How has the pandemic affected the mental health of healthcare workers?

Covid-19 has taken a heavy toll on the mental health of medical staff working on the frontline. Providing resources and support benefits not only these individuals but also society as a whole by improving job performance and attitudes towards patients.

The pandemic is as much a crisis of mental health as of physical health. For healthcare workers who have been directly involved in the diagnoses, treatment and care of Covid-19 patients, the impact has been particularly acute. A recent survey by the Royal College of Physicians found that around 29% of doctors have sought mental health support during the pandemic.

How was the wellbeing of healthcare staff before Covid-19?

Working in healthcare is associated with significant work-related mental health distress. A comprehensive review of physician burnouts (characterised by emotional exhaustion, depersonalisation and diminished feelings of personal accomplishment) highlights high levels of emotional exhaustion across a spectrum of healthcare workers, including medical students, resident doctors and attending physicians in the United States. This pattern applies to both men and women (Eckleberry-Hunt et al, 2017).

But is this simply part of the job? There is a lack of strong evidence, but cross-sectional and correlational data suggest that the inherent stress stemming from working with chronic suffering and patient deaths does not entirely explain this phenomenon (Guest et al, 2011; Firth-Cozens, 2001).

The researchers who conducted the comprehensive review argue that modifiable workplace factors are increasingly associated with physician stress and burnout (Eckleberry-Hunt et al, 2017). These include a lack of work control and work-life balance (Frank et al, 1999; Glasheen et al, 2011; Linzer et al, 2001; Spinelli et al, 2016), and long working hours and irregular shifts (Mansukhani et al, 2012).

Institutional support – or the lack of it – also affects the mental health of medical staff. For example, poor leadership (Shanafelt et al, 2015), poor support staff (Deckard et al, 1994) and lack of financial rewards (Scheurer et al, 2009) all affect healthcare workers’ mental wellbeing.

In addition to workplace conditions, personal factors play a role in physician burnout. Certain personality traits – such as pessimism and perfectionism – are predictive of burnout (Eckleberry-Hunt et al, 2009). Similarly, different coping strategies are effective to varying degrees: for example, taking time out is associated with lower frequency of emotional exhaustion, while concentrating on what to do next is associated with higher frequency of emotional exhaustion (Lemaire and Wallace, 2010). This evidence indicates that the mental health of healthcare workers is affected by factors beyond the nature of the work.

Proposals to improve physician wellbeing – and consequently patient welfare – have therefore focused on workplace changes. These include increasing support personnel, aligning goals between physicians and leadership, and establishing wellness focus groups.

How has the pandemic affected the mental health of healthcare staff?

Covid-19 has intensified mental distress among healthcare workers, including anxiety and depression. A number of surveys across different countries find prevalent mental health issues among healthcare workers during the pandemic.

A global survey covering 2,707 healthcare workers from 60 countries finds self-reported burnout among 51% of the respondents (Morgantini et al, 2020). In a survey of 7,000 doctors in the UK, the British Medical Association (BMA) finds that 41% of doctors reported suffering with a work-related mental health condition, with 29% stating that this had got worse during the pandemic (BMA, 2020).

Similarly, a cross-sectional survey of 595 healthcare workers in Italy finds that working with Covid-19 patients was a risk factor for higher levels of stress (Babore et al, 2020). In Spain too, a survey of 506 healthcare workers, conducted during the period of the highest incidence of cases and highest mortality rates due to Covid?19, shows medium-to-high levels of compassion fatigue and burnout among respondents (Ruiz-Fernández et al, 2020). In another Spanish survey, 39% of respondents reported high depersonalisation and 43% considered that they might need psychological or psychiatric treatment in the future (Martínez-López et al, 2020).

Surveys in other countries (including Turkey, Oman, China and Ethiopia) show a consistent pattern of high levels of mental distress among healthcare workers during the pandemic (Alan et al, 2020; Badahdah et al, 2020; Wu et al, 2020; Yitayih et al, 2021).

Higher workload, feeling pushed beyond training and making life-prioritising decisions are all found to be predictive of burnout (BMA 2020; Morgantini et al, 2020). Whether exposure to Covid-19 patients increases the risk of poor mental health is uncertain (Amanullah and Ramesh Shankar, 2020).

