Depression, Anxiety, and Stress Associated with Coronavirus Disease (COVID-19) Pandemic among Health-care Professionals in Lebanon and Iraq

Zaid Ayad; Samaa Al Tabbah; Bassima Hazimeh; Loubna Sinno

doi:10.4103/wsp.wsp_74_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 3 | Issue : 1 | Page : 36-44

Depression, Anxiety, and Stress Associated with Coronavirus Disease (COVID-19) Pandemic among Health-care Professionals in Lebanon and Iraq

Zaid Ayad¹, Samaa Al Tabbah², Bassima Hazimeh³, Loubna Sinno⁴
¹ Sales Department, Integrated Solution for Medical Projects, Baghdad, Iraq
² School of Pharmacy at the Lebanese American University, Beirut, Lebanon
³ School of Pharmacy at Beirut Arab University, Beirut, Lebanon
⁴ Research Unit, Makassed General Hospital, Beirut, Lebanon

Date of Submission	09-Sep-2020
Date of Decision	03-Dec-2020
Date of Acceptance	03-Dec-2020
Date of Web Publication	29-Apr-2021

Correspondence Address:
Ms. Loubna Sinno
Research Unit, Makassed General Hospital, Beirut
Lebanon

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_74_20

Abstract

Background: Health-care workers during the COVID-19 outbreak are vulnerable to psychological distress due to increased workload, inadequate equipment, isolation, and risk of infection transmission. The objective of this study was to assess the psychological status of health-care professionals in Lebanon and Iraq during the period of COVID-19 outbreak. The primary outcome was the prevalence of depression, anxiety, and stress among the health-care workers. Methods: We carried out a cross-sectional study to assess the psychological well-being of health-care professionals in Lebanon and Iraq during the COVID-19 pandemic. Psychological health was assessed using the validated “Depression, Anxiety, and Stress Scale-21.” Results: A total of 518 health-care professionals were included, of which 287 (55.4%) were from Lebanon and 231 (44.6%) were from Iraq. Overall, 60.0%, 42.9%, and 43.4% of all participants reported depression, anxiety, and stress, respectively. Health-care workers from Iraq had more severe symptoms on all measurements compared to those from Lebanon. Psychological distress was associated with caring for elderly parents, going home after duty only 2–4 times/week, working overtime, and in the front line. The results present concerns about the psychological health of nurses and physicians. Those who did not use protective equipment were more distressed. Participants who had direct or indirect contact with COVID-19 cases and those who tested positive had significantly higher depression, anxiety, and stress. Conclusions: This survey on health-care workers reported high rates of depression, anxiety, and stress during the COVID-19 pandemic. Protecting health-care professionals is a major public health measure for addressing COVID-19 outbreak.

Keywords: Anxiety, COVID-19, depression, pandemic, stress

How to cite this article:
Ayad Z, Al Tabbah S, Hazimeh B, Sinno L. Depression, Anxiety, and Stress Associated with Coronavirus Disease (COVID-19) Pandemic among Health-care Professionals in Lebanon and Iraq. World Soc Psychiatry 2021;3:36-44

How to cite this URL:
Ayad Z, Al Tabbah S, Hazimeh B, Sinno L. Depression, Anxiety, and Stress Associated with Coronavirus Disease (COVID-19) Pandemic among Health-care Professionals in Lebanon and Iraq. World Soc Psychiatry [serial online] 2021 [cited 2023 Mar 27];3:36-44. Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/1/36/315128

Introduction

Research related to coronavirus disease (COVID-19) outbreak focused on identifying the epidemiology and clinical characteristics of infected patients, the characteristics of the virus, and the challenges for the general population and global health against the virus.^[1],[2] Recently, more emphasis has been placed on health-care workers since they play an essential role in combating the pandemic. Health-care workers are vulnerable to psychological distress and complex emotional reactions due to the increased workload, inadequate equipment, physical exhaustion, isolation, loss of social support, and risk of infection transmission. This in turn could impair their cognitive functioning and clinical decision-making, thereby increasing the occurrence of medical errors and the complexity of the situation.^[3] Therefore, the mental and psychological problems of health-care workers during the COVID-19 outbreak have become a major public health concern.

