Dear Editor,
The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has produced unprecedented pressure on healthcare systems.
In Italy, the first western nation to be affected by the pandemic, to date, 226.699 people have been found COVID-19 positive, and 32.169 have died due to this condition. Among the latter, 164 were medical doctors and 57 were general practitioners (GPs) (FNOMCeO, 2020).
While hospitals are involved in the treatment of patients with moderate/severe symptoms of COVID-19, GPs exert incredible effort as gatekeepers of the healthcare system by detecting patients with suspected infection. Furthermore, this effort is made without clear guidelines on COVID-19 management or protection, risking infection and spread to the community (De Sutter et al., 2020; Shanafelt et al., 2020).
On these bases, the present study aimed to investigate the psychological impact of the COVID-19 pandemic on GPs. Specifically, we aimed to investigate anxiety, depression, and post-traumatic stress symptoms (PTSS) on a convenience sample of GPs practicing in Piedmont, one of the most affected Italian regions. In addition, we explored whether any sociodemographic or work-related variables could be associated with these psychological symptoms.
In order to reach these goals, a convenience sample of 2049 GPs (out of a total of 3100 GPs in Piedmont) affiliated with the regional FIMMG, Italy's most popular general practitioner union, were contacted via email and asked to participate in an anonymous online survey about the spread of SARS-CoV-2. Data were collected from April 28, 2020 to May 10, 2020.
A total of 246 GPs (12% of the contacted GPs) completed the survey. For the purpose of this study, we analysed sociodemographic information, work-related variables, and the results of three self-report scales investigating symptoms of anxiety, depression, and post-traumatic stress: the State-Trait Anxiety Inventory-Form Y1 (STAI Y1), the Beck Depression Inventory (BDI-II), and the PTSD Checklist for DSM-5 (PCL-5), respectively.
The study was approved by the University of Turin Ethics Committee and conducted in accordance with the Declaration of Helsinki. All the participants gave their written informed consent to participate in the study.
With regard to sociodemographic and clinical characteristics of the total sample, participants had a mean age of 51.1 (SD = 13.1) years and 56% (138) of them were female. The majority of the GPs had at least one child (64%, 157) and had no previous medical condition (69%, 170).
Results of the psychological assessment showed that 32% (79) of the GPs presented significant PTSS, whereas 75% (185) and 37% (91) of the GPs reported clinically relevant anxiety and depressive symptoms, respectively. Furthermore, concerning the work-related questions, 41% (100) of GPs reported not having Personal Protective Equipment (PPE) at their disposal, 48% (119) reported not receiving adequate information to protect their families, and 61% (149) did not receive clear diagnostic/therapeutic guidelines on COVID-19 to do their jobs.
Comparisons between GPs based on psychopathology scale results are reported in Table 1 .
Table 1.
Sociodemographic, clinical, and work-related characteristics of the general practitioners who scored above (clinically relevant symptoms) vs below the cutoff score for the PCL-5 (≥ 33), BDI-II (>13), and STAI Y1 (≥ 41). The mean (SD) or percentage, t-test or chi-square (χ2) test are listed.
