REVIEW ARTICLE

Anxiety, Depression, Traumatic Stress, Burnout, and Insomnia;

Abstract

The systematic review was to assess the mental health status of healthcare workers due to the COVID-19 Pandemic. For this systematic review, 25 articles were selected manually from 2021 and 2022. The selected articles focused on the effects of COVID-19 on health workers like burnout, insomnia depression, anxiety, and traumatic stress. Original peer-reviewed observational and descriptive studies were identified using PubMed, and Google Scholar engine. Articles revealed a high significance between health care professionals’ post-traumatic stress disorder, sleeplessness, burnout, and depression, whereas few studies mainly indicated the positive correlation between burnout and stress among HCWs, with insomnia highly significant. The systematic review concluded that among healthcare personnel, an elevated risk of developing psychological distress, burnout, sleep quality, and insomnia during the COVID-19 pandemic exists. Our review underlines the requirement for intervention and further longitudinal study designs directed at prevention, treatment, and effective ways to delineate the causation of mental health outcomes in healthcare workers.

Keywords: depression, burn-out, post-traumatic stress disorder, health care providers, COVID-19.

INTRODUCTION

Novel Corona Virus immensely appeared in 2019 and turned out to be a global health concern, as it proved devastating to humankind, distressed society, and an economic disaster [1]. The virus was similar to the previous pathogens like SARS-CoV cases reported, MERS-CoV (Middle East respiratory syndrome coronavirus) discovered in the patient’s sputum, linked to the death as another novel coronavirus reported in the history of medicine [1]. This innovative virus was highly destructive with terrible outcomes mentally, physically, and socially for the world. The pathway of conversion of a Pandemic situation to an Epidemic, Alpha to Omni, and symptoms presenting as simple flu to being admitted to ICU, this virus has exposed itself like no other outbreak found in the modern world and history [1]. Moreover, the wrathful virus has been found destructive for all races, and socioeconomic communities of all ages. Who can forget the quarantine, isolation, lockdowns, and social distancing? Like others, the unprecedented time of the deadly COVID-19 was also perplexing for the public health custodian. Especially the health care providers who performed their duty on-site when all other professionals were working from home [2]. This virus has shaken the globe, which still tries to heal through prevention. Despite, all the management and protection many healthcare providers are still facing psychological instability due to this deadly virus.

The second and more deadly version came out at the end of 2019, and initially, the disease became fatal to China [2]. It was noted when patients with acute pneumonia and multiple symptoms appeared out of nowhere in Wuhan, China [3]. Later, a novel version of the coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the sickness known as coronavirus disease 2019 [4]. Nonetheless, this time in November 2020 the disastrous virus shocked the world with its consecutive cases reported worldwide; with a huge number of cases i.e. 48,539,872 COVID-19 diseased cases and 1,232,791 deaths due to COVID-19 became terrifying for healthcare teams and policymakers. The deadly COVID-19 engulfed around 215 countries and territories [5]. Pakistan is listed among those unfortunate countries according to the COVID-19 dashboard and situation updates provided by the Ministry of National Health Services Regulation and Cooperation on November 14, 2020. Pakistan currently has confirmed cases totaling 354,461, new cases 2,165, recovered cases 322,414 (98%), and the deaths count is 7109 (2%), with the first case being reported on February 25, 2020 [6].

While the catastrophic COVID-19 was challenging to Politicians, Economists, and Scientists, the most challenging situation was for the health workforce. Although the healthcare providers were gravely affected, still they played a major role to tackle this dilemma and

persistently provided essential care to patients. The

disease affected front-line workers in a way that they lost their physical as well as mental stability while fighting against it. Various scholars have highlighted this issue in the literature that COVID-19 is extremely dangerous

Liaquat National Journal of Primary Care 2024; 6(2): 157-164 ISSN: 2708-9134 (Online) (All articles are published under the Creative Commons Attribution License) 157

as the spread among the front healthcare providers is higher among them. According to preliminary estimates, front-line healthcare providers [6, 7] may make 10–20% of all diagnoses including minority, Asian, and Black ethnicity at risk [8]. A report by WHO in 2021 estimated the number of healthcare worker’s death as the sum of 6633 globally out of which European 1395, Americas 4858, Eastern Mediterranean 302, and Western Pacific 78 while Africa and South Africa counted zero. Hence, this COVID-19 surveillance database from January 2020 to May 2021 indicates COVID-19 severity for healthcare workers [8].

