Abstract
Background:
Healthcare providers faced the challenge of managing coronavirus disease 2019 (COVID-19)-infected patients. At the onset of the spread of the coronavirus infection across the globe, awareness of the treatment modalities was poor. Interns were relatively new to treating patients as they had just started their clinical postings in February or March 2020. Working in the COVID-19 wards with the sudden influx of a large number of patients, treating them with ever-changing guidelines did cause increased physical and mental stress. Thus, to understand the impact of coronavirus infection on interns this study was conducted.
Materials and Methods:
An online survey was conducted among interns of various medical colleges of Nagpur, Mumbai, Pune, and Miraj using Google Forms. Participation was anonymous and voluntary. Responses were accepted for 1 week from March 27, 2020, till April 3, 2020. Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder 7 Scale (GAD-7) (9) were used to assess anxiety and depression.
Result:
Our study showed that 36.3% of the interns who were posted for COVID-19 duty had depression, whereas 34% had anxiety symptoms. Anxiety and depression were comparable in interns posted for COVID-19 duty and those posted in other clinical departments. Young age, female gender, and perceived risk of contracting COVID-19 were the predictors for anxiety and depression.
Conclusion:
There was a high level of anxiety and depression among interns working in hospitals during the COVID-19 pandemic irrespective of whether they were posted for COVID-19 duty or not. Reporting such information is important to plan further management of mental health needs.
Keywords: Anxiety, COVID-19, depression, interns
The coronavirus disease 2019 (COVID-19) infection spread like wildfire and severely affected many countries throughout the world. Declared as a pandemic by the World Health Organization (WHO) on March 11, 2020, the infection spread rapidly in India with over 2000 cases at the time of the study.[1] Maharashtra had been the worst affected of all the states in India at that time, of which Mumbai, Pune, and Nagpur had the maximum cases.[2]
Healthcare providers faced the challenge of managing patients with COVID-19 infection for which no cure or vaccine was available at that time.[3] As this infection was known to spread by droplets or fomites, healthcare providers were themselves at risk of contracting the disease.[4] In these testing times, managing mental health and psychosocial well-being was equally important as managing physical health.[5] Data from countries such as China, Italy, and Spain have shown that healthcare providers are at greater risk of infection than the general population.[6,7] Indian studies also replicate a similar picture.[8,9]
The compulsory internship is 1 year following Bachelor of Medicine and Bachelor of Surgery (MBBS) during which the intern is required to undergo clinical or acquisition of skills under supervision in all clinical departments of the hospital on a rotation.[10] At the time of the coronavirus pandemic, interns were relatively new to treating patients as they had just started their clinical postings in February or March 2020. Working in the COVID-19 wards with the sudden influx of a huge number of patients, treating them with ever-changing guidelines might have caused increased mental stress considering their inexperience. Thus, to understand the mental health concerns of coronavirus infection on interns this study was conducted.
MATERIALS AND METHODS
The study was conducted on a cross-sectional basis at a tertiary care center attached to a medical college in Western Maharashtra. The hospital was a designated COVID-19 treatment center during the COVID-19 pandemic. Before starting the study, approval was obtained from the institutional ethics committee (DYPV/EC/857/22 dated August 18, 2022). All the participants gave written informed consent.
Google Forms were used to make an online questionnaire. The link was distributed among interns through WhatsApp (snowball sampling). The Google Form was circulated among interns of medical colleges in Mumbai, Pune, Nagpur, and Sangli. Responses were accepted for 1 week from March 27, 2020, till April 3, 2020. The Google Form was divided into three sections. After receiving the informed consent, the intern was directed toward the questionnaire. Section I of the questionnaire consisted of demographic details, which included age, sex, name of institution, whether they were posted for COVID-19 screening, whether they received any training regarding COVID-19 screening, the risk they were at for contracting COVID-19, and whether they had taken any prophylactic medication. Section II consisted of the Patient Health Questionnaire (PHQ-9), which is a 9-item scale for depression.[11] Section III comprised the Generalised Anxiety Disorder 7 Scale (GAD-7), and cutoff scores were as follows: 5: mild, 10: moderate, and 15: severe anxiety on the GAD-7.[12] Participants took approximately 5 minutes to complete the Google Form. Incomplete forms were not accepted. Strict confidentiality was maintained in all data collection.