| PCL-5 | BDI-II | STAI-Y1 | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Above cut-off (n = 79) |
Below cut-off (n = 167) |
Test (df) | Above cut-off (n = 91) |
Below cut-off (n = 155) |
Test (df) | Above cut-off (n = 185) |
Below cut-off (n = 61) |
Test (df) | |
| Sociodemographic and clinical data | |||||||||
| Age (years) | 49.8 (12.6) | 51.7 (13.3) | t(244) = 1.12 | 48.2 (13.0) | 52.8 (12.8) | t(244) = 2.73⁎⁎ | 49.80 (13.4) | 55.0 (11.3) | t(119.6) = 2.98⁎⁎ |
| Gender | χ2(1) = 0.21 | χ2(1) = 11.88⁎⁎ | χ2(1) = 7.52⁎⁎ | ||||||
| Female | 46 (58.2%) | 92 (55.1%) | 64 (70.3%) | 74 (47.7%) | 113 (61.1%) | 25 (41.0%) | |||
| Male | 33 (41.8%) | 75 (44.9%) | 27 (29.7%) | 81 (52.3%) | 72 (38.9%) | 36 (59.0%) | |||
| Children | χ2(1) = 2.37 | χ2(1) = 3.78 | χ2(1) = 0.88 | ||||||
| Yes | 45 (57.0%) | 112 (67.1%) | 51 (56.0%) | 106 (68.4%) | 115 (62.2%) | 42 (68.9%) | |||
| No | 34 (43.0%) | 55 (32.9%) | 40 (44.0%) | 49 (31.6%) | 70 (37.8%) | 19 (31.1%) | |||
| Medical diseases | χ2(1) = 1.70 | χ2 (1) = 0. 10 | χ2(1) = 0.47 | ||||||
| Yes | 20 (25.3%) | 56 (33.5%) | 27 (29.7%) | 49 (31.6%) | 55 (29.7%) | 21 (34.4%) | |||
| No | 59 (74.7%) | 111 (66.5%) | 64 (70.3%) | 106 (68.4%) | 130 (70.3%) | 40 (65.6%) | |||
| Work-related data | |||||||||
| Years of practice | 21.4 (13.3) | 23.2 (13.3) | t(244) = 1.02 | 19.8 (13.4) | 24.3 (13.0) | t(244) = 2.57* | 21.3 (13.5) | 26.6 (11.9) | t(114.3) = 2.90⁎⁎ |
| Number of patients | 1064.8 (567.9) | 1108.6 (585.6) | t(244) = 0.55 | 1029.4 (592.9) | 1032.8 (569.4) | t(244) = 1.35 | 1073.3 (582.9) | 1158.7 (567.6) | t(244) = 0.99 |
| Personal protective equipment | χ2(1) = 1.84 | χ2(1) = 1.16 | χ2(1) = 0.29 | ||||||
| Yes | 42 (53.2%) | 104 (62.3%) | 50 (54.9%) | 96 (61.9%) | 108 (58.4%) | 38 (62.3%) | |||
| No | 63 (46.8%) | 37 (37.7%) | 41 (45.1%) | 59 (38.1%) | 77 (41.6%) | 23 (37.7%) | |||
| Adequate information to protect family | χ2(1) = 8.13⁎⁎ | χ2(1) = 6.60⁎⁎ | χ2(1) = 10.59⁎⁎ | ||||||
| Yes | 31 (39.2%) | 98 (58.7%) | 38 (41.8%) | 91 (54.7%) | 86 (46.5%) | 43 (70.5%) | |||
| No | 48 (60.8%) | 69 (41.3%) | 53 (58.2%) | 64 (41.3%) | 99 (53.5%) | 18 (29.5%) | |||
| Guidelines on COVID-19 management | χ2(1) = 3.99* | χ2(1) = 8.65⁎⁎ | χ2(1) = 4.40* | ||||||
| Yes | 24 (30.4%) | 73 (43.7%) | 25 (27.5%) | 72 (46.5%) | 66 (35.7%) | 31 (50.8%) | |||
| No | 55 (69.6%) | 94 (56.3%) | 66 (72.5%) | 83 (53.5%) | 119 (64.3%) | 30 (49.2%) | |||
SD = Standard deviation; df = Degrees of freedom; PCL-5 = PTSD Checklist for DSM-5; BDI-II = Beck Depression Inventory; STAI Y1 = State-Trait Anxiety Inventory Form Y1.
* p<0.05; ** p<0.01.
GPs with clinically relevant anxiety and depressive symptoms were younger, more likely to be female, and had been practicing for fewer years, than GPs without anxiety/depression symptoms.
Moreover, GPs that showed clinically relevant PTSS in addition to anxiety and depression, are the ones that have reported in significantly higher percentage that they have not received adequate information to protect their families and clear diagnostic/therapeutic guidelines on COVID-19 to do their jobs.
The results of the present study highlight that an extremely high percentage of GPs experienced clinically relevant anxiety and depressive symptoms, as well as significant PTSS, because of the SARS-CoV-2 pandemic.
