BACKGROUND
The COVID-19 pandemic is a persistent stressor for healthcare workers (HCWs) globally. Systematic reviews demonstrate that many HCWs reported heightened levels of anxiety and depressive symptoms during the initial stages of the pandemic.1,2 However, most studies used data from non-US health systems and may reflect systemic differences in COVID-19 response compared to the US health system (e.g., lockdown measures). Quantifying and identifying correlates of pandemic-related mental health burden among US HCWs can inform policy and intervention design as part of the national response to COVID-19-related distress among HCWs. This study assessed the prevalence and determinants of anxiety and depression risk among US HCWs during the COVID-19 pandemic.
METHODS
We used July 2021–May 2022 U.S. Census Bureau Household Pulse survey data, which included anxiety and depression screenings, demographic factors (sex, race, ethnicity, age, disability, COVID-19 vaccination status), and social determinants of health (living alone, marital status, having children, financial hardship, US region).3 We restricted the sample to HCW respondents (unweighted n=39,566). Healthcare workers were defined as those who worked in hospital, nursing, and residential healthcare facility, pharmacy, and ambulatory healthcare center settings. Anxiety symptoms were measured by the Generalized Anxiety Disorder-2 (GAD-2) instrument. Depressive symptoms were measured by the Patient Health Questionnaire-2 (PHQ-2) instrument. A GAD-2 score of 3 or greater was used to indicate being at risk for anxiety. A PHQ-2 score of 3 or greater was used to indicate being at risk for depression.
We conducted multivariable logistic regression models to identify factors associated with being at risk for anxiety and depression when controlling for other factors. To develop nationally representative estimates, we used jackknife replication weights. We interpreted p<0.05 as significant. All analyses were conducted using Stata 17.0 (StataCorp).
RESULTS
Using the weighted sample (n=9,566,489 HCWs), we estimated that 66.8% were at risk for anxiety and 54.2% were at risk for depression (Table 1). After controlling for other factors, HCWs had greater odds of anxiety risk when reporting having a little (OR=2.53, 95% CI: 2.27–2.81), somewhat (OR=3.60, 95% CI: 3.06–4.23), or very challenging time (OR=7.36, 95% CI: 5.68–9.54) paying their bills compared to those who reported no difficulties. Similarly, HCWs had greater odds of depression risk when reporting having a little (OR=2.67, 95% CI: 2.41–2.97), somewhat (OR=3.87, 95% CI: 3.30–4.54), or very challenging time (OR=7.81, 95% CI: 5.91–10.32) paying their bills compared to those who reported no difficulties. Female HCWs had greater odds of being at risk for anxiety (OR=1.68, 95% CI: 1.50–1.88) and depression (OR=1.60, 95% CI: 1.43–1.79) than male HCWs. HCWs that had at least one disability had greater odds of being at risk for anxiety (OR=2.86, 95% CI: 2.60–3.14) and depression (OR=3.10, 95% CI: 2.83–3.40). We also observed differences in the risk of anxiety or depression by race, age, marital status, and COVID-19 vaccination status (Table 2).
Table 1.
Sample characteristics (Weighted N = 9,566,489)a–b
| Characteristic | Unweighted n (%) | Weighted n (%) |
|---|---|---|
| At risk for anxiety | ||
| No | 13,901 (35.1) | 3,179,751 (33.2) |
| Yes | 25,665 (64.9) | 6,386,738 (66.8) |
| At risk for depression | ||
| No | 12,512 (31.6) | 4,379,908 (45.8) |
| Yes | 27,054 (68.4) | 5,186,581 (54.2) |
| Sex | ||
| Male | 9193 (23.2) | 2,652,633 (27.7) |
| Female | 30,373 (76.8) | 6,913,856 (72.3) |
| Race | ||
| White, alone | 32,688 (82.6) | 7,229,371 (75.6) |
| Black, alone | 3049 (7.7) | 1,189,379 (12.4) |
| Asian, alone | 2235 (5.7) | 673,655 (7.0) |
| Any other race alone, or race in combination | 1594 (4.0) | 474,084 (5.0) |
| Ethnicity | ||
| Not of Hispanic, Latino, or Spanish origin | 36,866 (93.2) | 8,497,681 (88.8) |