Statistical analyses
Analysis of descriptive data was on the parameters of mean ± standard deviation (SD), range, and frequencies. Continuous variables were analyzed using Student's t-test, and ordinal data were analyzed using the Mann–Whitney U-test. Categorical data were analyzed by the Chi-square test or Fisher's exact test as applicable. Multiple regression analysis was performed for predictors of depression and anxiety. The statistical software Statistical Package for the Social Sciences (SPSS) version 22.0 was used.
RESULTS
The survey received 227 responses, of which seven were duplicates and three were incomplete. Thus, an analysis of 217 responses was performed (n = 217). The demographic characteristics of participants are presented in Table 1. The mean age of the participants was 22.57 ± 0.83. One hundred and twenty-two (56.2%) participants were female. Of the 217 interns, 47 (21.7%) were posted for COVID-19 duty, whereas 170 (78.3%) were posted in other departments. The mean age of interns posted for COVID-19 duty was 22.48 ± 0.92, whereas for those posted in other departments, it was 22.6 ± 0.81. The difference was statistically not significant. Twenty-nine females were posted for COVID-19 duty, whereas 97 female interns were posted in other departments. The difference was not statistically significant. Twenty-one (44.7%) interns who were posted for COVID-19 duty took some medication as prophylaxis for COVID-19, whereas 36 (21.2%) interns posted in other departments took some medication as prophylaxis for COVID-19. The difference was statistically significant (P = 0.00). The mean perceived risk of contracting COVID-19 infection was 5.29. Among the interns posted for COVID-19 duty, the mean perceived risk of contracting COVID-19 infection was 6.82 ± 2.12, while it was 4.86 ± 2.46 in those posted in other departments. The difference was not statistically significant.
Table 1.
Sociodemographic characteristics of interns posted for COVID-19 duty and those posted in other departments
| Total (n=217) | Performed COVID-19 duty (n=47) | Not performed COVID-19 duty (n=170) | t-test/Chi-square/MW test | P | |
|---|---|---|---|---|---|
| Age | |||||
| Range | 21-25 | 21-25 | 21 – 25 | 0.47 | 0.42 |
| Mean (SD) | 22.57 (0.83) | 22.48 (0.92) | 22.60 (0.81) | ||
| Sex | |||||
| Female | 122 (56.22) | 29 | 93 | 3800.5 | 0.553 |
| Male | 95 (43.77) | 18 | 77 | ||
| Prophylaxis taken | |||||
| Yes | 57 (26.26) | 21 (44.68) | 36 (21.18) | 2971.0 | 0.000 |
| No | 160 (73.73) | 26 (55.32) | 134 (78.82) | ||
| Perceived risk | |||||
| Range | 0-10 | 2-10 | 0-10 | 3934.500 | 0.921 |
| Mean (SD) | 5.29 (2.14) | 6.82 (2.12) | 4.86 (2.46) | ||
| GAD-7 score | |||||
| Mean (SD) | 7.88 (5.72) | 43.46 (8.66) | 44.74 (8.04) | 3503.5 | 0.197 |
| PHQ-9 score | |||||
| Mean (SD) | 7.93 (6.38) | 11.55 (7.47) | 11.97 (6.94) | 3763.5 | 0.543 |
Based on the GAD-7 score, 74 participants had mild anxiety symptoms, of which 18 were posted for COVID-19 duty, while 56 were posted in other departments. Forty-two participants showed moderate anxiety symptoms, of which nine were posted for COVID-19 duty, while 33 were posted in other departments. Moderate anxiety symptoms were seen in 42 participants, of whom nine were posted for COVID-19 duty, while 33 were posted in other departments. Severe anxiety was seen in 33 participants, of whom eight were posted for COVID-19 duty. The difference was statistically not significant [Table 2].
Table 2.