Some studies explored the effect of the COVID-19 pandemic on the psychological and mental health of health-care workers in China, India, and Singapore.^{[4],[5],[6],[7]} However, to our knowledge, no studies examined the psychological impact of COVID-19 on health-care professionals in the Arab region.

The objective of this study was to assess the psychological status of health-care professionals in Lebanon and Iraq during the period of COVID-19 outbreak. The primary outcome was to measure the prevalence of depression, anxiety, and stress among health-care workers. The secondary outcomes were the association between depression, anxiety, and stress with sociodemographic characteristics, prevention practices, as well as contact with COVID-19-infected patients.

Methods

Setting and participants

We carried out a cross-sectional study between May 7, 2020, and June 12, 2020, to assess the psychological health response of health-care professionals in Lebanon and Iraq, during the COVID-19 pandemic through an anonymous online survey. Study participants included treating physicians, residents, nurses, pharmacists, dentists, and other health-care professionals (such as pharmacist assistant, laboratory, and radiology technician). Eligibility criteria for this study were health-care professionals who are associated with either a specialty or a discipline, who are qualified and allowed by regulatory bodies to provide health-care services to patients, and who are actively working in Lebanon and Iraq. The study was reviewed by the Institutional Review Board of Iraqi health authorities. Online consent was obtained from all participants. Confidentiality of all information collected in this study was guaranteed, and all data were protected through appropriate measures.

Survey development and data collection

Participants completed the survey through an online questionnaire distributed through Google Docs platform. Data collected included information about the health-care professionals, more specifically: information on their sociodemographic characteristics, their protective and preventive practices during COVID-19, their contact history with COVID-19 cases, as well as their psychological health status (depression, anxiety, and stress) during COVID-19.

Sociodemographic variables included demographic variables: (age, gender, residential location, smoking status, chronic illness, and previous diagnosis with a mental health disorder), family and social life variables: (marital status, care of elderly parents, care of young children, and rate of presence at home after duty), professional life variables: (specialty, working position, years of working experience, and working overtime). Working position was classified as front line or nonfrontline. Front line was defined as being directly engaged in diagnosing, treating, or caring for confirmed or suspected COVID patients
Protective and prevention practices variables included availability of personal protective equipment (PPE) at the workplace, use of PPE, training on hand hygiene at workplace, and application of hand hygiene practices at the workplace
Contact history variables included close contact with confirmed COVID-19 case, indirect contact with confirmed COVID-19 case, contact with suspected case or material contaminated with coronavirus, and whether took the test for COVID-19
Psychological health status assessment: Psychological health status was measured using a validated scale: the “Depression, Anxiety, and Stress Scale (DASS-21)”^[6] The DASS-21 has been demonstrated to be a reliable and valid measure in assessing mental health status. Cutoff scores of >9, >7, and >14 represented a positive screen of depression, anxiety, and stress, respectively
The total depression subscale score was divided into normal (0–9), mild depression (10–13), moderate depression (14–20), severe depression (21–27), and extremely severe depression (28–42)
The total anxiety subscale score was divided into normal (0–7), mild anxiety (8–9), moderate anxiety (10–14), severe anxiety (15–19), and extremely severe anxiety (20–42)
The total stress subscale score was divided into normal (0–14), mild stress (15–18), moderate stress (19–25), severe stress (26–33), and extremely severe stress (34–42).^[6]

Statistical analysis

The Statistical Package for the Social Sciences (SPSS version 24, IBM Corporation, Armonk, NY, USA) software was used for data cleaning, management, and analyses. Bivariate analyses were carried out using the Chi-square test for categorical variables and Student's t-test or one-way analyses of variance (as appropriate) for continuous variables. Categorical variables were presented as number and percent. The scores of DASS-21 subscales were expressed as mean and standard deviation. P < 0.05 indicated statistical significance.