Some studies find that exposure predicts high rates of burnout (Babore et al, 2020; Kannampallil et al, 2020; Morgantini et al, 2020; Ruiz-Fernández et al, 2020). Others find that frontline workers directly dealing with infected patients appear to experience less burnout, in comparison with other healthcare workers who continue to practice in their usual wards (Giusti et al, 2020; Wu et al, 2020).

A lack of institutional support also increases the risk of poor mental health among healthcare staff. During the pandemic, inadequate access to personal protective equipment (PPE) is predictive of healthcare workers’ mental distress globally (Amanullah and Ramesh Shankar, 2020; Morgantini et al, 2020). Further, insufficient mental health resources – which are acknowledged to be needed to support healthcare workers at the institutional level – has been highlighted as an issue(Alan et al, 2020; Amanullah and Ramesh Shankar, 2020; Martínez-López et al, 2020; Morgantini et al, 2020).

Work-related stress can also affect healthcare workers beyond the working environment. The work-life balance of healthcare workers has been adversely affected by Covid-19, and this is strongly correlated with burnout (Morgantini et al, 2020). Fear of transmitting Covid-19 to family members has also affected medical staff and is associated with higher levels of distress (Wu et al, 2020). Further, healthcare workers report not disclosing mental health difficulties or seeking support for fear of stigma (Galbraith et al, 2020; Yitayih et al, 2021). Concerns about being rejected in their local communities because of hospital work also added to mental distress for healthcare workers at the start of the pandemic (Yitayih et al, 2021).

Are there common trends and lessons across countries?

Poor mental health among healthcare workers is a source of concern both for them and the patients for whom they care. Mental distress of medical staff can negatively affect healthcare through absences, as well as leading to lower quality of care provided.

As a result, providing psychological assistance to healthcare workers may be beneficial both for the individuals directly affected and for their patients. Knowledge of the scale of mental health challenges faced by healthcare workers, and their prevalence, is useful for the design of such psychological interventions.

The first repeated cross-country analyses of mental wellbeing among healthcare workers during the pandemic – run in collaboration with six medical institutions in Italy, Spain and the UK – has collected more than 5,000 responses from medical doctors on their mental wellbeing. The survey was repeated at two points (June 2020 and November/December 2020) during the first two waves of the pandemic (Quintana-Domeque et al, 2021).

Across all three countries, this study finds high risks of anxiety and depression symptoms among medical doctors. Italy had the highest rates of reported anxiety and depression symptoms, while the UK had the lowest. Doctors who are women, who are aged 60 or younger, or who feel vulnerable or exposed at work, as well as those reporting normal or below-normal health, are at particularly high risks. Across time, the study finds no differences in mental health between June and November/December 2020, highlighting a persistent trend in the first and second waves of Covid-19.

These findings are consistent with other studies conducted individually in Italy (Conti et al, 2020, 2021), Spain (Alonso et al, 2021) and the UK (Greene et al, 2021). They are also consistent with existing knowledge on mental health risk factors among healthcare workers – for example, women and those with underlying health conditions being at higher risk (De Kock et al, 2021). The findings from this survey also mirror existing research showing the negative effects of concerns about workplace safety (Cai et al, 2020; Yin and Zeng, 2020) and exposure to Covid-19 (Lai et al, 2020; Lu et al, 2020; Wang et al, 2020) on mental wellbeing.

Are any groups or countries particularly affected?

The study measures risks of anxiety using the Generalised Anxiety Disorder Assessment (GAD-7), and risks of depression with the Patient Health Questionnaire (PHQ-9) (Quintana-Domeque et al, 2021).

Figure 1 shows the prevalence of moderate/above-moderate anxiety (GAD-≥10) and depression (PHQ-9≥10) among medical doctors in Spain, Italy and the UK and over time. In June 2020, the prevalence of anxiety (panel A) was higher in Italy (24.6%) than in Catalonia (15.9%) and the UK (11.7%). At the same time, rates of moderate/above-moderate depression (panel B) were highest in Italy (20.1%), second highest in Catalonia (17.4%), and lowest in the UK (13.7%).

There were no significant differences in the prevalence of anxiety and depression across the two rounds of the survey in any of the three countries, suggesting that the mental health repercussions of the pandemic among medical doctors might be persistent.

