Abstract

Introduction

A novel coronavirus, named SARS-CoV2, emerging from Wuhan, China, has led to a fast spread outbreak of COVID-19 pneumonia. World health organization has declared COVID-19 as a public health emergency of international concern [1]. By April 26th, 2020, four months after outbreak, more than 2,800,000 confirmed cases and almost 200,000 deaths due to SARS-CoV-2 have been reported [2].

Major epidemic outbreaks pose an increasing demand for healthcare workers [3]. Constant increasing of infected cases, a rise in the rate of deaths, lack of any specific medicine or vaccine, extensive media coverage, massive workload, lack of personal protective equipment, and feelings of inadequate support all can contribute to the mental burden of these health care staff [4]. In these situations, it is expected of HCWs to work long hours while they are under overwhelming pressure. They are at the risk of being infected when treating ill patients. On the other hand, like other individuals, they are exposed to a considerable amount of fake news and rumors all of which increase their anxiety [5]. Reports indicated that several HCWs became infected with SARS-CoV-2 when they were in close contact with infected patients [6]. In the initial phase of the SARS-CoV-2 outbreak, 29% of all hospitalized patients were HCWs [7]. Working in these situations develops the risk of various psychological and mental illnesses as well as physical and emotional distress among medical staff [4, 6].

Research conducted on other infectious diseases, such as severe acute respiratory syndrome (SARS), the Middle East Respiratory Syndrome (MERS) and the Ebola virus, revealed that a considerable number of HCWs suffer from significant emotional distress during the outbreak [8]. A study by assessing 1257 health workers treated SARS-infected patients found that given the fast dissemination of infection in the early stage of the epidemic, feeling of uncertainty, the threat to life, and significant vulnerability characterized by somatic and cognitive symptoms of anxiety were prevalent [9]. On the other hand, even after the outbreak, symptoms, including depression, anxiety, traumatic stress, avoidance, and burnout were reported [8, 9]. While the results of adverse psychological effects of SARS were documented, infected patients of SARS-CoV-2 and related deaths have been several times that of SARS [7]. Some people have been comparing the current situation of rapidly spreading SARS-CoV-2 to “the end of the world.” Hospitals are “overwhelmed,” and there are many concerns about people’s daily lives [10]. This situational framework in all over the world can potentially put healthcare workers in an unprecedented situation, working under severe pressures [10, 11]. Healthcare workers, as a result, are susceptible to experience psychological and mental problems. Thus, in this critical situation the medical staff’ mental health should be considered an urgent public health concern [7].

Given the insights acquired from the previous global outbreaks and their psychosocial impacts, early assessment of medical staff’s mental health and considering appropriate psychological interventions is vital [12, 13]. Accordingly, considering comprehensive and practical actions to protect health care workers’ mental health are critical [14]. Up to now, few studies have evaluated the mental health of health care workers dealing with COVID-19 patients. Hence, this study designed to investigate the articles addressing the status of HCWs’ mental health during the SARS-CoV-2 outbreak. Moreover, several psychological interventions are provided to improve the overall mental health of this target group.

Methods

This review was presented based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [15].

Results

One hundred relevant articles identified through systematic search of four electronic databases including PubMed (n=21), EMBASE (n=28), Scopus (n=34), and WoS (n=17). Additionally, Google Scholar and references of the included studies were reviewed manually. After excluding 37 duplicated studies, the remained titles and abstracts were assessed, of which eleven studies were eligible for this review; seven articles were found through systematic search and four preprint articles were added manually (Fig. 1). The eligible articles had a mean NHLBI Quality assessment score of 11.81/14 (10–13/14). The study characteristics, outcome characteristics, findings, and quality score of all selected papers are shown in Table ​Table22.

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Fig. 1

PRISMA diagram for searching resources

Table 2

The psychological outcomes of the included studies (based on severity, sex, and population)