Distribution of GAD-7 scores of the participants
| Score range | Severity of anxiety | Total (n=217) | Performed COVID-19 duty (n=47) | Not performed COVID-19 duty (n=170) | Chi-square test | P |
|---|---|---|---|---|---|---|
| 0–4 | No anxiety | 68 (31.3) | 12 (25.5) | 56 (32.9) | 1.086 | 0.780 |
| 5–9 | Mild | 74 (34.1) | 18 (38.3) | 56 (32.9) | ||
| 10–14 | Moderate | 42 (19.4) | 9 (19.1) | 33 (19.4) | ||
| >15 | Severe | 33 (15.1) | 8 (17.0) | 25 (14.7) |
PHQ-9 score showed that 54 interns had mild depression, of whom 12 interns were posted for COVID-19 duty, while 42 were posted in other departments. Moderate depression was noticed in 43 interns, of whom 12 were posted for COVID-19 duty, while 31 were posted in other departments. Twenty-three interns had moderately severe depression, of which two were posted for COVID-19 duty and 21 were posted in other departments. Thirteen participants reported severe depression, of which four were doing COVID-19 duty, while nine were posted in other clinical departments. The difference was not statistically significant [Table 3].
Table 3.
PHQ-9 scores of the participants
| Score range | Severity of depression | Total | Performed COVID-19 duty | Not performed COVID-19 duty | Chi-square test | P |
|---|---|---|---|---|---|---|
| 0–4 | No depression | 84 (38.7) | 17 (36.2) | 67 (39.4) | 0.477 | 0.975 |
| 5–9 | Mild | 54 (24.9) | 12 (25.5) | 42 (24.7) | ||
| 10–14 | Moderate | 43 (19.7) | 12 (25.5) | 31 (18.2) | ||
| 15–19 | Moderately severe | 23 (10.6) | 2 (4.3) | 21 (12.4) | ||
| 20–27 | Severe | 13 (6.0) | 4 (8.5) | 9 (5.3) |
Multiple regression was run to predict anxiety from age, sex, perceived risk of COVID-19 infection, and PHQ scores, as shown in Table 4. These variables predicted anxiety, which were statistically significant, F (4, 212) = 18148.747, P < .000, and R2 = 0.997. The four variables were statistically significant to the prediction, P < .05.
Table 4.
Multiple regression for predictors of anxiety: Coefficients
| Model | Unstandardized coefficients |
Standardized coefficients | t | Sig. | 95.% confidence interval for B |
Collinearity statistics |
|||
|---|---|---|---|---|---|---|---|---|---|
| B | Std. error | Beta | Lower bound | Upper bound | Tolerance | VIF | |||
| 4 | |||||||||
| (Constant) | 1.278 | 0.783 | 1.633 | 0.104 | -0.264 | 2.821 | |||
| PHQ | 1.001 | 0.004 | 0.925 | 249.139 | 0.000 | 0.993 | 1.009 | 0.997 | 1.003 |
| RiskCOV | 0.995 | 0.012 | 0.317 | 84.744 | 0.000 | 0.972 | 1.018 | 0.984 | 1.016 |
| Age | 1.025 | 0.034 | 0.113 | 30.329 | 0.000 | 0.958 | 1.092 | 0.988 | 1.012 |
| Sex | 0.974 | 0.058 | 0.064 | 16.934 | 0.000 | 0.861 | 1.088 | 0.975 | 1.026 |
aDependent variable: GAD; RiskCOV - perceived risk of contracting COVID-19
Multiple regression was run to predict depression from age, sex, perceived risk of COVID-19, and GAD score, as shown in Table 5. These variables too predicted statistically significant depression, F (4, 210) = 15673.280, P < .000, and R2 = 0.997. All four variables were statistically significant to the prediction of depression at P < .05.
Table 5.
Multiple regression analysis for predictors of depression: Coefficients
| Model | Unstandardized coefficients |
Standardized coefficients | t | Sig. | 95.% confidence interval for B |
Collinearity statistics |
|||
|---|---|---|---|---|---|---|---|---|---|
| B | Std. error | Beta | Lower bound | Upper bound | Tolerance | VIF | |||
| 4 | |||||||||
| (Constant) | -1.334 | 0.779 | -1.713 | 0.088 | -2.870 | 0.202 | |||
| GAD | 0.995 | 0.004 | 1.073 | 250.125 | 0.000 | 0.987 | 1.003 | 0.864 | 1.157 |
| RiskCOV | -0.989 | 0.013 | -0.334 | -78.104 | 0.000 | -1.014 | -0.964 | 0.869 | 1.151 |
| Age | -1.016 | 0.034 | -0.121 | -30.066 | 0.000 | -1.083 | -0.950 | 0.976 | 1.024 |
| Sex | -0.964 | 0.057 | -0.068 | -16.795 | 0.000 | -1.077 | -0.851 | 0.977 | 1.024 |
aDependent variable: PHQ; RiskCOV: perceived risk of contracting COVID-19
DISCUSSION
Ever since COVID-19 became the pandemic, the levels of anxiety, depression, and other mental problems have been noted to be on the rise. The pandemic put tremendous stress on the healthcare system, particularly on healthcare professionals.[13] It was expected that the effect of the disease on health professionals would be higher than the general population as they are a vulnerable group and are at an increased risk of exposure.[14] This study addresses the effect of COVID-19 on the mental health of medical interns and also compares the mental health of interns posted for COVID-19 duty and those posted in other clinical departments.
