|Year : 2022 | Volume
| Issue : 4 | Page : 273-280
The mental health of health care workers in the UK during COVID-19: The prevalence of anxiety, depression, and stress
Ravi Chotalia1, Mohammed J Abbas2, Alisha Aggarwal3
1 University Hospitals of Leicester NHS Trust, Leicester, UK
2 Consultant Psychiatrist, Leicestershire Partnership NHS Trust & Associate Professor (Hon), Department of Health Sciences, University of Leicester, Leicester, UK
3 Medical Student, The Medical School, University of Sheffield, Sheffield, UK
|Date of Submission||12-Mar-2022|
|Date of Decision||07-May-2022|
|Date of Acceptance||17-Jun-2022|
|Date of Web Publication||24-Dec-2022|
Dr. Mohammed J Abbas
Bradgate Unit, Groby Road, Leicester, LE3 9EJ
Source of Support: None, Conflict of Interest: None
Introduction: The COVID-19 pandemic had a significant impact on the mental health of health care workers (HCWs). Aim: This study investigated the mental health of HCWs working in Leicester, UK during COVID-19. Settings: Two hospital trusts in Leicester, UK. Methods: An online survey was sent to HCWs in two trusts in July 2020. The Generalized Anxiety Disorder-7 scale (GAD-7) and the Patient Health Questionnaire-9 scale (PHQ-9) were used to measure the prevalence rates of anxiety and depression. The Perceived Stress Scale-14 (PSS-14) was used to measure levels of perceived stress. Other questions were used to identify the prevalence of increased alcohol intake and possible risk factors. Statistical Analysis Used: Chi-square test, independent sample t-test, ANOVA, and logistic regression. Results: A total of 1009 HCWs completed the survey. Using a cutoff score of 5 (mild symptoms), for both GAD-7 and PHQ-9, 80.2% of participants had at least one condition and 71.5% had both. Using the cutoff score of 10 (moderate/severe symptoms), 27.2% had at least one condition and 27.25% had both conditions. In addition, 37.5% of those who did not report pre-existing mental health conditions now have at least one condition. About 33.6% of participants reported an increase in alcohol consumption. A number of risk factors were identified: having less social support, not feeling supported at work, and poor pre-existing mental health. Conclusions: The pandemic had a significant impact on mental health of HCWs. Health organizations need to monitor and address these emerging effects.
Keywords: COVID-19, Health-care workers, Mental health, Depression, Anxiety, Alcohol intake
|How to cite this article:|
Chotalia R, Abbas MJ, Aggarwal A. The mental health of health care workers in the UK during COVID-19: The prevalence of anxiety, depression, and stress. Indian J Occup Environ Med 2022;26:273-80
|How to cite this URL:|
Chotalia R, Abbas MJ, Aggarwal A. The mental health of health care workers in the UK during COVID-19: The prevalence of anxiety, depression, and stress. Indian J Occup Environ Med [serial online] 2022 [cited 2023 Mar 20];26:273-80. Available from: https://www.ijoem.com/text.asp?2022/26/4/273/364944
| Introduction|| |
The COVID-19 pandemic has led to global changes in almost all aspects of daily life. In addition to these, health care workers (HCWs) have faced other changes and challenges. Some examples of these challenges include the risk of infection to themselves and families, the lack of availability of personal protective equipment, self-isolation, an increased workload, and working in unfamiliar settings. Therefore, the strain on the mental health of HCWs has been both unprecedented and unique. Stressful work situations for HCWs, especially in disasters, are known to cause mental health problems.,, A rapidly evolving body of literature has shown a similar picture following COVID-19.,,,,
However, most of these studies have originated from China. Examining this issue in the UK is of high urgency.
The UK had one of the highest levels of COVID-19 cases and mortality in Europe. At the beginning of our data collection (31/7/2020), there were 305,571 cases and 41,250 deaths in the UK, including deaths of 313 HCWs in the UK between 9th March and 27th July 2020. To add the UK literature, this study aimed to investigate the prevalence of anxiety, depression, and perceived stress in HCWs working in two National Health Service (NHS) trusts in Leicester, United Kingdom.
| Methods|| |
This is a cross-sectional observational study. A survey was conducted in two NHS trusts that provide health care services for Leicester, Leicestershire, and Rutland (LLR). University Hospitals of Leicester (UHL) NHS Trust provide secondary health services excluding mental health services and community health services that are provided by Leicestershire Partnership (LPT) NHS Trust. UHL has 16,011 employees, 77.2% of them are females. LPT has a workforce of 6699 employees, 82.3% of them are females. Leicester has been a unique setting as it is the first city in the UK to experience a second lockdown because of a rapid rise in cases of COVID-19. During the time of data collection, Leicester was still in a partial lockdown. The project was approved by the UK Health Research Authority (IRAS project ID 285841) in July 2020 and by the Research and Ethics Departments of both trusts. All data collected were anonymous.
