Abstract
The current COVID-19 pandemic could lead to an increase in mental health problems among a range of populations, including healthcare workers involved in the pandemic. However, little is known about the lasting health effects of the pandemic after the epidemic eased. The current study was designed to investigate anxiety and depression symptoms and related predictive factors among healthcare workers in China immediately after the epidemic and lockdown eased. A total of 459 healthcare workers in the COVID-19 designated hospital (59.9% females; a mean age of 36.7 ± 9.6) completed an online survey from 14 to 23 April, 2020. The survey instruments were comprised of the Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, the Perceived Social Support Scale (PSSS), and a questionnaire assessing pandemic-related stressors and mental health needs during the pandemic. Bivariate and multivariate logistic regression analyses were conducted to identify potential predictors of mental health outcomes. The prevalence of probable anxiety and depression were 4.8% and 12.4%, respectively. Multivariable logistic regression analyses indicated that gender (OR (95% CI) = 0.26 (0.08–0.83), P < .05), mental health needs during the pandemic (OR (95% CI) = 3.06 (1.15–8.14), P < .05) and PSSS scores (OR (95% CI) = 0.93 (0.90–0.96), P < .05)were independently, and significantly associated with anxiety, while other diseases during the epidemic (OR (95% CI) = 3.47 (1.38–8.68), P < .05), mental health needs during the pandemic (OR (95% CI) = 2.89 (1.49–5.61), P < .05), and PSSS scores (OR (95% CI) = 0.94 (0.92–0.96), P < .05) were significant predictors of depression. Although the prevalence of anxiety and depression decreased among healthcare workers in China following the epidemic, further attention should be paid to the lasting effects of the epidemic on depression symptoms after the epidemic eased among this population.
Keywords: anxiety, COVID-19, depression, healthcare workers, mental health
1. Introduction
The novel coronavirus disease (COVID-19) had been characterized as a pandemic by World Health Organization on March 11, 2020 due to its infectiousness and risk to public health.[1] Given the seriousness of COVID-19, the Chinese government implemented lockdown measures in Wuhan on January 23, 2020 to prevent the spread of infection. People in other places were also restricted from outside activities. Benefiting from comprehensive prevention measures, China managed the outbreak effectively and lifted its blockade policy on 8 April. For Anhui province in China, the government implemented lockdown measures on January 24, 2020 and lifted its blockade policy on March 18, 2020. However, the COVID-19 epidemic is still ongoing worldwide. As of April 7, 2021, more than 100 million people have been diagnosed with COVID-19, with over 2.8 million deaths.[2]
Apart from concerns about infection, people are also under the stress of quarantine and interpersonal isolation during the COVID-19 epidemic.[3,4] These factors may have psychological effects and trigger mental health problems.[5] Many previous studies have reported the psychological impact of the COVID-19 epidemic in general populations. For example, the first nationwide survey in China showed that almost 35% of the participants experienced psychological distress.[6] Nationwide studies in other countries in general populations also showed that about one-third of participants might experience psychological distress.[7,8]
Healthcare workers were under tremendous stress in fighting with the pandemic. This stress may lead to mental health problems, including common mental disorders, depression and anxiety. According to the DSM-5,[9] the essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation) about a number of events or activities while the essential feature of depression is persistent feelings of sadness and hopelessness and loss of interest in activities they once enjoyed. Some studies were conducted to investigate the prevalence of depression and anxiety among healthcare workers. For example, Lai et al[10] conducted a study during the first 2 months of 2020 among Chinese health care workers from 34 hospitals in provinces with high prevalence rates of COVID-19. They found that 50.4% and 44.6% of participants reported depression and anxiety symptoms, respectively. Another study conducted among 8817 healthcare workers in COVID-19 designated hospitals in Chongqing, China, in February 2020 reported that the prevalence rates of depression and anxiety were 30.2% and 20.7%, respectively.[11] Salari et al[12] conducted a systematic review and meta-regression on current studies about the prevalence of depression and anxiety among healthcare workers under the COVID-19 epidemic and found that the prevalence of depression and anxiety was 24.3%, and 25.8%, respectively. Apart from estimating the prevalence of disorders, studies also investigated factors associated with the risk of depression and anxiety. The risk factors of depression and anxiety involved several aspects: sociodemographic factors, current or past medical history, psychological and social factors, and job-related factors.[13]
Of particular note is that almost all extant studies among healthcare workers were conducted during the severe epidemic phase. Few studies have focused on depression and anxiety symptoms among healthcare workers after the epidemic eased. According to Holmes et al, the longer-term consequences of COVID-19 on mental health are largely unknown and should be prioritized.[3] In order to explore the longer-term consequences of COVID-19 on mental health, the current study investigated depression and anxiety symptoms in a sample of Chinese healthcare workers immediately after the COVID-19 epidemic and lockdown eased, and further identified related predictive factors.