The COVID-19 pandemic instigated generalized fear and uncertainty, particularly among healthcare professionals, due to causes such as difficulties during the lockdown, the rapid spread of COVID-19, the highly contagious nature of the disease, morbidity and mortality, the lack of knowledge of the disease, and deaths among health professionals. The unavailability of personal protection equipment, frequently updated information, lack of disease-specific drugs, the shortage of oxygen concentrators and ventilators, and beds in intensive care units necessary to address the increased inflow of severely ill patients added to the problems.[6] In our study, the mean perceived risk of contracting COVID-19 infection was 5.29 as in a study by Khalid Seetan et al.[15] One hundred and eighty (32.5%) doctors had concerns about being infected by COVID-19. Multiple regression analysis also showed perceived risk of contracting COVID-19 infection as the predictor for anxiety and depression.
Multiple regression analysis showed female gender to be a predictor for depression. Tuna et al.[16] in their study found that female doctors had a higher level of anxiety and depression, whereas in our study the difference was not significant although anxiety and depression were slightly higher in females.
Our study showed that 36.3% of the interns who were posted for COVID-19 duty suffered from depression. This finding was comparable to a study by Sridevi et al.[17] who found that 42.1% of doctors posted in a COVID-19 isolation ward were depressed. In a study by Suryavanshi et al.,[18] 47% of healthcare providers suffered from depression, whereas 50% had anxiety. In our study, 33.2% suffered from generalized anxiety disorder. The prevalence of mild-to-severe anxiety and depression among medical students was noted to be 38.1% and 27.6%, respectively, by Nakhostin-Ansari A et al.[13] The prevalence of anxiety and depression was 32.5 and 34.2%, respectively, in a study conducted in Bangladesh by Khatun et al.[19] In a study by Zhu J, the prevalence rate of anxiety and depression symptoms among doctors fighting against COVID-19 was 11.4% and 45.6%, respectively, whereas in our study anxiety and depression were 34% and 36.3%, respectively.[7] There is a concern that health professionals are at higher risk of anxiety and depression, which can have long-term psychological implications.[6,20] The prevalence of mental morbidity in the age group of 18 to 29 was 7.5% according to a national mental health survey, while in our study we found that 46% of the participants who all belonged to this age group suffered psychiatric morbidity.[21]
In our study, there was no statistically significant difference in anxiety or depression among interns posted for COVID-19 duty and those posted in other departments. Yuksel et al.[22] found a higher level of anxiety and depression among resident doctors who treated COVID-19 patients compared with resident doctors who were not treating COVID-19 patients. This could be because of a sense of insecurity secondary to unconfirmed diagnoses in patients of other departments as all patients were not tested for COVID-19 infection even though some asymptomatic patients were potential spreaders for COVID-19 infection. Pandey et al.[14] also did not find any significant difference between junior doctors posted for COVID-19 duty and those posted elsewhere.
Limitations
The data were not cross-verified with medical records.
The sample size of the study was modest.
CONCLUSION
There was a considerable level of anxiety and depression among interns posted for COVID-19 duty and those posted in other clinical departments in the COVID-19-affected regions of Maharashtra State. Anxiety and depression were higher in interns with younger age, female gender. A higher perceived risk of contracting COVID-19 infection is a predictor for anxiety and depression. Reporting such information is important to plan further management of mental healthcare needs. Organized effort to improve the mental health of healthcare professionals is necessary as a step toward preparedness for future pandemics.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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