Results

In the present study, a total of 518 health-care professionals were included, of which 287 (55.4%) were from Lebanon and 231 (44.6%) were from Iraq. Using the predefined cutoff scores for the DASS-21 to measure depression, anxiety, and stress, the prevalence of depression was 60.0%, while that of anxiety was 42.9% and stress was 43.4%. The overall mean DASS-21 score for depression was 13.04 ± 10.22. Of the 311 health-care workers who had depression, 130 (41.8%) had moderate depression, 52 (16.7%) had severe, and 61 (19.6%) had extremely severe depression. The overall mean DASS-21 score for anxiety was 8.36 ± 9.43. Of the 222 participants who had anxiety, 89 (40.1%) showed moderate anxiety, 32 (14.4%) had severe, and 67 (30.2%) had extremely severe anxiety. In terms of the DASS-21 for stress, the overall mean score was 14.81 ± 12.15. Of the 225 who had stress, 84 (37.3%) were moderately stressed, 41 (18.2%) were severely stressed, and 52 (23.1%) were extremely severely stressed [Figure 1].

Figure 1: Psychological status of participants stratified by severity using Depression, Anxiety, and Stress Scale-21 (depression, anxiety, and stress)

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Regarding the participants' demographic characteristics, 44.2% were in the age group between 18 and 34 years. The percentage of males was 46.1%. Around 27.6% were smokers and 15.4% had chronic illness [Table 1]. There was no significant difference in the prevalence or scores of depression, anxiety, and stress among health-care workers in terms of demographic characteristics except for location. The prevalence of depression was 68.4% among Iraqis compared to 53.3% among Lebanese (P < 0.0001). Similarly, the mean DASS-21 depression score was higher for Iraqi participants than Lebanese (15.11 ± 10.71 vs. 11.38 ± 9.50, respectively, P < 0.0001). The prevalence of stress was 50.6% in Iraqis, whereas it was 36.6% in Lebanese (P = 0.001). The average DASS-21 score for anxiety was significantly higher for Iraqis (10.44 ± 10.90) in comparison to Lebanese (6.68 ± 7.68) (P < 0.0001). The prevalence of stress was similar in both groups (44.2% vs. 42.9% for Iraqis vs. Lebanese, respectively). Yet, the mean DASS-21 stress score was higher for Iraqis (16.82 ± 13.76) more than Lebanese (13.20 ± 10.42) (P = 0.001).

Table 1: Association between demographic variables and the psychological impact of the 2019 coronavirus disease outbreak

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In terms of family and social characteristics, the majority of the health-care workers were married (68.7%), 41.7% cared for elderly parents, and 59.8% cared for young children [Table 2]. Psychological distress was not significantly associated with marital status and caring for young children. The depression and anxiety scores were slightly higher for those who cared for elderly parents compared to those who did not (depression: 14.18 ± 11.42 vs. 12.23 ± 9.19; anxiety: 9.42 ± 10.38 vs. 7.60 ± 8.63, respectively, P = 0.04). Around 22.2% of the health-care workers went home after duty only 2–4 times per week [Table 2]. These had the highest depression prevalence (71.3%, P = 0.008) and mean score (15.17 ± 10.46, P = 0.04). About half of them had anxiety, but the difference was not statistically significant. Yet, the mean DASS-21 anxiety score was significantly higher than that of those who went home 5–7 times per week (10.30 ± 10.81 vs. 7.57 ± 8.41, respectively, P = 0.02).