2. Methods
2.1. Procedure and participants
The current study was a cross-sectional study. On April 8, 2020, China managed the COVID-19 outbreak effectively and lifted its blockade policy. Data collection of this study took place over 6 days (April 14–23, 2020) among healthcare workers in Anhui Provincial Hospital immediately after the epidemic eased. The Anhui Provincial Hospital was the COVID-19 designated hospital in Anhui province. A quick response code for an online questionnaire was shared in a WeChat workgroup. Healthcare workers were encouraged to finish the questionnaires voluntarily after confirming the electronic informed consent.
Finally, a total of 459 participants with a mean age of 36.7 (SD = 9.6, range: 21–46) took part in this study. Of the participants, 275 (59.9%) were females and 184 (40.1%) were males. The majority of participants (84.1%) completed a bachelor or higher education. Regarding marital status, 337 (73.5%) participants were unmarried, while 102 (22.2%) were married. The study protocol was reviewed and approved by the Institutional Review Board of the Institute of Psychology, Chinese Academy of Sciences.
2.2. Measures
The Generalized Anxiety Disorder-7 (GAD-7) was used to evaluate anxiety symptoms. Items are scored from 0 (not at all) to 3 (nearly every day) to reflect the frequency of a particular symptom during the last 2 weeks. A GAD-7 summed score of at least 10 represents clinically significant anxiety symptoms.[14] The GAD-7 has been validated and widely used in Chinese.[15,16] Cronbach’α for GAD-7 was 0.93 in this sample.
The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression symptoms. The PHQ-9 is a self-report instrument rated from 0 (not at all) to 3 (nearly every day) to reflect the particular experience of the respondent about depression symptoms in the past 2 weeks.[17] A cut score of ≥ 10 has been recommended to identify cases of possible depression.[17] The PHQ-9 has been demonstrated to have excellent reliability and was previously validated for use in the Chinese population.[18] Cronbach’α for PHQ-9 was 0.89 in this sample.
Social support was measured with the Perceived Social Support Scale (PSSS).[19] This scale consists of 12 items; each item is scored using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores indicate more perceived social support. The PSSS has excellent reliability and has previously been validated and used in Chinese samples.[20,21] Cronbach’α for PSSS was 0.92 in this study.
Pandemic-related stressors and mental health needs were measured with 14 yes (1) or no (0) questions. The detailed items including 13 items for pandemic-related stressors and 1 item for mental health needs were listed in Table 3.
Table 3.
Bivariate analysis of effects of pandemic-related stressor, mental health needs and social support on odds of prevalence of probable anxiety and depression.
| Variables | Total | Anxiety | Depression | |
|---|---|---|---|---|
| n | % | OR (95% CI) | OR (95% CI) | |
| Worked in COVID-19 related departments | ||||
| No (reference) | 93 | 79.7 | – | – |
| Yes | 366 | 20.3 | 0.42 (0.17–1.04) | 0.84 (0.43–1.64) |
| Went to Wuhan | ||||
| No (reference) | 388 | 84.5 | – | – |
| Yes | 71 | 15.5 | 0.86 (0.25–3.00) | 1.03 (0.48–2.20) |
| In contact with confirmed cases | ||||
| No (reference) | 221 | 48.1 | – | – |
| Yes | 238 | 51.9 | 0.51 (0.21–1.25) | 0.96 (0.55–1.67) |
| In contact with suspected cases | ||||
| No (reference) | 151 | 32.9 | – | – |
| Yes | 308 | 67.1 | 0.70 (0.29–1.67) | 1.30 (0.70–2.39) |
| Suspected cases among close relatives | ||||
| No (reference) | 437 | 95.2 | – | – |
| Yes | 22 | 4.8 | 0.94 (0.12–7.35) | 0.70 (0.16–3.05) |