Figure 1: Prevalence of anxiety and depression symptoms by country over time

(A) Anxiety

(B) Depression

Source: Quintana-Domeque et al, 2021

Note: Grey bars correspond to Nov 2020 for Catalonia and UK, and to Dec 2020 for Italy. Anxiety symptoms = 1 if GAD-7≥ 10 and depression symptoms = 1 if PHQ-9≥ 10. 95% confidence intervals.

Women, those aged under 60, those who feel more exposed to Covid-19 at work and those reporting normal or below-normal health all face higher risks of both anxiety and depression. Figure 2 shows the differences in the prevalence of moderate/above-moderate symptoms of anxiety and depression among medical doctors by sex and age across countries.

In all three countries in the study, rates of moderate/above-moderate symptoms of anxiety (panel A) and depression (panel B) are higher among women than men. Similarly, younger respondents are more likely to report moderate/above-moderate symptoms of anxiety (panel C) and moderate/above-moderate symptoms of depression (panel D).

Figure 2: Prevalence of anxiety and depression by sex and age across countries

(A) Anxiety by sex

(B) Depression by sex

(C) Anxiety by age

(D) Depression by age

Source: Quintana-Domeque et al, 2021

Note: Grey bars are for women (panel A and B) and over 60 (panels C and B). Anxiety symptoms = 1 if GAD-7≥ 10 and depression symptoms = 1 if PHQ-9≥ 10. 95% confidence intervals.

What support is required and what support is available?

Figure 3 shows perceptions of workplace safety and exposure to Covid-19. Around half (50.1%) of Italian respondents did not agree with the statement ‘my workplace is providing me with the necessary PPE’ in June 2020 (panel A). This fell to 30.1% in December 2020, showing a relatively large improvement in safety measures.

In Catalonia, the percentage was 25.8% in June 2020 and 15.4% in November 2020. In the UK, 16.1% of respondents disagreed with this statement in June 2020 and only 10.1% respondents disagreed in November 2020. The percentage of respondents who agreed with the statement ‘I feel vulnerable and exposed at work’ remained constant between rounds. Italy has the lowest rates of perceived workplace safety, as well as the highest rates of anxiety symptoms.

Panel C reports information on the share of respondents that ‘directly looked after Covid-19 patients last week’. This percentage increased between June and November 2020 in Catalonia and rose strongly in Italy between June and November 2020, from one fourth to over half of respondents (58%). Panel D shows that one in five respondents in Catalonia were aware of at least one Covid-19 death among healthcare workers in their workplace in both June 2020 and November 2020. In Italy, this ratio increased from 31.4% in June 2020 to 40.6% in December 2020. In the UK, it remained relatively stable at around 40%.

Figure 3: Perceptions of safety and Covid-19 exposure in the workplace

(A) Do not have necessary PPE

(B) Feel vulnerable and exposed

(C) Directly treat Covid-19 patients

(D) At least one Covid-19 death at workplace

Source: Quintana-Domeque et al, 2021

Note: Panel A: Percentage of respondents who did not agree with the statement ‘my workplace is providing me with the necessary Protective Personal Equipment’; Panel B: Percentage of respondents who agreed/strongly agreed with the statement ‘I feel vulnerable and exposed at work’; Panel C: Percentage of respondents who ‘directly looked after COVID-19 patients last week’; Panel D: Percentage of respondents who were aware of ‘at least one Covid-19 death among healthcare workers in their workplace’.

It is clear that the pandemic presents serious consequences for the mental health of healthcare workers across countries. They have been directly involved in the management of Covid-19 patients since the beginning of the pandemic, and institutional support is vital to address the challenges they face – from access to protective equipment to improved working arrangements. Making mental health resources readily available and encouraging healthcare workers to seek help should be an essential component of institutional support.

While the wellbeing of healthcare professionals clearly needs to be a policy goal in and of itself, policy-makers should note that supporting healthcare workers also benefits society as a whole. Healthcare workers’ mental health and perceived support will also affect their performance, their attitudes towards their patients as well as their likelihood of leaving their jobs – all of which are crucial variables in fighting the current and future pandemics.

Where can I find out more?

Anxiety and depression among medical doctors in Catalonia, Italy, and the UK during the COVID-19 pandemic: Study by Quintana-Domeque et al, 2021
British Medical Association (BMA) report on the impact of Covid-19 on doctors’ wellbeing
Review article on the impact of COVID-19 on the mental health of healthcare workers
NHS blog article