Since the healthcare force cannot perform their work from home even during such events, have dual burdens and more responsibilities like overtime, more patient load, and an imbalance work life. Therefore, they are more likely to get affected by the COVID and other psychological effects such as stress, burnout, lack of sleep, anxiety even depression, and addiction have also been reported. Another study found evidence of this group’s mental health and psychological welfare which had been recognized as a significant healthcare concern, as shown by the rising incidence of stress, burnout, depression, drug and alcohol dependence, and suicide across various levels of health professionals, in multiple countries [9]. Brooks also explained psychological impacts and affirmed that most healthcare practitioners are psychologically strong individuals who have had training and experience in coping with disease and death [10].

Many studies demonstrated that employees on the treatment team suffered from depression and anxiety during the COVID-19 pandemic. Coping with the critical situation puts medical personnel at risk of mental and emotional disorders. Stress is the most important risk factor as long-term stress can increase the risk for infection. Healthcare providers’ high-quality performance and competence depend on the mental health and severity of the perceived as this leads to good services to patients [11].

Frontline healthcare workers’ mental and emotional health was affected by COVID-19 due to extreme situations like life-and-death decisions that increased the risk of infection and aggravated previous psychiatric conditions [12].

As this issue has arisen across the world, the front- line workforce of Pakistan has been bearing the same concern as highlighted by a recent cross-sectional study among 112 participants, conducted in May 2020 at several hospitals located in Karachi, Pakistan. While Using the Depression Anxiety Stress Scale-21 (DASS- 21) the results were alarming as the average scores for stress, depression, and anxiety were 20, 12, 10, 19, and 9. A prevalence of 85.7% for moderate to extremely severe anxiety, 72.3% for moderate to extremely severe sadness, and 90.1% for moderate to intense tension was

noted [13]. This is a huge concern for the psychological condition of healthcare professionals comprising of nurses, physicians, pharmacists, and paramedics as they play an important role in the provision of efficient care, hence reducing morbidity and death [14]. The purpose of this systematic review is to identify the effect of Corona Virus Disease-2019 on the mental health status of healthcare providers from existing literature. Multiple studies have been conducted in Pakistan and globally using various study designs. The data for this review were taken from multiple studies conducted nationally and globally as well to answer our research question of whether anxiety, depression burnout, and insomnia affected healthcare providers during COVID-19.

MATERIALS AND METHODS

Study Design and Setting

To assess the psychological symptoms of depression, anxiety, traumatic stress, and insomnia among Health care providers throughout the COVID-19 Pandemic evolution a systematic review was conducted, as per the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For the systematic review, we selected 25 articles published during one year, in 2021 and 2022. The selected articles were focused on Health Care Workers’ mental health impaired due to COVID-19 Pandemic leading to depression, anxiety, traumatic stress, burnout, and insomnia.

Data Sources

This review aimed to investigate the latest literature on depression, anxiety, traumatic stress, and insomnia among healthcare providers during the COVID-19 pandemic. The study searched for original observational and descriptive studies from Scopus, PubMed, and Google Scholar between 2021 and 2022, with a focus on web-based surveys. The study excluded systematic reviews and studies with less than 30 participants. The authors independently participated in each phase of the review, including screening, eligibility, and inclusion. The selection process involved manual review and physical gathering of articles, with only English-language articles considered for the study. The study included global articles with a particular emphasis on articles specific to Asia. The articles related to healthcare professionals working in hospitals, medical centers, and clinics who treat COVID-19 patients were eligible. The study also included published articles where healthcare workers such as doctors, pharmacists, nurses, biomedical staff, OT technicians, and other front-line professionals reported information on the psychological impact of COVID-19. The review provided insight through a widespread analysis of the latest literature on the psychological impacts of the COVID-19 pandemic on healthcare providers, highlighting the importance of supporting their mental health during this challenging time.