| Suspected cases among acquaintances | ||||
| No (reference) | 423 | 92.2 | – | – |
| Yes | 36 | 7.8 | 1.19 (0.27–5.29) | 1.46 (0.58–3.68) |
| Confirmed cases among close relatives | ||||
| No (reference) | 445 | 96.9 | – | – |
| Yes | 14 | 3.1 | – | 1.18 (0.26–5.42) |
| Confirmed cases among acquaintances | ||||
| No (reference) | 432 | 94.1 | – | – |
| Yes | 27 | 5.9 | 0.75 (0.10–5.82) | 2.67 (1.08–6.64)* |
| Witness COVID-19 deaths | ||||
| No (reference) | 403 | 87.8 | – | – |
| Yes | 56 | 12.2 | 0.33 (0.04–2.51) | 0.83 (0.34–2.03) |
| Witness emergency treatment | ||||
| No (reference) | 359 | 78.2 | – | – |
| Yes | 100 | 21.8 | 1.72 (0.68–4.36) | 1.07 (0.55–2.08) |
| Participate in treatment | ||||
| No (reference) | 352 | 76.7 | – | – |
| Yes | 107 | 23.3 | 0.72 (0.24–2.18) | 1.20 (0.64–2.27) |
| Extended working hours | ||||
| No (reference) | 194 | 42.3 | – | – |
| Yes | 265 | 57.7 | 2.01 (0.77–5.24) | 2.04 (1.11–3.75)* |
| Other diseases during the epidemic | ||||
| No (reference) | 431 | 93.9 | – | – |
| Yes | 28 | 6.1 | 2.60 (0.72–9.38) | 4.54 (1.98–10.41)* |
| Psychological service needs | ||||
| No (reference) | 378 | 82.4 | – | – |
| Yes | 81 | 17.6 | 3.51 (1.45–8.52)* | 3.65 (2.00–6.66)* |
| Perceived social support | 459 | 100 | 0.93 (0.90–0.96)* | 0.94 (0.92–0.96)* |
Bold values indicate statistical significance at the α = 0.05 level.
P < .05.
2.3. Data analysis
All statistics were performed with SPSS 19.0 (Armonk, NY). Univariate descriptive statistics were computed for demographic characteristics, pandemic-related stressor indicators, mental health needs rates, PSSS score, and prevalence rates for anxiety and depression symptoms. Bivariate associations between probable anxiety and depression and each of the predictors were tested with regression analyses. Variables with a significance level of P < .05 were further submitted to the simultaneous multivariable regression model to identify significant correlates of probable anxiety and depression.
3. Results
The descriptive statistics for the GAD-7, the PHQ-9, and the PSSS are presented in Table 1. The prevalence of probable anxiety and depression were 4.8% and 12.4%, respectively. Results of bivariate associations showed that demographic characteristics were not significantly associated with probable anxiety and depression (Table 2). Results of bivariate associations between pandemic-related stressor indicators, mental health needs, social support and probable anxiety and depression are presented in Table 3. The significant factors associated with anxiety included having mental health needs during the pandemic (OR (95% CI) = 3.51 (1.45–8.52), P < .05) and PSSS scores (OR (95% CI) = 0.93 (0.90–0.96), P < .05). The significant factors associated with depression included having confirmed cases among acquaintances (OR (95% CI) = 2.67 (1.08–6.64), P < .05), having extended working hours (OR (95% CI) = 2.04 (1.11–3.75), P < .05), having mental health needs during the pandemic (OR (95% CI) = 3.65 (2.00–6.66), P < .05), having other diseases during the epidemic (OR (95% CI) = 4.54 (1.98–10.41), P < .05), and the PSSS scores (OR (95% CI) = 0.94 (0.92–0.96), P < .05).
Table 1.
Descriptive analysis of GAD-7, PHQ-9, and PSSS scores.
| Mean score | SD | Minimum | Maximum | |
|---|---|---|---|---|
| GAD-7 | 3.2 | 3.6 | 0 | 21 |
| PHQ-9 | 4.6 | 4.5 | 0 | 27 |
| PSSS | 63.6 | 12.6 | 12 | 84 |
GAD-7 = Generalized Anxiety Disorder-7, PHQ-9 = Patient Health Questionnaire-9, PSSS = Perceived Social Support Scale.
Table 2.
Bivariate analysis of effects of demographic variables on odds of prevalence of probable anxiety and depression.
