “medical” (physicians, nurses)
and “nonmedical” personnel (allied health professionals,
pharmacists, technicians, administrators, clerical staff, and
maintenance workers). The primary outcome was the preva-
lence of depression, stress, anxiety, and posttraumatic stress
disorder (PTSD) among all health care workers (Table 2). Sec-
ondary outcomes were comparison of the prevalence of de-
pression, anxiety, stress, and PTSD, and mean DASS-21 and
IES-R scores between medical and nonmedical health care
workers. The Pearson �2 test and student t test were used to
compare categorical and continuous outcomes, respectively,
between the 2 groups. Multivariable regression was used to
adjust for the a priori defined confounders of age, sex, ethnic-
ity, marital status, presence of comorbid conditions, and sur-
vey completion date.

Of 500 invited health care workers, 470 (94%) partici-
pated in the study; baseline characteristics are shown in Table
1. Sixty-eight (14.5%) participants screened positive for anxi-
ety, 42 (8.9%) for depression, 31 (6.6%) for stress, and 36

(7.7%) for clinical concern of PTSD. The prevalence of anxiety
was higher among nonmedical health care workers than med-
ical personnel (20.7% versus 10.8%; adjusted prevalence ra-
tio, 1.85 [95% CI, 1.15 to 2.99]; P = 0.011), after adjustment for
age, sex, ethnicity, marital status, survey completion date, and
presence of comorbid conditions. Similarly, higher mean
DASS-21 anxiety and stress subscale scores and higher IES-R
total and subscale scores were observed in nonmedical health
care workers (Table 2).

Discussion: Overall mean DASS-21 and IES-R scores
among health care workers were lower than those in the pub-
lished literature from previous disease outbreaks, such as se-
vere acute respiratory syndrome (SARS). A previous study in
Singapore found higher IES scores among physicians and
nurses during the SARS outbreak, and an almost 3 times
higher prevalence of PTSD, than those in our study (4). This
could be attributed to increased mental preparedness and
stringent infection control measures after Singapore’s SARS
experience.

Of note, nonmedical health care workers had higher
prevalence of anxiety even after adjustment for possible con-
founders. Our findings are consistent with those of a recent
COVID-19 study demonstrating that frontline nurses had sig-

Table 1. Participant Characteristics at Baseline

Characteristic Overall
(n � 470)

Nonmedical Health Care
Personnel (n � 174)

Medical Health Care
Personnel (n � 296)

Sex, n (%)
Female 321 (68.3) 119 (68.4) 202 (68.2)
Male 149 (31.7) 55 (31.6) 94 (31.8)

Median age (IQR), y 31 (28–36) 33 (28–39) 30 (28–35)

Ethnicity, n (%)
Chinese 292 (62.1) 100 (57.5) 192 (64.9)
Indian 78 (16.6) 39 (22.4) 39 (13.2)
Malay 42 (8.9) 20 (11.5) 22 (7.4)
Other 58 (12.4) 15 (8.6) 43 (14.5)

Marital status, n (%)
Single 228 (48.5) 83 (47.7) 145 (49.0)
Married 232 (49.4) 85 (48.9) 147 (49.7)
Divorced, separated, or widowed 10 (2.1) 6 (3.4) 4 (1.3)

Occupation, n (%)
Physician 135 (28.7) — 135 (45.6)
Nurse 161 (34.3) — 161 (54.4)
Allied health care professional 65 (13.8) 65 (37.4) —
Technician 10 (2.1) 10 (5.7) —
Clerical staff 30 (6.4) 30 (17.2) —
Administrator 33 (7.0) 33 (19.0) —
Maintenance worker 36 (7.7) 36 (20.7) —

Medical history, n (%)
Hypertension 20 (4.3) 13 (7.5) 7 (2.4)
Hyperlipidemia 19 (4.0) 11 (6.3) 8 (2.7)
Diabetes mellitus 5 (1.1) 1 (0.6) 4 (1.4)
Asthma 26 (5.5) 10 (5.7) 16 (5.4)
Eczema 35 (7.4) 10 (5.7) 25 (8.4)
Migraine 58 (12.3) 27 (15.5) 31 (10.5)
Cigarette smoking 17 (3.6) 16 (9.2) 1 (0.3)
Ischemic heart disease 3 (0.6) 3 (1.7) 0
Stroke 1 (0.2) 1 (0.6) 0
Preexisting psychiatric illness 0 0 0
Other comorbid conditions 27 (5.7) 11 (6.3) 16 (5.4)

IQR = interquartile range.

