Letter to the Editor:
Surgeons working during the coronavirus disease 2019 (COVID-19) pandemic are facing unprecedented challenges, such as risk of infection, shortage of personal protective equipment, socioeconomic challenges, the decreased ability to obtain family support, and the cancellation of elective operations with redeployment of surgeons to other departments.1 , 2 In addition, surgeons working in Libya during the civil war conflict are at greater risk of physical and verbal abuse by the militias during the conflicts of the civil war; for example, when the relatives or friends of these militias are injured/diseased or even die in the hospital, they attack surgeons and physicians who were caring for that patient, especially in working settings that suffer from a shortage of equipment and resources during the COVID-19 pandemic.3 Thus, surgeons working in Libya are at greater risk of mental illness owing to the civil war, financial crisis, lack of training, shortage of personal protective equipment, and risk of COVID-19 infection. Therefore, we aim to provide an overview of the mental health status among surgeons during COVID-19.
An online, anonymous, cross-sectional survey was conducted using email and mobile messages among surgical staff and residents working in Libyan hospitals during May 2020 to measure their anxiety and depressive symptoms and to provide an overview of physical and verbal abuse. The survey included basic demographic characteristics, the incidence of physical and verbal abuse owing to the civil war conflict, and history of COVID-19 infection. The second part of the survey included a mental health assessment comprising a self-administered, 9-item Patient Health Questionnaire (PHQ-9)4 , 5 with ≥15 as the cutoff score for depressive symptoms and the 7-item, Generalized Anxiety Disorder scale (GAD-7)6 with ≥15 as the cutoff score for anxiety symptoms.
A total of 309 participant surgeons, 201 (65%) surgery residents and 108 (35%) surgical staff from Libyan hospitals, have completed the survey. The mean age of participants (SD) was 32.8 (7.1). Among study participants, 212 (68.6%) were men, and 97 (31.4%) were women. Table I illustrates the basic study characteristics of the participants along with association with depressive and anxiety symptoms. Based on the cutoff scores of the PHQ-9 and the GAD-7 to determine the presence of depressive and anxiety symptoms, 36 (11.7%) participants reached the cutoff score for a diagnosis of depressive symptoms as determined by a PHQ-9 score ≥15, while 47 (15.2%) reached the cutoff score for anxiety symptoms as determined by a GAD-7 score ≥15. The mean (SD) score for the PHQ-9 was 11.1 (2.9), while the mean (SD) for the GAD-7 was 10.7 (3.5).
Table I.
Basic characteristics of study population and psychologic status association (N = 309)
| Characteristics | n (%) | Depressive symptoms |
Anxiety symptoms |
||||||
|---|---|---|---|---|---|---|---|---|---|
| PHQ-9 ≥15 | PHQ-9 <15 | χ2 | P value | GAD-7 ≥15 | GAD-7 <15 | χ2 | P value | ||
| Age (y) | 1.807 | .179 | 6.720 | .01∗ | |||||
| <35 | 229 (74.1) | 30 (83) | 199 (72.9) | 42 (89) | 187 (71.4) | ||||
| ≥35 | 80 (25.9) | 6 (17) | 74 (27.1) | 5 (11) | 75 (28.6) | ||||
| Sex-male | 212 (68.6) | 22 (61) | 190 (69.6) | 1.063 | .302 | 30 (64) | 182 (69.5) | 0.588 | .443 |
| Female | 97 (31.4) | 14 (39) | 83 (30.4) | 17 (36) | 80 (30.5) | ||||
| Marital status n (%) | 0.04 | .841 | 0.855 | .355 | |||||
| Single | 185 (59.9) | 21 (58) | 164 (60.1) | 31 (66) | 154 (58.8) | ||||
| Married | 124 (40.1) | 15 (42) | 109 (39.9) | 16 (34) | 108 (41.2) | ||||
| Living arrangement | 0.327 | .568 | 0.351 | .553 | |||||
| Alone | 44 (14.2) | 32 (89) | 40 (14.7) | 8 (17) | 36 (13.7) | ||||
| Within family | 265 (85.8) | 4 (11) | 233 (85.3) | 39 (83) | 226 (86.3) | ||||
| Y of experience | 1.775 | .183 | 3.251 | .071 | |||||
| <5 | 201 (65) | 27 (75) | 174 (63.7) | 36 (77) | 165 (63) | ||||
| ≥5 | 108 (35) | 9 (25) | 99 (36.3) | 11 (23) | 97 (37) | ||||
| Surgical specialty | 3.871 | .869 | 15.965 | .043∗ | |||||
| General and GI surgery | 74 (23.9) | 8 (22) | 66 (24.2) | 4 (9) | 70 (26.7) | ||||