#	Study characteristics		Outcome characteristics				Findings				QS (0–14)
	Study [ref] Country	Population/ sample size	Type of mental health	Measurements tool (range of score)	Definition of outcome	Measure	Total	By severity of outcome	By sex	By population
1	Lai et al. [4] China	Medical staff T: 1257 P: 493 (39.22%) N: 764 (60.77%)	Depression Anxiety Insomnia Distress	PHQ-9 (0–27) GAD-7 (0–21) ISI-7 (0–28) IE-22 (0–88)	PHQ-9, normal (0–4), mild (5–9), mod (10–14), severe (15–21) GAD-7, normal (0–4), mild (5–9), mod (10–14), severe (15–21) ISI, normal(0–7), sub (8–14), mod (15–21), severe (22–28) IES-R, normal (0–8),mild (9–25), mod (26–43), severe (44–88)	Prevalence (%)	Depression 50.4% Anxiety 44.6% Insomnia 34.0% Distress 71.5%	Depression Mild: 35.6% Mod: 8.6% Severe: 6.2% Anxiety Mild: 32.3% Mod: 7.0% Severe: 5.3% Insomnia Subthreshold: 26.2% Mod: 6.8% Severe: 1.0% Distress Mild: 36.5% Mod: 24.5% Severe: 10.5%	Depression M: 41.7% F: 53.2% Anxiety M: 35.5% F: 47.4% Insomnia M: 29.1% F: 35.5% Distress M: 58.4% F: 75.6%	Depression N: 53.5% P: 45.6% Anxiety N: 47.1% P: 40.6% Insomnia N: 38.2% P: 27.4% Distress N: 74.5% P: 66.9%	13
2	Kang et al. [14] China	Medical staff T: 994 P: 183 N: 811	Mental health disturbances	PHQ-9 (0–27) GAD-7 (0–21) ISI-7 (0–28) IE-22 (0–88)	According to these four questionnaires by Ward method and using cluster analysis	Prevalence (%)	63%	Mild 34.4% Mod 22.4% Severe 6.2%	M: 56.9% F: 64.1%	N: 64.11% P: 58.46%	11
3	Lu et al. [18] China	Medical staff P+N: 2042 Administrative staff: 257	Fear Anxiety Depression	NRS (0–10) HAMA (0–70) HAMD (0–85)	Fear scale, 0–3 (no/mild) 4–6 (moderate) 7–10 (severe/extreme) HAMA, 0–6 (no) 7–13 (mild/moderate) ≥14 (severe/extreme) HAMD, 0–6 (no) 7–23 (mild/moderate) ≥24 (severe/extreme)	Prevalence (%)	Fear 70.6% Anxiety 25.5% Depression 12.1%	Fear no/mild: 29.4% Mod: 43.9% severe/extreme: 26.7% Anxiety mild/mod: 22.6% severe/extreme: 2.9% Depression no: 87.9% mild/moderate: 11.8% severe/extreme: 0.3%	NR	Fear Medical staff: 70.6% Administrative staff: 58.4% Anxiety Medical staff: 25.5% Administrative staff: 20% Depression Medical staff: 12.1% Administrative staff: 8.2%	12
4	Liang et al. [23] China	Medical staff T: 59 COVID-19 department’s staff: 38 Other department’s staff: 21	Anxiety Depression	SDS SAS	NA	Mean score±SD	SDS 30.23±7.98 SAS 28.34±5.16	NR	NR	SDS COVID-19 department’s staff: 29.61±8.02 Other department’s staff: 31.36±7.92 SAS COVID-19 department’s staff: 27.88±5.32 Other department’s staff: 29.20±4.52	11
5	Xiao et al. [6] China	Medical staff T: 180	Anxiety Self-efficacy Stress Sleep quality Social support	SSRS (7–56) SAS (0–80) GSES (10–40) SASR (0–150) PSQI (0–21)	NA	Mean score±SD	SSRS 34.172±10.263 GSES 2.267±0.767 SAS 55.256±14.183 SASR 77.589±29.525 PSQI 8.583±4.567	NR	NR	NR	12
6	Li et al. [12] China	Medical staff T: 740 GP: 214 FLN: 234nFLN: 292	Vicarious trauma	38–190	NA	Median (25th–75th)		NR	NR	GP 75.5 (62–88.3) FLNs 64 (52–75) nFLNs 75.5 (63–92)	10
7	Mo et al. [19] China	Nurse N: 180	Anxiety Stress	SOS (22–110) SAS (20–80)	NA	Mean score±SD	SOS 39.91±12.92 SAS 32.19±7.56	NR	NR	NR	13
8	Dai et al. [20] China	Medical staff T: 4357 N: 2343 (53.77%) P: 1419 (32.56%) Technician: 437 (10%) Support staff: 158 (3.6%)	Psychological distress	GHQ-12 (0–12)	GHQ≥3	Prevalence (%)	39.1%	NR	M: 32.2% F: 41.2%	P: 39% N: 41.3% Technician: 30.7% Support staff: 30.4%	12
9	Zhu et al. [7] China	Medical staff T: 5062 P: 1004 N: 3417 Technician: 641	Stress Depression Anxiety	PHQ-9 GAD-7 IES-R	PHQ-9≥10 GAD-7≥8 IES-R> 33	Prevalence (%)	Stress 29.8% Depression 13.5% Anxiety 24.1%	NR	Depression M: 71 (9/36%) F: 610 (14.17%) Anxiety M: 137 (18.07%) F: 1081 (25.11%) Psychological stress M: 153 (20.18%) F: 1356 (31.5%)	Depression P: 11.35% N: 14.31% Technician: 12.16% Anxiety P: 23.1% N: 25.25% Technician: 19.18% Psychological stress P: 24.2% N: 33.06% Technician: 21.21%	13
10	Simione and Gnagnarella [22] Italy	T: 353 GP: 186 Medical staff: 167	Stress Anxiety Existential concerns Socially desirable manner COVID-19-related experience and personal opinion	PSS (4–20) STAI (6–24) ECQ (5–20) M&C (9–54)	NA	Mean score	ECQ 8.92 PSS 6.58 STAI 14.06	NR	NR	ECQ Med: 9.05 GP: 8.81 PSS Med: 6.62 GP: 6.55 STAI Med: 14.08 GP: 14.06	11
11	Odriozola-González et al. [21] Spain	T: 3550 GP: 3204 (90.3) Med: 346 (9.7%)	-the 21-item version of the Depression Anxiety Stress Scales -the Impact of EventScale (IES)	DASS-21 (0–63) IES (0–75)	NA	Mean score±SD	Depression 5.06±4.76 Anxiety 3.15±3.76 Stress 6.50±4.69	NR	NR	NR	12
						Prevalence (%)	Depression 55.89% Anxiety 67.55% Stress 62.99%