GPs who were female, younger, and less experienced showed significantly higher levels of anxiety and depressive symptoms compared to male, older, and more experienced GPs. This evidence confirmed the data in the general health care population (Kisely et al., 2020). Conversely, no significant differences on the levels of psychopathological symptoms were found between GPs who had or not a medical condition and between GPs who had or not children. As regards to the medical condition, we think that this is due to the extreme variability of the medical conditions reported by the participants. Further studies with larger sample should investigate this issue. As regards to the children variable, we can hypothesize that our negative evidence can be due to the relatively small sample size; indeed, our results showed a higher presence of psychopathology in GPs with children with respect to GPs without children (see Table 1) even if this difference is not statistically significant. An extremely low percentage of GPs (39%) received clear guidelines on COVID-19 management, confirming the results from a sample of GPs from Lombardy, a region near Piedmont (Fiorino et al., 2020). In addition, high percentages of GPs, 41% and 48%, had not received either PPE or clear information on how to avoid infecting their families, respectively. Despite those results, having or not having PPE was not found to be significantly associated with psychopathological symptoms in our group of GPs. A possible explanation for this finding could rely on the containment measures that have been carried out in order to reduce the contacts between GPs and patients (e.g., online prescriptions).
Conversely, our results provide evidence that clear guidelines on COVID-19 management are a key unmet need (Thornton, 2020). In fact, the less GPs are informed about how to protect their families and adequately manage their patients, the more they experience psychopathological symptoms. In addition, since significant PTSS can result in post-traumatic stress disorder beyond the immediate situation, it is essential to develop timely screening programs to identify GPs at risk.
These results highlight that GPs are forced to perform their job in incredibly stressful conditions, such as working without clear guidelines and, in many cases, without adequate PPE. This is reflected in clinically relevant psychopathology.
Health care providers should deploy clear and shared guidelines on COVID-19 management in order to reduce the psychological impact of this pandemic on GPs. Additionally, they should implement a psychological screening program to identify GPs at risk and, eventually, refer them to psychological treatment.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Lorys Castelli: Conceptualization, Writing - original draft, Writing - review & editing. Marialaura Di Tella: Data curation, Formal analysis, Writing - review & editing. Agata Benfante: Data curation, Writing - review & editing. Alessandra Taraschi: Conceptualization, Investigation, Writing - review & editing. Gabriele Bonagura: Investigation, Writing - review & editing. Andrea Pizzini: Investigation, Writing - review & editing. Annunziata Romeo: Conceptualization, Formal analysis, Writing - review & editing.
Declaration of Competing Interest
All authors declare no conflict of interest.
Acknowledgement
The authors would like to thank the participants involved in the study and Editage Services for English editing.
References
- de Sutter A., Llor C., Maier M., Mallen C., Tatsioni A., van Weert H., Windak A., Stoffers J. Family medicine in times of “COVID-19”: a generalists' voice. Eur. J. Gen. Pract. 2020;26:58–60. doi: 10.1080/13814788.2020.1757312. [DOI] [PMC free article] [PubMed] [Google Scholar]
- FNOMCeO, 2020, Federazione Nazionale degli Ordini dei Medici Chirurghi e degli Odontoiatri. https://portale.fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19/ (accessed 20 May 2020). [PubMed]
- Fiorino G., Colombo M., Natale C., Azzolini E., Lagioia M., Danese S. Clinician education, and adoption of preventive measures for COVID-19: a survey of a convenience sample of general practitioners in Lombardy, Italy. Ann. Intern. Med. 2020 doi: 10.7326/M20-1447. M20–1447. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kisely S., Warren N., McMahon L., Dalais C., Henry I., Siskind D. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ. 2020;369:m1642. doi: 10.1136/bmj.m1642. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Shanafelt T., Ripp J., Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323:2133–2134. doi: 10.1001/jama.2020.5893. [DOI] [PubMed] [Google Scholar]
- Thornton J. Covid-19: how coronavirus will change the face of general practice forever. BMJ. 2020;368:m1279. doi: 10.1136/bmj.m1279. [DOI] [PubMed] [Google Scholar]