| Trauma and emergency | 100 (32.4) | 10 (28) | 90 (33) | 20 (43) | 80 (30.5) | ||||
| Orthopedic | 40 (12.9) | 6 (17) | 34 (12.5) | 9 (19) | 31 (11.8) | ||||
| Urology | 10 (3.2) | 2 (6) | 8 (2.9) | 3 (6) | 7 (2.7) | ||||
| Head and neck | 9 (2.9) | 2 (6) | 7 (2.6) | 3 (6) | 6 (2.3) | ||||
| Cardiothoracic | 6 (1.9) | 1 (3) | 5 (1.8) | 0 | 6 (2.3) | ||||
| Plastic surgery | 4 (1.3) | 0 | 4 (1.5) | 0 | 4 (1.5) | ||||
| Neurosurgery | 6 (1.9) | 0 | 6 (2.2) | 0 | 6 (2.3) | ||||
| Other | 60 (19.4) | 7 (19) | 53 (19.4) | 8 (17) | 52 (19.8) | ||||
| Smoking | 0.802 | .37 | 2.21 | .145 | |||||
| Yes | 79 (25.6) | 7 (19) | 72 (26.4) | 8 (17) | 71 (27.1) | ||||
| No | 230 (74.4) | 29 (81) | 201 (73.6) | 39 (83) | 191 (72.9) | ||||
| Living in conflict area | 2.560 | .11 | 0.793 | .373 | |||||
| Yes | 101 (32.7) | 16 (44) | 85 (31.1) | 18 (38) | 83 (31.7) | ||||
| No | 208 (67.3) | 20 (56) | 188 (68.9) | 29 (62) | 179 (68.3) | ||||
| Verbal abuse episode | 0.302 | .583 | 1.308 | .253 | |||||
| Yes | 167 (54) | 21 (58) | 146 (53.5) | 29 (62) | 138 (52.7) | ||||
| No | 142 (46) | 15 (42) | 127 (46.5) | 18 (38) | 124 (47.3) | ||||
| Physical abuse episode | 1.85 | .174 | 0.029 | .865 | |||||
| Yes | 50 (16.2) | 3 (8) | 47 (17.2) | 8 (17) | 42 (16) | ||||
| No | 259 (83.8) | 33 (92) | 226 (82.8) | 39 (83) | 220 (84) | ||||
GI, gastrointestinal.
Significant at (P < .05).
Among the study participants, 101 (32.7%) live in a conflict area, 167 (54%) have had an episode of verbal abuse by militia or armed forces during the civil war conflict, and 50 (16.2%) have encountered physical abuse by these militias or armed forces while treating injured militia patients, their relatives, or friends. Regarding abuse and threatening behavior, 21 (6.8%) reported being frightened and threatened with a weapon, 13 (4.2%) experienced a sharp object being thrown, and 18 (5.8%) experienced a blow from a hand and/or kicking. Sixteen (5.2%) reported severe, life-threatening injuries; indeed, their life was in endangered because of physical abuse. Among the participants, 91 (29.4%) reported an adverse consequence of abuse in terms of their family or quality of life. Only age and surgical specialty were associated with anxiety symptoms (P < .05) The sex of the responder, marital status, living arrangements, smoking, living in a conflict area, and verbal and physical abuse did not appear to be associated with depressive or anxiety symptoms.
Our study demonstrated a high prevalence of anxiety and depressive symptoms among surgical staff during COVID-19. In addition, we demonstrated a great number of abuse episodes among surgical staff in Libya. The working style of surgeons is another risk factor for increased psychological pressure. Surgical staff suffer from the risk of infection and cross-contamination, which increases the psychological burden that may result in more anxiety and depression. Additionally, as the COVID-19 pandemic has affected surgical training, there is a high burden of stress regarding their future career opportunities especially in the surgery trainees. It is therefore necessary to pay particular attention to the psychological status of surgical staff and to implement strategies aimed to provide psychological and socioeconomic support. Psychotherapy sessions have been proposed as a method to ensure that the mental health status of both the medical and especially surgical staff will not affect their performance.7
Conflict of interest/Disclosures
The authors declare that they have no competing interests.
Funding/Support
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
We would like to thank those who participated in the study.
Footnotes
Ethics approval and consent to participate
The study was approved by the Bioethics Committee at the Biotechnology Research Center in Libya. All participants provided consent before participating in the study.
Authors' contributions
ME and AM analyzed and interpreted the patients’ data. ME proposed the idea and wrote the first draft of the manuscript. All authors read and approved the final manuscript.
References
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