Sample and data collection
The data were collected between 31/7/2020 and 18/8/2020 using an online Google form as an open survey. This was a voluntary survey with no incentives provided. The invitation to participate in the survey was sent by e-mail through the trusts' email directory to a total of 22,710 HCWs. The survey link and invitation was also placed on the trusts' main website. The only inclusion criterion was that they work for either of the two hospital trusts. Both patient-facing and non-patient-facing staff were included. The invitation included a link that took participants to the Google form. The first section of the form gave brief information about the purpose of the survey, a link to the full information leaflet, and a statement confirming that participants gave consent by continuing to complete the questionnaire. Participants were assured that all the data collected were anonymous. At the end of the questionnaire, a support line (Samaritans) was provided for staff who were distressed by answering the questionnaire. The full survey consisted of one page and took HCWs an average of 15–20 min to complete in a test sample. Email address of one of the investigators was also provided.
Demographic, clinical, and work-related data
This section of the questionnaire covered questions about demographic details and work-related questions, including the type of work, the exposure to COVID-19 patients, the support system available to staff, and history of mental health problems before and after the COVID-19 period.
The Generalized Anxiety Disorder-7(GAD-7) scale is a seven-item scale that measures the frequency of anxiety symptoms within the last 2 weeks. Responses range from 0 (not at all) to 3 (nearly every day). Scores range from 0 to 21, with scores of 5, 10, and 15 representing mild, moderate, and severe levels of anxiety symptoms, respectively. A review of studies that used GAD-7 showed that a cutoff score of ≥10 produced a sensitivity of 0.89 and a specificity of 0.82 for anxiety. In addition, GAD-7 also proved to have good sensitivity and specificity as a screening tool for panic, social anxiety, and post-traumatic stress disorder. The Patient Health Questionnaire (PHQ-9) is a nine-item measure used to assess the frequency of depressive symptoms within the last 2 weeks. Responses range from 0 (not at all) to 3 (nearly every day). Scores range from 0 to 27, with scores of 5, 10, and 15 representing mild, moderate, and severe levels, respectively, of depressive symptoms. A review of studies that used PHQ-9, most of which had a cutoff score of ≥10, showed a sensitivity of 0.77–0.88 and a specificity 0.88–0.94. This cutoff score is recommended for a diagnosis of major depression. In this study, the cutoff score of ≥10 was used for both GAD-7 and PHQ-9 as this is the optimal cutoff score for clinically significant symptoms.
The Perceived Stress Scale-14 (PSS-14) is a widely used measure to assess “the degree to which situations in one's life are appraised as stressful” and one's life is perceived as “unpredictable, uncontrollable, and overloading.” Items are rated on a 5-point scale (0 = Never to 4 = very often). Some items are scored reversely. A review of articles using PSS-14 showed a Cronbach's alpha of >0.70. PSS-14 was found to be a valid measure of stress and a better predictor of outcomes than life-event scores. It was also shown to have a correlation with depression, anxiety, physical symptoms, and cortisol levels.
For univariate analysis, the Chi-square test was used to compare categorical variables and the independent sample t test and ANOVA for continuous variables. The ratings of state of mental health before and during the pandemic were compared using the Wilkinson Signed Rank test on the raw data (5-points ranging from very bad to very good). The total score for the three scales was calculated. Missing items were replaced by zero for a conservative measure of the outcome variables. The three scales showed acceptable levels of normality (GAD-7: skewness = 0.56, Kurtosis = –0.53;PHQ-9: skewness = 0.65, Kurtosis = –0.24; and PSS-14: skewness = –0.23, Kurtosis = –0.05). The GAD-7 and PHQ-9 total scores were converted into binary variables using a cutoff score of ≥10. This allows a clinically meaningful interpretation of the results. No agreed cutoff scores are available for PSS-14 and hence, this was treated as a continuous variable. The proportions of anxiety and depression and the mean score of PSS-14 were compared across a number of demographics, work-related factors, and other characteristics. Statistically significant variables (P < 0.05) were then entered into regression analysis to assess for independent risk factors or predictors of anxiety, depression, and higher levels of perceived stress. Binary logistic regression was used for anxiety and depression and multiple linear regression for perceived stress. Adjusted odd ratios and adjusted mean scores and their confidence intervals were calculated. All statistical analyses were done using the Statistical Package for Social Sciences (SPSS version 22 for Windows).