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QS: Quality score; T: Total; P: Physician; N: Nurse; FLN: Front-line nurses; nFLNs: Non-front-line nurses; GP: General public; Med: Medical staff; mod: Moderate; sub: Subthreshold; NA: Not applicable; NR: Not reported; *: not peer-reviewed; SD: Standard deviation; PHQ-9: The 9-item Patient Health Questionnaire; GAD-7: The 7-item Generalized Anxiety Disorder scale; ISI-7: The 7-item Insomnia Severity Index; IE-22: The 22-item Impact of Event Scale–Revised; NRS: The numeric rating scale on fear; HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale; SDS: Self-rating depression scale; SAS: Self-rating anxiety scale; GSES: The General Self-Efficacy Scale; SASR: The Stanford Acute Stress Reaction questionnaire; PSQI: The Pittsburgh Sleep Quality Index; SSRS: The Social Support Rate Scale; GHQ: General Health Questionnaire; PSS: The 4-item Perceived Stress Scale; STAI: The 6-item version of State-Trait Anxiety Inventory; ECQ: The death anxiety scale of the Existential Concerns Questionnaire; M&C: The Marlowe & Crowne social desirability scale; DASS-21: Depression Anxiety Stress Scale

The characteristics of the included studies showed that most of the studies exclusively evaluated the psychological status of HCWs under SARS-CoV-2 pandemic. Three studies address both general populations and HCWs. Nurses composed the main proportion of medical staff evaluated in these studies. Moreover, most of the respondents in all studies were female. Nine studies were performed in China as the first country struggling with SARS-CoV-2. Italy and Spain were the other settings that assessed the mental health of HCWs.

The most studied outcomes were anxiety (9 /11) followed by depression (6/11), stress (5/11), insomnia (2/11), and distress (4/11). Furthermore, fear, self-efficacy, sleep quality, risk perception, death anxiety, social desirability, and social support, separately were the main outcome in one study (Table ​(Table22).

The prevalence of anxiety reported by health care workers in included studies varied from 24.1% [7], 25.5% [18], to 44.6% [4]. In another study, the total anxiety score was 32.19±7.56 points, which was significantly higher than the standard of national points (29.78+0.46), (t=4.27, p<0.001). This study also revealed that anxiety positively correlated with total stress load score and all its dimensions [19].