Table 2: Association between family and social characteristics and the psychological impact of the 2019 coronavirus disease outbreak

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Regarding the professional characteristics, the distribution of health-care workers who participated in the study was as follows: 43.6% pharmacists, 28.0% practicing physicians, 8.7% residents, 3.1% dentists, 7.1% nurses, and 9.5% others [Table 3]. Although the proportion of participants with psychological distress was similar among the different categories; however, the mean DASS-21 depression and anxiety scores were the highest among nurses and lowest among pharmacists (17.35 ± 12.47 vs. 10.98 ± 9.30 and 13.41 ± 12.26 vs. 6.68 ± 7.32, respectively, P = 0.001), whereas the highest average DASS-21 stress score was highest for physicians and lowest for pharmacists (18.51 ± 14.76 vs. 12.04 ± 9.61, P < 0.0001). A total of 138 participants were in the front line (26.6%). The prevalence and scores of depression, anxiety, and stress were significantly higher in the frontline workers of whom 70.3% had depression, 59.4% had anxiety, and 63.0% had stress compared to nonfrontline workers, of whom 56.3% were depressed, 36.8% were anxious, and 36.3% were stressed. Psychological distress was not associated with the years of working. Working overtime had a significant effect on psychological well-being. Of those who worked overtime (226 participants), 63.3% had depression, 51.3% had anxiety, and 52.7% had stress.

Table 3: Association between professional life characteristics and the psychological impact of the 2019 coronavirus disease outbreak

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As for the prevention practices [Table 4], the majority (83%) had PPE available at their workplace. This did not affect their psychological health. Only 10 (1.9%) did not use PPEs. These had the highest anxiety rate (50%) compared to those who sometimes (37.4%) or always (44.9%) use PPEs though the difference was not statistically significant. The mean DASS anxiety score was significantly higher (14.00 ± 16.33) in those who never used PPEs compared to those who sometimes (6.78 ± 8.17) or always (8.84 ± 9.58) used PPEs (P = 0.01). Similarly, stress rate and score were significantly higher in the nonusers. The participants who received training on hand hygiene had significantly higher depression, anxiety, and stress rates and scores compared to those who did not receive training. There was no association between performing hand hygiene practices at the workplace and the development of psychological problems.

Table 4: Association between prevention practices and the psychological impact of the 2019 coronavirus disease outbreak

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Regarding contact with COVID-19 cases [Table 5], 74 health-care workers had close contact with confirmed cases. This was significantly associated with psychological distress since a considerable proportion of them had depression (75.7%) and their mean depression DASS score was high (20.84 ± 12.88) compared to those who did not have close contact (57.4%, P = 0.003; and 11.74 ± 9.09, P < 0.0001). This was also the trend for anxiety and stress, which were significantly higher in those who contacted confirmed case (P < 0.0001). Similarly, indirect contact with confirmed cases and contact with suspected cases or material significantly increased the depression, anxiety, and stress rates and scores. As for doing the test for COVID-19, of the seven who tested positive, six had depression and stress and their mean DASS scores were significantly high (depression: 24.00 ± 13.47, stress: 30.57 ± 11.82). All of them had anxiety and their mean score was 24.29 ± 16.75.

Table 5: Association between contact history in the past week and the psychological impact of the 2019 coronavirus disease outbreak

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Discussion

The present study showed that the COVID-19 pandemic had a significant impact on the psychological well-being of health-care workers in Lebanon and Iraq. Overall, 60.0%, 42.9%, and 43.4% of all participants reported depression, anxiety, and stress, respectively. Health-care workers from Iraq had more severe symptoms on all measurements compared to those from Lebanon. Our study further indicated that psychological distress was associated with caring for elderly parents, going home after duty only 2–4 times per week and working overtime. Working in the front line was a significant risk factor for worse psychological outcomes. The study results present concerns about the psychological health of nurses and physicians. Regarding prevention practices, those who did not use PPEs were more distressed. Participants who had direct or indirect contact with COVID-19 cases as well as those who tested positive had significantly higher depression, anxiety, and stress.

