Damian Sendler, M.D. An epidemic or pandemic can have a significant impact on the mental health of healthcare workers (HCWs). As the number of infectious diseases continues to rise, it is important to review and synthesize the evidence on the psychological impact of disease outbreaks on health care workers (HCWs). It was thus necessary to conduct research on how epidemics and pandemic affect the mental health of health care workers (HCWs).
Damian Jacob Sendler: This review included a total of 76 studies. Some 34 (45%), 28 (37%), seven (9%), four (5), and one (1%) focused on SARS, COVID-19, MERS, H1N1 influenza, and Ebola, respectively. The vast majority of studies (93 percent) were cross-sectional and conducted in a hospital environment (95 percent ). Anxiety, depression, insomnia, burnout and post-traumatic stress disorder (PTSD) were the most common mental health symptoms found in this review. Being female, a nurse, and working in a high-risk environment (frontline) were all associated with an increased risk of contracting the virus. Other risk factors included a lack of appropriate PPE, working longer shifts without adequate knowledge of the virus, and having less experience in the healthcare field.
Dr. Sendler: Population growth, global interconnectedness, microbial adaptation and change, economic development, land use changes and climate change have all contributed to an increase in disease outbreaks over the last century [1]. SARS in 2003, Influenza A virus subtype H1N1 in 2009, Middle East respiratory syndrome coronavirus (MERS-COV) in 2012, Ebola virus disease (EVD) in 2014, influenza A virus subtype H7N9 in December 2019, and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019 have all caused epidemics in the past two decades.
Shocking rises in mortality and morbidity from epidemics put additional strain on already overburdened healthcare systems [3]. There has been a dramatic decrease in the number of healthcare workers (HCW) to patients, which has led to an increase in workload. Health care workers (HCWs) are overworked and underrested as a result of the long hours they work and the additional night shifts they may be required to work. Mental health symptoms may persist even after the epidemic has ended for those who work on the front lines, diagnosing, managing, and caring for sick patients [4].
The massive influx of patients causes healthcare systems to become overwhelmed, resulting in ethical dilemmas over the distribution of essential healthcare and medical supplies. Every day, health care workers (HCWs) face “life or death” decisions, such as which patients should be admitted into intensive care and when to turn off life support [5]. When more people die, healthcare workers (HCWs) have to break bad news in ways they are not used to, such as over the phone, which can be distressing [6]. It’s difficult to deal with the news that the number of confirmed cases and deaths keeps on rising.
Personal protective equipment (PPE) shortages may increase the risk and fear of contagious disease [7]. This period is marked by an elevated level of anxiety and fear among health care workers, which is exacerbated when one of their colleagues is infected or dies [8]. They are afraid of spreading the infection to their loved ones and of being stigmatized and discriminated against in their communities as a result of their concerns about spreading the infection. Discrimination against people with disabilities may result in physical violence, harassment, and even eviction from their homes by their landlords [9]. HCWs’ already high levels of work-related stress are exacerbated further by social exclusion [10].
Negative psychological factors not only affect HCWs but also reduce their ability to fight epidemics, which in turn affects the entire population. Research on how epidemics and pandemics affect healthcare workers’ mental health will be compiled in this systematic review, which will serve as a guide and source of best practices for policies aimed at providing psychological support and mental health interventions to HCWs. There have been similar systematic reviews in the recent past [11–16], but they were either limited to a single pandemic [11] (e.g., SARS) or a single study [13–16] and only included one study from a low- and middle-income country (i.e. Covid-19) [12,13,16].
Increased working time per week [35], frequent changes in infection control measures/protocols [79], and seeing a coworker getting sick/intubated/dead increased stress [57], while those who received adequate social support were least likely to have posttraumatic stress disorder [90]. High levels of PTSD were found in those who had been quarantined during the outbreak [4,62,83]. Stress levels were significantly reduced when PPE was readily available [38,49,90].
Damian Sendler
Across all virus exposures, the prevalence of anxiety ranged from 7% to 78%. According to a total of nine studies, health care workers (HCWs) who had been exposed to confirmed cases reported higher levels of anxiety than those who had not been exposed to confirmed cases. Worrying that you might infect your family members is one of the most common causes of anxiety. Compared to doctors, nurses reported higher levels of anxiety [27,30,35,37,38,50,88]. Study after study found that women in the healthcare field were more likely than men to suffer from anxiety. HCWs in Wuhan, which was the epicenter of COVID-19 at the time, had significantly higher levels of anxiety compared to HCWs in other regions of China [30,33]. HCWs in Toronto who had more contact with SARS patients reported higher levels of burnout and distress than HCWs in Hamilton who had fewer confirmed cases [73]. When a coworker fell ill or died, the level of anxiety and fear skyrocketed. Health care workers’ resilience and social support were found to be negatively correlated with their own stress levels and the fear of infection they felt during their shifts on duty [26,28]. Anxiety levels were found to be positively correlated with the number of hours worked during a disease outbreak [27,35]. Anxiety was also linked to a lack of knowledge of the virus [59].