| Results|| |
Demographic, work-related, and other characteristics
One thousand and nine HCWs participated in this study. [Table 1] shows the demographics, work-related, and other characteristics of the sample.
|Table 1: Demographic, occupational, and other characteristics of the responders|
Click here to view
The majority of participants rated their general mental health before the pandemic as either very good/good (713, 71.2%) or fair (250, 25.0%) with a very small minority reported it to be bad/very bad (39, 3.9%). This profile changed significantly after the pandemic where the very good/good ratings were reduced to 279 (27.9%), whereas the fair (457, 45.7%) and bad/very bad (264, 26.4%) ratings were increased. Using Wilkinson Signed Rank test on the raw data, this difference was statistically significant (P = 0.001) in both trusts. Of the 325 (32.5%) HCWs who reported pre-existing mental health problems before the pandemic, 230 (70.6%) of them reported that these problems were worsened during the pandemic. About one third (335, 33.6%) of participants reported an increase in alcohol consumption during the pandemic [Figure 1].
|Figure 1: Mental Health before and after the pandemic, impact on pre-existing mental health conditions, and prevalence of increased alcohol intake|
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The mean scores for anxiety (GAD-7), depression (PHQ-9), and perceived stress (PSS-14) are displayed in [Table 2].
Using a cutoff score of 5 for both GAD-7 and PHQ-9, 80.2% had at least one condition (depression or anxiety) and 71.6% had both conditions [Figure 2]. About 71.6% of our sample reported anxiety symptoms and 70.4% reported depressive symptoms. Using the more conservative cutoff score of 10 for both scales showed that almost half had at least one condition and about a quarter had both conditions [Figure 2]. More than one third had clinically significant anxiety (356, 35.3%) and depressive (395, 39.1%) symptoms. It is of interest that 37.5% of those who did not report pre-existing mental health conditions now have at least one condition with a prevalence rate of 26.6% for anxiety and 28.9% for depression.
The use of logistic regression, after accounting for levels of perceived stress, identified several independent risk factors for anxiety and depression [Table 3]. These were the following: not feeling supported at work (B = 0.65, SE = 0.19, adjusted OR = 1.91 (1.33–2.75), P < 0.001), having social support only little (B = 0.83, SE = 0.32, adjusted OR = 2.28 (1.23–4.24), P = 0.009) or some of the time (B = 0.49, SE = 0.24, adjusted OR = 1.64 (1.03–2.63), P = 0.04), and having pre-existing mental health problems (B = 0.67, SE = 0.19, adjusted OR = 1.96 (1.35–2.85), P < 0.001).
|Table 3: Risk factors/predictors of anxiety, depression, and perceived stress using logistic and linear regression analyses|
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Increased alcohol intake
Logistic binary regression (adjusted R square = 0.10, P < 0.001) showed that increased alcohol intake was associated with White ethnicity (B = 1.35, SE = 0.22, adjusted OR = 3.89 (2.5–6.06), P < 0.001), having had COVID-19 symptoms (B = 0.41, SE = 0.16, adjusted OR = 1.50 (1.10–2.06), P = 0.01), and having higher PSS-14 scores (B = 0.03, SE = 0.009, adjusted OR = 1.03 (1.01–1.04), P = 0.001).
| Discussion|| |
This study investigated the prevalence of anxiety, depression, perceived stress, and increased alcohol intake during the COVID-19 pandemic in HCWs working in two NHS trusts in the UK. The findings of this study suggest that the pandemic had a significant impact on the mental health of HCWs with significant proportions reporting depression, anxiety, and increased alcohol intake.