The relatively high rate of depression (60.0%), anxiety (42.9%), and stress (43.4%) reported in this study was similar to those of health-care workers treating patients with COVID-19 in China (50.4%, 44.6%, and 71.5%, respectively).^[5] Another study on medical workers in China also had a high prevalence (50.7%, 44.7%, and 73.4%, respectively).^[8] In addition, a study on medical and nursing staff in Wuhan concluded that 8.9% of the participants had mild mental health disturbances, 22.4% had moderate, and 6.2% had severe disturbances.^[9] A lower prevalence of depression, anxiety, and stress of health-care workers was reported by a study in Singapore (8.9%, 14.5%, and 6.6%).^[7] Similarly, another recent study in India and Singapore had a low rate (10.6%, 15.7%, and 5.2%, respectively).^[6] In our study, Iraqi participants had significantly higher psychological distress compared to Lebanese. This could be attributed to the higher rate of confirmed COVID-19 cases and mortality in Iraq. Till the end of the study period (June 12, 2020), Iraq reported 17,770 confirmed COVID-19 cases with 496 deaths, while Lebanon had 1422 cases with a total mortality of 31.^[10]

Infectious disease outbreaks are shown to have psychological impact on the whole population as well as health-care professionals.^[6] Previous examples were the psychological consequences associated with severe acute respiratory syndrome (SARS), Ebola, and H1N1 outbreaks.^{[11],[12],[13]} Recently, the highly infectious novel coronavirus (SARS-CoV-2) pandemic had also raised concern regarding its effect on mental health across the general population and vulnerable groups such as health-care workers.^{[2],[14],[15]} Several studies were conducted to assess the influence of COVID-19 on the mental or psychological well-being of health-care workers. Most of these studies were done in China, where the outbreak first emerged.^{[5],[8],[9],[16],[17],[18],[19],[20],[21],[22],[23]} A single study was performed in Singapore, and another study was multinational involving India and Singapore.^[6],[7] To our knowledge, our study is one of the first studies conducted in the Arab region, particularly in Lebanon and Iraq.

According to the recent studies, several factors influenced the psychological well-being of personnel who work in the health-care field during the COVID-19 outbreak. Some demographic characteristics were associated with the development of psychological problems. These include age, gender, and presence of comorbidity. Several studies reported that younger age (<30 years) and females had higher depression and insomnia compared to older age and males.^{[5],[8],[17],[23]} However, in the present study, age and gender were not significantly associated with psychological distress. Similarly, Kang et al. reported that mental health disturbances were not different across age groups and between males and females among medical and nursing staff in Wuhan.^[9] Liu et al. also noted that age and gender did not increase anxiety scores among medical workers.^[19] Moreover, a study associated the presence of chronic diseases with stress, depression, and anxiety among health-care workers during the COVID-19 pandemic, while another study associated the presence of organic disease with insomnia.^[4],[22] Yet, this was not a risk factor in the present study.

Furthermore, social factors were found to have an impact on psychological health such as marital status and living with family. A study by Liu et al. showed that divorced or widowed medical staff had a higher risk of psychological distress.^[18] In the present study, marital status was not associated with psychological distress. Similarly, other studies did not find a relation between marriage and mental health problems or insomnia.^[8],[9] Regarding living with family, our study showed that caring for elderly parents slightly increased depression and anxiety. Similarly, Zhu et al.^[4] reported that living with family was a risk factor for depression, anxiety, and stress, while Zhang et al.^[8] found that living with family was associated with insomnia. This could be related to the fear from possibly transmitting the virus to family members.^[19],[20] Zhu et al. also found that those who had two or more children had a higher risk of stress, probably due to their burdensome family responsibilities.^[4] The present study showed that health-care workers who went home after duty only 2–4 times per week had the highest depression prevalence. Liu et al. mentioned that medical staff who seldom or did not live with family members tended to have mental health problems compared to those who lived with their family everyday or most of the time.^[18]