| Of Hispanic, Latino, or Spanish origin | 2700 (6.8) | 1,068,808 (11.1) |
| Age (in years) | ||
| 18–34 | 4268 (10.8) | 1,734,047 (18.1) |
| 35–50 | 15,579 (39.4) | 3,351,496 (35.0) |
| 51–64 | 11,723 (29.6) | 2,392,556 (25.0) |
| 65–74 | 4011 (10.1) | 751,697 (7.9) |
| 75 or older | 3985 (10.1) | 1,336,693 (14.0) |
| Marital status | ||
| Not married | 15,881 (40.1) | 3,935,941 (41.1) |
| Married | 23,685 (59.9) | 5,630,548 (58.9) |
| Lives alone | ||
| No | 33,498 (84.7) | 8,873,773 (92.8) |
| Yes | 6068 (15.3) | 692,716 (7.2) |
| Having children in household | ||
| None | 23,916 (60.5) | 5,606,590 (58.6) |
| Only children under 5 year old | 2657 (6.7) | 786,325 (8.2) |
| Only children aged between 5 and 11 years old | 3128 (7.9) | 764,517 (8.0) |
| Only children aged between 12 and 17 years old | 4847 (12.3) | 1,183,875 (12.4) |
| Children across multiple age groups | 5018 (12.7) | 1,225,182 (12.8) |
| Disability status | ||
| No disability | 18,811 (47.5) | 4,387,089 (45.9) |
| Has at least one disability | 20,755 (52.5) | 5,179,400 (54.1) |
| COVID-19 vaccination status | ||
| Yes | 37,230 (94.1) | 8,804,288 (92.0) |
| No | 2336 (5.9) | 762,201 (8.0) |
| Financial hardship | ||
| Not at all | 22,731 (57.5) | 4,718,942 (49.3) |
| A little bit | 9248 (23.4) | 2,495,654 (26.1) |
| Somewhat challenging | 4966 (12.6) | 1,458,901 (15.3) |
| Very challenging | 2621 (6.6) | 892,992 (9.3) |
| US region | ||
| Northeast | 6801 (17.2) | 1,835,746 (19.2) |
| South | 11,587 (29.3) | 3,408,240 (35.6) |
| Midwest | 9517 (24.1) | 2,319,678 (24.2) |
| West | 11,661 (29.5) | 2,002,825 (20.9) |
| Week | ||
| Jul 21–Aug 2, 2021 | 3218 (8.1) | 778,755 (8.1) |
| Aug 4–Aug 16, 2021 | 3570 (9.0) | 859,126 (9.0) |
| Aug 18–Aug 30, 2021 | 3623 (9.2) | 786,996 (8.2) |
| Sep 1–Sep 13, 2021 | 3336 (8.4) | 819,848 (8.6) |
| Sep 15–Sep 27, 2021 | 3043 (7.7) | 821,026 (8.6) |
| Sep 29–Oct 11, 2021 | 3002 (7.6) | 892,291 (9.3) |
| Dec 1–Dec 13, 2021 | 2952 (7.5) | 811,426 (8.5) |
| Dec 29, 2021–Jan 10, 2022 | 3570 (9.0) | 775,115 (8.1) |
| Jan 26–Feb 7, 2022 | 3632 (9.2) | 792,742 (8.3) |
| Mar 2–Mar 14, 2022 | 3869 (9.8) | 764,416 (8.0) |
| Mar 30–Apr 11, 2022 | 2932 (7.4) | 737,518 (7.7) |
| Apr 27–May 9, 2022 | 2819 (7.1) | 727,229 (7.6) |
Table 2.
Adjusted odds ratios for being at-risk for anxiety and depression among US healthcare professionals (Weighted n = 9,566,489)a–b
| Characteristic | At risk for anxiety OR (95% CI) |
p-value | At risk for depression OR (95% CI) |
p-value |
|---|---|---|---|---|
| Sex | ||||
| Male | Ref | --- | Ref | --- |
| Female | 1.68 (1.50–1.88) | <0.001 | 1.60 (1.43–1.79) | <0.001 |
| Race | ||||
| White, alone | Ref | --- | Ref | --- |
| Black, alone | 0.53 (0.45–0.64) | <0.001 | 0.58 (0.48–0.70) | <0.001 |
| Asian, alone | 0.68 (0.58–0.79) | <0.001 | 0.73 (0.63–0.85) | <0.001 |
| Any other race alone, or race in combination | 1.15 (0.93–1.43) | 0.199 | 1.23 (0.97–1.55) | 0.086 |
| Ethnicity | ||||
| Not of Hispanic, Latino, or Spanish origin | Ref | --- | Ref | --- |
| Of Hispanic, Latino, or Spanish origin | 0.87 (0.72–1.06) | 0.160 | 0.86 (0.71–1.05) | 0.143 |
| Age (in years) | ||||
| 18–34 | Ref | --- | Ref | --- |
| 35–50 | 0.67 (0.59–0.76) | <0.001 | 0.66 (0.59–0.75) | <0.001 |
| 51–64 | 0.37 (0.32–0.44) | <0.001 | 0.36 (0.31–0.42) | <0.001 |
| 65–74 | 0.23 (0.19–0.27) | <0.001 | 0.23 (0.19–0.27) | <0.001 |
| 75 or older | 0.73 (0.60–0.89) | 0.002 | 0.69 (0.57–0.84) | <0.001 |
| Marital status | ||||
| Not married | Ref | --- | Ref | --- |
| Married | 0.85 (0.77–0.94) | 0.003 | 0.81 (0.72–0.91) | <0.001 |
| Lives alone | ||||
| No | Ref | --- | Ref | --- |
| Yes | 0.90 (0.79–1.03) | 0.133 | 0.94 (0.79–1.10) | 0.421 |
| Having children in household | ||||
| None | Ref | --- | Ref | --- |
| Only children under 5 year old | 1.01 (0.82–1.25) | 0.937 | 0.93 (0.75–1.17) | 0.550 |