| Variables | Total | Anxiety | Depression | |||
|---|---|---|---|---|---|---|
| n | % | Mean | SD | OR (95% CI) | OR (95% CI) | |
| Gender | ||||||
| Female | 275 | 59.9 | – | – | ||
| Male | 184 | 40.1 | 0.32 (0.11–0.95)* | 0.72 (0.40–1.29) | ||
| Age (yr) | 36.7 | 9.6 | 0.98 (0.94–1.03) | 0.99 (0.96–1.02) | ||
| Occupation | ||||||
| Doctors | 253 | 55.6 | – | – | ||
| Nurses | 178 | 39.1 | 0.82 (0.32–2.13) | 1.19 (0.66–2.15) | ||
| Others | 24 | 5.3 | 2.41 (0.64–9.12) | 2.19 (0.82–5.87) | ||
| Education | ||||||
| Senior high school or below | 73 | 15.9 | – | – | ||
| Bachelor or above | 386 | 84.1 | 0.84 (0.28–2.57) | 0.59 (0.30–1.17) | ||
| Marital status | ||||||
| Married | 102 | 22.2 | – | – | ||
| Unmarried (single/divorced/separated/widowed) | 357 | 77.8 | 1.30 (0.43–3.93) | 0.37 (0.37–1.30) | ||
| Have any child | ||||||
| No | 122 | 26.5 | – | – | ||
| Yes | 337 | 73.5 | 0.77 (0.30–1.92) | 0.63 (0.35–1.13) | ||
| History of disease | ||||||
| No | 421 | 91.7 | – | – | ||
| Yes | 38 | 8.3 | 1.81 (0.51–6.43) | 1.68 (0.70–4.01) | ||
Bold values indicate statistical significance at the α = 0.05 level.
P < .05.
To identify the independent role of each variable as a correlate of anxiety and depression, significant variables identified in bivariate analyses were included in simultaneous logistic multivariable regression models. The multivariable regression analysis results are presented in Table 4. The results showed that females (OR (95% CI) = 0.26 (0.08–0.83), P < .05), having mental health needs during the pandemic (OR (95% CI) = 3.06 (1.15–8.14), P < .05), and lower PSSS scores (OR (95% CI) = 0.93 (0.90–0.96), P < .05) were significantly associated with a higher probability of anxiety. Moreover, having other diseases during the epidemic (OR (95% CI) = 3.47 (1.38–8.68), P < .05), having mental health needs during the pandemic (OR (95% CI) = 2.89 (1.49–5.61), P < .05), and lower PSSS scores (OR (95% CI) = 0.94 (0.92–0.96), P < .05) were significant positive correlates of depression.
Table 4.
Multivariate analysis of effects of demographic, stressors, psychological services needs and social support on odds of prevalence of probable anxiety and depression.
| Variables | Anxiety | Depression |
|---|---|---|
| OR (95% CI) | OR (95% CI) | |
| Gender | ||
| Female | – | |
| Male | 0.26 (0.08–0.83)* | |
| Confirmed cases among acquaintances | ||
| No (reference) | – | |
| Yes | 1.95 (0.71–5.35) | |
| Extended working hours | ||
| No (reference) | – | |
| Yes | 1.63 (0.84–3.15) | |
| Other diseases during the epidemic | ||
| No (reference) | – | |
| Yes | 3.47 (1.38–8.68)* | |
| Psychological service needs | ||
| No (reference) | – | – |
| Yes | 3.06 (1.15–8.14)* | 2.89 (1.49–5.61)* |
| Perceived social support | 0.93 (0.90–0.96)* | 0.94 (0.92–0.96)* |
Bold values indicate statistical significance at the α = 0.05 level.
P < .05.
4. Discussion
This study was the first known to investigate the effects of the COVID-19 pandemic on depression and anxiety after the epidemic eased among healthcare workers. Results showed that among healthcare workers in China after the epidemic eased, the prevalence of anxiety and depression were 4.8% and 12.4%, respectively. Moreover, significant correlates of anxiety were gender, having mental health needs during the pandemic, and the level of social support while significant correlates of depression were having other diseases during the epidemic, having mental health needs during the pandemic and the level of social support.
Compared with general populations[22] and healthcare workers[10,11] during the pandemic, the prevalence of depression and anxiety among healthcare workers decreased after the epidemic eased. Specifically, the prevalence of anxiety decreased remarkably while depression was maintained at a certain level. According to the classical theory of stress, anxiety, known as the fight-or-flight response, is an emotion that helps to defend against threats.[23] Anxiety symptoms decrease when the threat disappears.[24] Depression is a chronic maladaptive response following exposure to stressors.[25,26] These results were roughly in accord with previous studies showing that anxiety was less persistent than depression in short-term follow-up studies.[27] Therefore, further attention should be paid to the lasting effects of the epidemic on depression symptoms among this population.
This study found that the level of social support was a significant independent predictor of anxiety and depression. These results were generally congruent with previous studies reporting that a higher level of social support was associated with low rates of depression[28,29] and anxiety[30] under the stress of COVID-19 epidemic. Social support can play a direct beneficial effect on mental health by providing affectively consequential conversations and shared activities. Moreover, social support could also provide an indirect stress-buffering effect on mental health.[31] These results further support the significant role of social support and carry implications for effective interventions.