In various studies, 12.1% [18], 13.5% [7], and 50.4% [4] of HCWs expressed degrees of moderate and severe depression. Moreover, stress was a prevalent mental problem in HCWs. In a study by Zhu et al. 29.8% of HCWs reported stress [7]. The overall prevalence of psychological disturbance in HCWs was high. In a study that assessed anxiety, stress, depression, and insomnia, 63% of health care workers reported mental disturbance [14]. Also, in the study conducted by Dai et al. 39.1% of respondents reported GHQ-12 score≥3, which was significantly higher than normal times [20]. The lowest reported prevalence of anxiety, depression, and stress among HCEs was 24.1% [7], 12.1% [18], and 29.8% [7], respectively. On the other hand, the highest reported prevalence of these problems was attributed to Spain, where 67.55%, 55.89%, and 62.99% of HCWs expressed anxiety, depression, and stress, respectively [21]. (Table ​(Table22).

Not surprisingly, a noticeable percentage of medical staff suffered from sleep disturbance and low sleep quality [6]. In one study, 34.0% of respondents complained of insomnia [4]. Anxiety, stress, and self-efficacy as mediating variables were associated with sleep quality and social support. Sleep quality was negatively affected by the levels of anxiety [6]. On the other hand, social support of HCWs was positively associated with self-efficacy and sleep quality and negatively associated with anxiety and stress [6]. Fear was also a psychological problem assessed in a study by Lu et al. [18]. A significant proportion of medical staff experienced moderate and severe fear that was significantly higher than the administrative staff group, 70.6% and 58.4%, respectively [18]. Li et al. [12] with comparing three groups; general public, front-line nurses and non-front-line nurses, found that the severity of vicarious traumatization caused by the SARS-CoV-2 pandemic in non-front-line nurses and the general public was higher than that of the front-line nurses who were responsible for close care for COVID-19 patients. The fact that people in Wuhan were in guarantee and were deprived of face to face contact with others was the possible reason for this finding [12].

These studies showed that various factors were associated with mental pressures experienced by the HCWs. Working in areas with a high incidence of infection was significantly associated with higher stress and psychological disturbance. These results were more highlighted when HCWs worked in Wuhan which is supposed to be the origin of SARS-CoV-2 infection with the highest concentration of infected cases in China. HCWs in these areas expressed higher mental disturbance than those in other regions [4, 20]. Also, medical staff working in North Italy with the highest number of patients reported higher levels of anxiety and stress than HCWs or the general public from other regions of Italy [22].

Moreover, nurses [4], women [4, 7, 20], front-line health care workers [4], and younger medical staff [23] reported more severe degrees of all psychological symptoms except the vicarious traumatization than other health care workers. Also, being the only child in their families, the severity of patients, working hours per week, diet, and sleep status influenced HCWs’ stress [19].

Discussion

In March 2020, SARS-CoV-2 was declared as a pandemic by the WHO, while more than 200 countries are currently struggling with this infectious disease [24]. This poses a tremendous pressure on the HCWs [25].

During the viral epidemics, the mental health of HCWs confronts serious challenges [7]. HCWs face the death of their colleagues and threats to their lives. Moreover, the fear of becoming infected, the absence of an effective social support system, and the high workload all increase mental disorders [26]. However, few studies have addressed the psychiatric morbidity and mental health problems of HCWs during the SARS-CoV-2 pandemic. Based on data retrieved from included studies, a substantial proportion of the analyzed sample showed degrees of psychological symptoms.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a member of the coronaviruses family that can lead to a common cold to a Severe Acute Respiratory Syndrome (SARS) and the Middle East Respiratory Syndrome (MERS) diseases [27]. Reports of these infections’ acute psychological impact on hospital workers, indicated that high levels of distress, depression, anxiety, fear, and frustration were common [13, 28]. One of the best-documented outbreaks occurred over the last decade was the SARS outbreak as an emerging infectious disease, observed first in China in 2002 and then spread to 29 countries [29]. A study found that 89% of health care workers during this outbreak reported psychological disorders [4]. Also, in another study assessed the psychological impact of SARS, the prevalence of anxiety and worries, depression, somatic symptoms, and sleep problems in HCWs were 77.4%, 74.2%, 69.0%, and 52.3%, respectively [9]. Tam et al. (2004) [30] using the GHQ-12 questionnaire, found that 57% of medical staff suffered from psychological distress due to SARS outbreak. Similarly, in initial stages of the MERS outbreak, HCWs showed higher distress when measured by the Impact of Event Scale-Revised (IES-R) [8]. Although these results indicated the high-risk of psychological problems in HCWs, our results found the lower prevalence of mental health problems in HCWs dealing with SARS-CoV-2 patients. This could be the result of the lower fatality rate of SARS-CoV-2 compared to SARS and MERS.