| Only children aged between 5 and 11 years old | 1.16 (0.95–1.41) | 0.143 | 1.12 (0.92–1.36) | 0.260 |
| Only children aged between 12 and 17 years old | 0.92 (0.79–1.08) | 0.303 | 0.86 (0.73–1.01) | 0.063 |
| Children across multiple age groups | 1.03 (0.89–1.19) | 0.732 | 0.98 (0.84–1.14) | 0.768 |
| Disability status | ||||
| No disability | Ref | --- | Ref | --- |
| Has at least one disability | 2.86 (2.60–3.14) | <0.001 | 3.10 (2.83–3.40) | <0.001 |
| COVID-19 vaccination status | ||||
| Yes | Ref | --- | Ref | --- |
| No | 0.46 (0.38–0.55) | <0.001 | 0.45 (0.37–0.54) | <0.001 |
| Financial hardship | ||||
| Not at all | Ref | --- | Ref | --- |
| A little bit | 2.53 (2.27–2.81) | <0.001 | 2.67 (2.41–2.97) | <0.001 |
| Somewhat challenging | 3.60 (3.06–4.23) | <0.001 | 3.87 (3.30–4.54) | <0.001 |
| Very challenging | 7.36 (5.68–9.54) | <0.001 | 7.81 (5.91–10.32) | <0.001 |
| US region | ||||
| Northeast | Ref | --- | Ref | --- |
| South | 0.91 (0.79–1.04) | 0.175 | 0.88 (0.75–1.02) | 0.091 |
| Midwest | 0.89 (0.77–1.02) | 0.085 | 0.84 (0.72–0.97) | 0.021 |
| West | 0.99 (0.84–1.16) | 0.882 | 0.98 (0.82–1.17) | 0.821 |
| Week | ||||
| Jul 21–Aug 2, 2021 | Ref | --- | Ref | --- |
| Aug 4–Aug 16, 2021 | 1.07 (0.90–1.27) | 0.459 | 1.05 (0.87–1.27) | 0.587 |
| Aug 18–Aug 30, 2021 | 1.17 (0.94–1.46) | 0.164 | 1.17 (0.96–1.44) | 0.121 |
| Sep 1–Sep 13, 2021 | 1.21 (1.01–1.44) | 0.037 | 1.20 (1.00–1.44) | 0.053 |
| Sep 15–Sep 27, 2021 | 1.21 (0.95–1.55) | 0.127 | 1.20 (0.95–1.52) | 0.128 |
| Sep 29–Oct 11, 2021 | 0.89 (0.73–1.10) | 0.270 | 0.93 (0.73–1.19) | 0.580 |
| Dec 1–Dec 13, 2021 | 1.06 (0.84–1.33) | 0.624 | 1.03 (0.82–1.29) | 0.801 |
| Dec 29, 2021–Jan 10, 2022 | 1.34 (1.12–1.60) | 0.002 | 1.42 (1.18–1.71) | <0.001 |
| Jan 26–Feb 7, 2022 | 1.01 (0.84–1.21) | 0.957 | 0.99 (0.81–1.20) | 0.882 |
| Mar 2–Mar 14, 2022 | 1.03 (0.84–1.25) | 0.805 | 1.09 (0.89–1.33) | 0.421 |
| Mar 30–Apr 11, 2022 | 0.85 (0.71–1.03) | 0.103 | 0.92 (0.75–1.12) | 0.397 |
| Apr 27–May 9, 2022 | 0.89 (0.74–1.09) | 0.259 | 0.92 (0.75–1.14) | 0.459 |
DISCUSSION
Our findings suggest that, during COVID-19, over half of US HCWs were at risk for anxiety or depression based on brief screeners, which exceeded estimates from non-US samples.1,2 These differences in prevalence rates may stem from variability in national responses to COVID-19 (e.g., speed of implementing social distancing requirements, acceptability of masking, and vaccine requirements) and overall sociopolitcal environment. Consistent with findings in the general population,4 factors associated with being at risk for anxiety or depression among HCWs included having financial hardship, younger age, and female sex. Additional efforts are needed to implement and evaluate interventions to improve mental health among US HCWs.5 Our findings suggest that interventions to reduce financial hardship and better support younger and female HCWs and those with disabilities may be needed.
Study limitations included self-report bias and limited information on HCW-specific variables (e.g., professional role, clinical setting, patient load)6 and COVID-19 rates and variants. Notwithstanding, this study offers nationally representative estimates of mental health burden among US HCWs during COVID-19 and identifies potential factors to inform future intervention design.
Acknowledgements
We would like to thank the peer reviewers and their comments that strengthened this manuscript.
Author Contribution
Conceptualization: Oliver T. Nguyen, Lisa J. Merlo, Katherine A. Meese, Amir Alishahi Tabriz, Kea Turner
Methodology: Oliver T. Nguyen, Lisa J. Merlo, Katherine A. Meese, Amir Alishahi Tabriz, Kea Turner
Formal analysis and investigation: Oliver T. Nguyen
Writing—original draft preparation: Oliver T. Nguyen
Writing—review and editing: Lisa J. Merlo, Katherine A. Meese, Amir Alishahi Tabriz, Kea Turner
Declarations
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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