Using a cutoff score of 5 in GAD-7 and PHQ-9, 80.2% of our sample had at least one condition (mild depression or anxiety) and 71.6% had both. Using a cutoff score of 10, which includes only the clinically significant moderate and severe symptoms, showed that almost half (47.2%) of our sample had at least one condition and a quarter (27.3%) had both. The prevalence rates for anxiety and depression were 35.3% and 39.1%, respectively. These rates are slightly higher than those found in similar studies. A meta-analysis of 13 studies that investigated the impact of COVID-19 pandemic on the mental health of HCWs found a pooled prevalence rate of 23.2% for anxiety and 22.8% for depression. Four of these studies used GAD-7 and found anxiety rates from 24.1% to 44.7%.,,,Furthermore, most of these studies used lower cutoff scores of 5 and above. Because most of these studies were done in China, further studies in the UK are needed to replicate and confirm the higher rates that have been found.
Although this study is not longitudinal in nature, some reasonable evidence in this study suggests that these conditions are new and related to the pandemic. The majority of our sample (67.5%) said that they did not have any pre-existing mental health conditions. Out of those, 37.5% of them now have enough clinically significant symptoms (moderate-severe) to be classified as having at least one condition (anxiety or depression). Of those who reported pre-existing mental health conditions, a very significant majority of them (70.6%) reported that these have worsened since the pandemic. In addition, there was a very significant change in the way HCWs rated their mental health before and after the pandemic.
Although a control group was not included from the general population, the fact that a difference was not found between those who worked directly with patients and those who did not could suggest that a similar picture might be found in the general population. Recent evidence from China suggests that the rates of anxiety and depression are comparable in HCWs and the general population.,
This study identified a number of these risk factors for anxiety and depression. Three factors (poor social support, feeling not supported at work, and pre-existing mental health conditions) were found to have an independent and direct impact on the risk of developing anxiety and depression. Previous similar studies have found that lower levels of social support, including support at work, are associated with higher rates of mental distress. This is not surprising because social interactions play a significant role in reducing mental health problems and in improving sleep.,Interestingly, this study did not find higher rates in those who worked directly with patients, in different groups of staff, in those who had contact with a higher number of COVID-19 positive cases, or those who have worked in the ITU. This suggested that it could be the effects of lockdown and social isolation that caused deterioration in mental health rather than directly working with COVID-19 patients. A similar finding was found in Italy.
One third of this sample reported an increase in their alcohol intake during the pandemic. It is possible that alcohol was used as a coping mechanism to deal with higher levels of stress or that depression and anxiety led to an increase in the alcohol intake.
This study has some limitations. The cross-sectional nature of this study could limit the generalizability of some of the conclusions about the rates. However, this study tried to address this by asking questions about mental health before the pandemic. This study did not include the general public as a control group because of logistical reasons. However, this study tried to compare those with higher risk of infection to those with lower risk within the trusts.
This study did not collect data about the specific pre-existing mental health conditions. It is possible that different conditions could lead to different reactions to the current situation. Although this study received a large number of responses, the response rate was still low. Hence, response bias in this study is a possibility: those who did not have mental health problems or those with severe mental health problems may have been missed.
Implications and future research
The higher rates of depression and anxiety could have a significant impact on the performance of HCWs. Mental health problems have been associated with poor cognitive function and clinical decision making in HCWs., Introducing measures to support staff seems an important strategy. In the two trusts where this research was conducted, measures were introduced to address this issue, for example, the creation of rest rooms, as well as free food and parking for staff. Staff support groups, including online ones, might be something to be explored.
This study has shown that a lot of participants suffer from mild symptoms of anxiety and depression. Further follow up needs to be done to assess if this progresses into moderate/severe symptoms. HCWs with pre-existing mental health conditions need specific attention because more than two thirds have reported worsening of their condition. Measures including mental health first aid has been suggested by the WHO., Future research needs to address the longitudinal picture and whether the effects are long lasting as there is already some evidence from the SARS epidemic.,The extent of the alcohol problems and whether the increased intake has reached harmful levels need to be explored.
This study has identified that during the current pandemic, a substantial proportion of HCWs in hospital suffered from high levels of poor mental health, with regard to depression, anxiety, perceived stress, and increased alcohol intake. The majority of risk factors identified centered around levels of social support – both inside and outside work. This data suggest that it is imperative that appropriate mental health and emotional support is offered to staff to ensure they cope with the pandemic and can function effectively.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]