LETTERS

318 Annals of Internal Medicine • Vol. 173 No. 4 • 18 August 2020 Annals.org

nificantly lower vicarious traumatization scores than non–
frontline nurses and the general public (5). Reasons for this
may include reduced accessibility to formal psychological
support, less first-hand medical information on the outbreak,
and less intensive training on personal protective equipment
and infection control measures.

As the pandemic continues, important clinical and policy
strategies are needed to support health care workers. Our
study identified a vulnerable group susceptible to psycholog-
ical distress. Educational interventions should target nonmed-
ical health care workers to ensure understanding and use of
infection control measures. Psychological support could in-
clude counseling services and development of support sys-
tems among colleagues.

Our study has limitations. First, data obtained from self-
reported questionnaires were not verified with medical re-
cords. Second, the study did not assess socioeconomic status,
which may be helpful in evaluating associations of outcomes
and tailoring specific interventions. Finally, the study was per-
formed early in the outbreak and only in Singapore, which
may limit the generalizability of the findings. Follow-up stud-
ies could help assess for progression or even a potential re-
bound effect of psychological manifestations once the immi-
nent threat of COVID-19 subsides.

In conclusion, our study highlights that nonmedical health
care personnel are at highest risk for psychological distress
during the COVID-19 outbreak. Early psychological interven-
tions targeting this vulnerable group may be beneficial.

Benjamin Y.Q. Tan, MD*
National University Health System and Yong Loo Lin School of

Medicine, National University of Singapore
Singapore

Nicholas W.S. Chew, MD*
National University Health System
Singapore

Grace K.H. Lee, MD
Yong Loo Lin School of Medicine, National University of

Singapore
Singapore

Mingxue Jing, MD
Yihui Goh, MD
National University Health System
Singapore

Leonard L.L. Yeo, MD
National University Health System and Yong Loo Lin School of

Medicine, National University of Singapore
Singapore

Ka Zhang, MD
Howe-Keat Chin, MD
National University Health System
Singapore

Aftab Ahmad, MD
Faheem Ahmed Khan, MD
Ganesh Napolean Shanmugam, MBBCh
Ng Teng Fong General Hospital
Singapore

Bernard P.L. Chan, MD
Sibi Sunny, MD

Table 2. Prevalence of Depression, Anxiety, Stress, and PTSD and Mean DASS-21 and IES-R Scores in Medical and
Nonmedical Health Care Personnel (n = 470)

Outcome Nonmedical Health Care
Personnel (n � 174)

Medical Health Care
Personnel (n � 296)

Crude Prevalence
Ratio (95% CI)

Adjusted Prevalence
Ratio (95% CI)*

Prevalence, n (%)*
Depression 18 (10.3) 24 (8.1) 1.28 (0.71 to 2.28) 1.12 (0.57 to 2.19)
Anxiety 36 (20.7) 32 (10.8) 1.91 (1.23 to 2.97) 1.85 (1.15 to 2.99)
Stress 12 (6.9) 19 (6.4) 1.07 (0.53 to 2.16) 1.01 (0.47 to 2.19)
PTSD 19 (10.9) 17 (5.7) 1.90 (1.02 to 3.56) 1.47 (0.71 to 3.04)

Crude Mean
Difference (95% CI)

Adjusted Mean
Difference (95% CI)†

Mean (SD) DASS-21
and IES-R scores

DASS depression 3.24 (5.07) 2.54 (5.23) 0.70 (–0.27 to 1.67) 0.46 (–0.62 to 1.54)
DASS anxiety 3.57 (3.91) 2.45 (4.28) 1.13 (0.35 to 1.91) 1.04 (0.15 to 1.94)
DASS stress 6.10 (5.95) 3.82 (5.74) 2.29 (1.19 to 3.38) 2.15 (0.88 to 3.41)
Total IES-R 9.40 (10.08) 5.85 (9.24) 3.55 (1.75 to 5.34) 3.35 (1.34 to 5.36)
IES-R Intrusion 0.47 (0.51) 0.31 (0.49) 0.16 (0.07 to 0.25) 0.15 (0.04 to 0.25)
IES-R Avoidance 0.46 (0.53) 0.27 (0.46) 0.19 (0.10 to 0.28) 0.18 (0.08 to 0.29)
IES-R Hyperarousal 0.35 (0.45) 0.22 (0.40) 0.13 (0.05 to 0.21) 0.12 (0.04 to 0.21)