In addition, professional attributes are shown to have psychological impact on health-care workers. Among the different occupations of health-care workers in this study, nurses had the highest depression and anxiety scores, while doctors had the highest stress scores. A study which included doctors and nurses concluded that nurses had a higher risk of depressive or anxious symptoms.^[18] Another study also showed that nurses had a higher depression in comparison to doctors and medical technicians.^[4] Zhang et al. reported that medical health workers (doctors and nurses) showed the higher prevalence of anxiety, depression, insomnia, and obsessive–compulsive symptoms than nonmedical health workers.^[22] A study on the general population in China found that health-care workers were more likely to have poor sleep quality compared to other occupations.^[24] This increased psychological burden on medical professionals could be attributed to their higher risk of exposure because they usually stay longer in wards and provide direct practice to patients. Their mental health status may also be influenced by the psychological distress of patients.^[18] On the contrary, Tan et al. mentioned that anxiety was more among nonmedically trained health-care personnel compared to the medically trained professionals.^[7] Another major risk factor for psychological suffering was being a frontline worker. Similar to this study, many studies reported that frontline health-care workers had higher depression, stress, and anxiety compared to nonfrontline workers.^{[16],[17],[19],[20]} The reason for this could be the continuous exposure of frontline workers with suspected or confirmed cases making them at a higher risk of acquiring the virus in addition to their long working hours which could make their immune systems more vulnerable.^[17] A different factor that was shown by Zhu et al. to influence the psychological health was years of working.^[4] They concluded that workers with more than 10 years of experience had a higher risk of distress.^[4] This was not shown in the present study. Our study showed that working overtime was associated with psychological disturbances. Many health-care workers are exposed to long and stressful work shifts to meet the health requirements.^[22]

Concerning the prevention practices, the shortage of PPE could increase the emergence of psychological symptoms.^[20] Zhu et al. mentioned that full coverage of all departments with protective measures for healthcare-associated infection was a protective factor.^[4] Implementing strict infection control, providing protective equipment, and giving practical guidance tend to protect the mental health of workers.^[9] In this study, availability of PPE was not associated with increased psychological distress and most of the participants used them; however, those who did not use them were more distressed. Nonetheless, health-care workers who received training on hand hygiene had significantly higher disturbances compared to those who did not receive training. Liu et al., 2020, reported a similar finding since most of their participants had training experiences; yet, medical staff from general hospitals had a higher risk of psychological distress. This could be because the training might not have been comprehensive.^[18]

Besides, the current study revealed that contact with suspected or confirmed COVID-19 cases had a significant effect on psychological health. Similarly, a study concluded that being at risk of contact with COVID-19 cases was a risk factor for depression, anxiety, obsessive–compulsive symptoms, and insomnia.^[22] Lu et al. demonstrated that medical staff working in departments with high-risk contact with COVID-19 patients exhibited significantly greater fear, depression, and anxiety than nonclinical staff who have low possibility to contact patients.^[20] Liu et al. found that health-care workers who directly diagnosed, treated, or looked after COVID-19 patients were more stressed and psychologically affected than workers who did not have direct contact with cases.^[19]

Although this study focused on an important public health issue, yet, it has some limitations. First, psychological assessment was based on an online survey and on self-report tools which could lack comprehensive assessment of the psychological well-being. Second, it was not possible to measure the participation rate because it is unknown how many health-care workers received the link for the survey. Third, the survey was distributed online which can impose selection bias. Fourth, a total of 287 participants from Lebanon and 231 from Iraq do not completely reflect the entire psychological health picture of Lebanese and Iraqi health-care workers.

Conclusions

This survey on health-care workers reported high rates of depression, anxiety, and stress during the COVID-19 pandemic. The reasons for the adverse psychological outcomes could be associated with excessive workload, long working hours, inadequate PPE, feeling unsupported, and concern about infecting their family. Protecting health-care professionals is a major public health measure for addressing COVID-19 outbreak that should not be underestimated. Interventions must be implemented to promote psychological well-being of health-care workers exposed to COVID-19 by keeping them updated about the disease prognosis, providing them support, and referring them to mental health specialists in addition to organizing their work duties. Special attention must be given to nurses, physicians, and frontline workers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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