Between 8.9% and 74.2 percent of people reported having depression at some point during the study period. There were five studies that found that females were more likely to suffer from depression than males. Frontline medical staff in the emergency, intensive care, and infectious disease units were twice as likely to be depressed as non-clinical staff to suffer from depression [30,34,44]. There was a higher rate of depression among SARS nurses compared to their counterparts in non-SARS units. As the COVID-19 pandemic swept through Wuhan, health care workers in that city suffered higher rates of depression than those working elsewhere in Hubei province [26,30]. [27,35] Longer working hours were linked to an increased risk of depression and hopelessness. Before the epidemic, those who had been exposed to trauma or had a psychiatric disorder were more likely to suffer from depression. Depressive symptoms were more common in HCWs who had no marital status than in those who did [46,62]. There was a link between higher levels of depression and a history of quarantine [62]. Lower levels of depression were associated with greater levels of support from family and friends [26,28,34], as well as psychological preparedness, altruistic acceptance, and the perception of the pandemic’s effectiveness.
In all 11 studies, between 26 and 45 percent of participants reported significant sleep disturbances. Depression and anxiety were found to be linked to insomnia [23,42]. Compared to second line workers, front-line HCWs reported higher levels of insomnia symptoms in three studies [30,36,37,42]. SARS nurses were more likely to suffer from insomnia than non-SARS nurses [97]. Compared to their counterparts in other parts of Hubei Province, healthcare workers in Wuhan reported more cases of insomnia [30].
Damian Jacob Markiewicz Sendler: Emotional exhaustion was more common among HCWs who worked in the frontline or had direct contact with confirmed cases [70,72,73,88], while one study found that front-line HCWs had lower levels of burnout compared to other HCWs. [70,72,73]. As a result of receiving timely and accurate information, front-line HCWs reported feeling more in control of their situation, according to the researchers [43]. HCWs who had spent more time in quarantine were found to have higher levels of burnout in two studies [70, 71]. Emotional exhaustion was directly linked to lower levels of organizational support, job stress, and poor hospital resources [58,70,72]. Self-efficacy, resilience, and family support were all found to be negative predictors of burnout [28]. Burnout was predicted by high anxiety scores [88].
Damian Jacob Sendler
Stigma affected 20% to 49% of health care providers. Stigmata was more prevalent among health care workers who had direct contact with confirmed cases and those who had been quarantined [76,92]. General practitioners were found to have more exposure to SARS patients and to suffer more stigma than Chinese traditional practitioners in a study comparing the two groups [92].
Several mental health symptoms, such as stress, depression, anxiety, insomnia, fear, stigma, and emotional exhaustion, were found to have a negative impact on the psychological well-being of healthcare workers (HCWs) during epidemics and pandemics.
This study identified common risk factors for developing mental health issues. When compared to non-frontline HCWs working in low-risk environments, frontline workers who were exposed to cases of SARS and COVID 19 reported more psychological symptoms. As a result of increased anxiety, stress, insomnia, and depression that comes from working with infectious patients, stigmatization, and isolation [34,54,72,88], those who work in such environments are more likely to suffer from these symptoms themselves [34,54,72,88]. If this is the case, it may explain why nurses were found to be more anxious, depressed, and stressed out than doctors. Nursing has a higher workload and spends more time in direct contact with patients while caring for them, according to most studies.
Recurrence of mental illness is more likely in those who have previously been exposed to trauma before a t outbreak [62,95]. Another risk factor for mental health symptoms was high perceived risk of infection and low self-efficacy [49,56,62,74]. In comparison to HCWs who were more confident and resilient [28,77], those who were less confident in their ability to contain the outbreak [49,56,62,74,87] showed signs of depression and a poor mental state. Low self-efficacy was linked to a lack of knowledge of the virus and outbreak management training Self-efficacy was also reduced and stress levels increased as a result of the constant changes in infection control measures and documentation processes. Being quarantined has been linked to an increased likelihood of developing depressive and PTSD symptoms. The increased fear of death from the disease was blamed for this. Increased levels of fear and stress among healthcare workers were linked to the isolation and loneliness they felt during quarantine.
Cohort studies are needed to better understand the long-term effects of a pandemic or epidemic on the mental health of health care workers (HCWs) at various stages of an outbreak.
Damien Sendler: Future studies should investigate the potential impact of work and exposure on mental health. Even though numerous studies have shown that female health care workers are more likely to suffer from mental health issues, it is still unclear whether gender is the only factor at play or if other factors are interfering with the picture. As an example, the majority of the female HCWs were nurses, a profession known for its high rates of stress-related mental health issues. Other studies have shown that emergency room and intensive care unit staff are more likely to suffer from burnout, depression, and job stress than their counterparts in other parts of the hospital [98,99]. In order to determine the effects of a pandemic or epidemic on mental health, future studies must rule out these aspects.
A pandemic is more likely to have a negative impact on an elderly person or someone with a history of chronic medical conditions. Consequently, future research should focus on the link between these factors and mental health outcomes.
Studies that collected data through online platforms have been found to have higher rates of sampling and response bias [101]. Even though face-to-face data collection was not possible due to social distancing guidelines, we consider this method appropriate for the current studies.
HCWs may benefit from the many protective factors identified in this review, including adequate information about the pandemic and clear guidelines and training, social support, the availability of specialized medical equipment, adequate personal protective equipment, and adequate time off work.