DASS-21 = Depression, Anxiety, and Stress Scales; IES-R = Impact of Events Scale–Revised; PTSD = posttraumatic stress disorder.
* The DASS-21 is a 21-item system that provides independent measures of depression, stress, and anxiety with recommended severity thresholds.
Cutoff scores >9, >7, and >14 indicate a positive screen for depression, anxiety, and stress, respectively. The IES-R is a 22-item self-report
instrument that measures the subjective distress caused by traumatic events. It has 3 subscales (intrusion, avoidance, and hyperarousal), which are
closely affiliated with PTSD symptoms. A total IES-R cutoff score of 24 is used to classify PTSD as a clinical concern.
† Adjusted for age, sex, ethnicity, marital status, presence of comorbid conditions, and survey completion date. The adjusted prevalence ratio was
derived from logistic regression models by calculating marginally adjusted prevalence for each group. The 95% CIs were derived by using the delta
method. The adjusted mean difference was obtained by using linear regression.

LETTERS

Annals.org Annals of Internal Medicine • Vol. 173 No. 4 • 18 August 2020 319

Bharatendu Chandra, MD
Jonathan J.Y. Ong, MD
Prakash R. Paliwal, MD
Lily Y.H. Wong, BN
Renarebecca Sagayanathan, BSc
Jin Tao Chen, BN
Alison Ying Ying Ng, Dip
Hock Luen Teoh, MD
National University Health System
Singapore

Cyrus S. Ho, MD
National University of Singapore
Singapore

Roger C. Ho, MD
Institute of Health Innovation and Technology (iHealthtech),

National University of Singapore
Singapore

Vijay K. Sharma, MD
National University Health System and Yong Loo Lin School of

Medicine, National University of Singapore
Singapore

* Drs. Tan and Chew contributed equally to this work.

Disclosures: Disclosures can be viewed at www.acponline.org
/authors/icmje/ConflictOfInterestForms.do?msNum=M20-1083.

Reproducible Research Statement: Study protocol and statistical
code: Available from Dr. Sharma (e-mail, vijay_kumar_sharma@nuhs
.edu.sg). Data set: Not available.

Corresponding Author: Vijay K. Sharma, MD, Division of Neurology,
National University Health System, NUHS Tower Block, Level 10, 1 East
Kent Ridge Road, Singapore 119228; e-mail, vijay_kumar_sharma
@nuhs.edu.sg.

This article was published at Annals.org on 6 April 2020.

doi:10.7326/M20-1083

References
1. Ministry of Health Singapore. Updates on COVID-19 (coronavirus disease

2019) local situation. Ministry of Health, Singapore. Accessed at www.moh.gov

.sg/covid-19 on 13 March 2020.

2. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales.

2nd ed. Psychology Foundation of Australia; 1995.

3. Creamer M, Bell R, Failla S. Psychometric properties of the Impact of Event

Scale – Revised. Behav Res Ther. 2003;41:1489-96. [PMID: 14705607]

4. Chan AO, Huak CY. Psychological impact of the 2003 severe acute respira-

tory syndrome outbreak on health care workers in a medium size regional

general hospital in Singapore. Occup Med (Lond). 2004;54:190-6. [PMID:

15133143]

5. Li Z, Ge J, Yang M, et al. Vicarious traumatization in the general public,

members, and non-members of medical teams aiding in COVID-19 control.

Brain Behav Immun. 2020. [PMID: 32169498] doi:10.1016/j.bbi.2020.03.007

LETTERS

320 Annals of Internal Medicine • Vol. 173 No. 4 • 18 August 2020 Annals.org

Copyright © American College of Physicians 2020.