A global pandemic can be a significant source of fear and concern [31]. During the SARS epidemic, HCWs reported anxiety and fear and some preferred to resign from their jobs [32]. Compared to the year of 2003, these days the fast spread of news might cause public fear, panic, and distress [7]. Health fear is created in the result of circumstances in which HCWs care of patients with contagious diseases, including SARS, MERS, and SARS-CoV-2. They are not only responsible for their patients but also are concerned of becoming infected and also transmitted the disease to their family members [32]. During the SARS outbreak, quarantined HCWs experienced fear, stigma, and frustration [33]. Isolation and working in high-risk departments and contact with infected people were considered the most causes of trauma [14]. Consistent with these findings, a considerable proportion of HCWs in this study reported fear (70.6%) [18]. Furthermore, studies have demonstrated that HCWs experienced emotional disturbance during the MERS outbreak. Medical staff suffered from the anxiety and nervousness, though at varying degrees [34]. The fact of human to human transmission of the SARS-CoV-2 infection and the presence of infected asymptomatic people are the common sources of anxiety and fear in HCWs [5].

These studies also found that mental disturbances were more common in nurses compared to the physicians. Nurses in SARS-affected hospitals also showed more distress than other hospital workforce [28]. Nurses are the largest occupational groups that directly and intensively are in constant contact with their patients [28]. Working in high-risk departments was another main reason of poor mental health in these studies. Being at the high-risk of contagion in such environments will increase the psychological problems, including fear, anxiety, stress, etc. furthermore, being quarantined as a result of working in high-risk wards was another source of mental disorders [29]. In a study conducted by Maunder et al. in Toronto, HCWs who during SARS outbreak worked in close contact with ill patients showed higher total IES score compared to the other medical staff [28]. The higher rate of psychiatric morbidities in HCWs in the result of SARS was three times higher than the general public, 75.3% and 24%, respectively [9].

HCWs as the frontiers in any outbreaks, suffer from mental distress during and even years after epidemics. These results were evident from the Ebola virus and SARS outbreak [34]. Similar concerns now have been voiced out about the psychological well-being of HCWs in facing the SARS-CoV-2 outbreak [4]. The number of COVID-19 patients is increasing dramatically. This leads to a heavier workload in life-threatening situations disturbing the psychological health of hospitals’ workforces [18]. Given the high transmission rate of the virus and the lack of any vaccine or medicine, infection’s control is a serious challenge [35]. High morbidity and mortality of SARS-CoV-2 can aggravate the risk perception in HCWs. Furthermore, the increasing number of patients and the shortages of protective equipment contribute to the high pressure on health care workers [4].

Conclusions

Consistent with Chong et al. (2004) that called SARS as a bio-disaster, we also suppose that the SARS-CoV-2 pandemic can be called a bio-disaster [9]. While outbreaks of emerging infectious diseases occur regularly, they provoke an intense response of medical staff. During the outbreaks, thousands of HCWs should fight with the disease in the front-line. The results of this study revealed that a considerable percentage of medical staff experience mental disorders. Now, we are in the midst of this pandemic. Addressing the psychological well-being of HCWs and also considering approaches to improve their mental health is essential.

Limitation

The limitation of this study is its small sample size. Furthermore, we excluded possible articles published in Chinese due to language strain.

Authors’ contributions

M.V. and M.E. significantly contributed to the study conception, literature searching, screening, and data extraction. M.Q. and S.M.A. considerably contributed to data extraction and analyzing them. Also, the methodology was examined and approved by all authors. The first draft of the manuscript was written by M.V., M.E., S.M., and Z.J.. Finally, all authors critically revised the final manuscript and approved it.

Data availability

Not applicable.

Compliance with ethical standards

Footnotes

Contributor Information

Maryam Vizheh, Email: moc.oohay@hehzivmayram.

Mostafa Qorbani, Email: moc.oohay@9731inabroqm.

Seyed Masoud Arzaghi, Email: [email protected].

Salut Muhidin, Email: [email protected].

Zohreh Javanmard, Email: [email protected].

Marzieh Esmaeili, Email: [email protected].

References