This study also found that having mental health needs during the pandemic was significantly associated with both anxiety and depression, indicating the importance of focusing on the mental health needs of healthcare workers. In the current study, gender was only significantly associated with anxiety but not depression, which was consistent with a recent study. Zhou et al[32] showed that women were a risk factor for anxiety symptoms rather than depression symptoms. However, recent reviews on the COVID-19 revealed that gender was associated with both depression and anxiety symptoms.[33,34] The role of gender in the mental health consequences of healthcare workers due to the COVID-19 epidemic needs to be further clarified. Furthermore, the results also showed that having other diseases during the epidemic was a specific factor for depression, which were partly consistent with previous studies showing that depression instead of anxiety was significantly associated with chronic physical symptoms.[35] It is well-established that there is a high level of comorbidity between chronic physical disorders and depressive disorders.[36] Our results further support the importance of paying attention to people with co-occurring physical diseases.
The current study provides insights that can be applied to clinical practice. First, this study found that the lasting effects of the COVID-19 epidemic were mainly manifested as depression, which suggests that more attention should probably be paid to depression after the epidemic eased. Second, our findings showed that having mental health needs during the pandemic was significantly associated with both anxiety and depression, which provided preliminary evidence to support the importance of focusing on the mental health needs of healthcare workers during the pandemic. However, access to mental health services among healthcare workers was suboptimal during the epidemic. Previous studies have pointed that the implementation of psychological interventions should be improved to deal better with the psychological problems of people affected by the COVID-19 pandemic.[37] Experts have given several suggestions on intervention improvement. For example, developing interventions based on comprehensive evidence,[3,37] adopting online mental health services instead of face-to-face intervention.[38] Further efforts should be made to develop an effective psychological intervention system. Third, the significant associations between social support and anxiety/depression suggest that programs to improve social support might have potential benefits for healthcare workers.
Several limitations of this study should be noted here. First, this study used a non-representative small sample which may not generalize to the healthcare workers across China. Second, the cross-sectional design of this study cannot reveal causal associations. Third, the findings of this study were limited by the usage of self-report measurements. Therefore, further longitudinal studies relying on interviews among representative samples are needed. Fourth, although using online survey to collect data is suitable in the context of the pandemic, the generalizability of the current findings may be limited by respondence bias. Moreover, the current study was conducted in a short time after the epidemic eased. Studies that evaluate the longer-term mental health effects of the pandemic are needed.
To the best of our knowledge, this study is the first to investigate anxiety and depression symptoms and related predictive factors among healthcare workers in China (especially among doctors and nurses) after the epidemic eased. The findings support that the lasting effect of the epidemic on depression, suggesting depression might deserve more attention. Our findings add to limited knowledge on the effect of the COVID-19 epidemic on the mental health of nurses and their colleagues after the epidemic eased. Moreover, the current findings provide primary evidence for the need to develop effective epidemic-related intervention programs to improve the mental health of healthcare workers, especially for doctors and nurses.
Author contributions
Conceptualization: Xiaowen Hu, Li Wang.
Data curation: Xue Qiao, Jie Cao, Ruojiao Fang, Xiaowen Hu.
Formal analysis: Xue Qiao, Ruojiao Fang.
Writing – original draft: Xue Qiao.
Writing – review & editing: Chengqi Cao, Li Wang, Brian J. Hall.
Abbreviations:
- COVID-19
- coronavirus disease 2019
- GAD-7
- Generalized Anxiety Disorder-7
- PHQ-9
- Patient Health Questionnaire-9
- PSSS
- Perceived Social Support Scale
XH, and LW contributed equally to this work.
This study was partially supported by the National Natural Science Foundation of China (no. U21A20364 and 31971020), the Key Project of the National Social Science Foundation of China (no. 20ZDA079), the Key Project of Research Base of Humanities and Social Sciences of Ministry of Education (no. 16JJD190006), and the Scientific Foundation of Institute of Psychology, Chinese Academy of Sciences (no. E2CX4115CX and E1CX161005).
This study was approved by the Institutional Review Board of the Institute of Psychology, Chinese Academy of Sciences.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.
How to cite this article: Qiao X, Cao J, Cao C, Fang R, Hu X, Wang L, Hall BJ. Anxiety and depression symptoms among healthcare workers in China after the coronavirus disease 2019 (COVID-19) epidemic eased: A cross-sectional study. Medicine 2023;102:26(e34179).
Contributor Information
Xue Qiao, Email: qiaox@psych.ac.cn.
Jie Cao, Email: caocq@psych.ac.cn.
Chengqi Cao, Email: caocq@psych.ac.cn.
Ruojiao Fang, Email: fangrj@psych.ac.cn.
Xiaowen Hu, Email: hu.xiaowen@hotmail.com.
Brian J. Hall, Email: bjh9622@nyu.edu.
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