Search Strategy

To conduct the study, we made the strategy to search using Boolean search strategies for the following keywords in the title

“Depression*” OR “Sadness” OR “Sorrow” AND “Anxiety*” AND “Stress*” OR “Tension” AND “Insomnia*” OR “Sleeplessness” OR “Sleep Disorder” OR “Lack of Sleep” AND “Frontline* AND Health Care Professionals*” OR “Healthcare Workers” OR “Healthcare Providers” OR “Frontline Staff” OR “Hospital Staff”, AND “COVID-19*” OR “Corona Outbreak” OR “COVID-19 Pandemic” OR “Corona Virus Disease” OR “Corona”, Depression AND Anxiety AND Traumatic Stress AND Insomnia among Health Care Workers during COVID-19 OR Anxiety among Health Care Workers during Corona Outbreak OR Psychological Distress due to Pandemic among HCWs OR Post Traumatic Stress among Frontline Healthcare force due to COVID OR Impacts of Corona Outbreak on Mental Health of Health Care Workers OR Burnout AND Depression among HCWs Due to Corona OR Pandemic effects on Mental Health of Health Care Workers AND Psychological response of Health Care Professionals against Pandemic OR Psychological responses of Hospital-Based Nurses against COVID-19 OR Psychological effects of COVID-19 on Paramedical Staff.

Study Selection

For the review, the selection of publications is based on their titles, abstracts, eligibility criteria, and findings. It also looked at factors including demographic state, gender, physical and mental health, profession, job hours, and direct interaction with COVID-19 wards and COVID-19 patients.

Furthermore, only papers written on COVID-19 Pandemic and its psychological effects were Peer Reviewed, published in English, and met eligibility requirements were included in the final report.

For the review, suitable studies selected were Cross- Sectional, Longitudinal Online Survey, Correlation study, and Prospective Cohort studies, besides that Study Reports, Incident Reports, and any articles with sample sizes of fewer than 30 were omitted from the study.

RESULTS

The search identified using the Boolean searching method and shortlisted 83 studies from PubMed, google scholar, and Scopus that were related closely to mental health and COVID-19 among healthcare workers (Fig. 1). After removing duplicates or unavailability of full-text, articles 58 publications were retrieved, to fulfill the requirements for inclusion in the study. The titles and abstract of 32 studies were reviewed and due to a lack of specificity for depression, anxiety, post-traumatic stress, burnout, and insomnia among healthcare providers, 25 studies were extracted meeting eligibility criteria and finally full text was assessed. The extracted studies had 21 cross-sectional studies, 02 were correlation and 02 were longitudinal online surveys. The findings of extracted articles have been organized in Table 1.

A review of 25 studies exhibited that depression was reported by 10 studies [13-21], twelve studies identified anxiety [13-15, 17-26], post-traumatic stress was present in 15 studies [13, 14, 16, 17, 20, 22, 24, 25, 27-33] among

healthcare professionals globally. Furthermore, the other reported conditions were burnout, lack, and burnout of sleep. Of the selected articles only 05 studies showed a positive association between burnout [13, 22, 34-36], 08

studies showed insomnia [15, 16, 18, 24, 29, 30, 36, 37] and 06 studies showed worsened sleep quality [19-21, 25, 36, 37] among HCWs during COVID-19.

DISCUSSION

Healthcare workers (HCWs) who were directly and indirectly, combatting the pandemic were under a great deal of stress because of COVID-19’s swift global spread, potentially raising the threat of adverse effects on mental health [38]. Unfortunately, there have been high incidents of suicides among medical workers as they deal with mounting psychological pressure and a strong fear of passing away [15]. The crisis’ psychological effects were felt by healthcare professionals from various disciplines, even surgeons and anesthesiologists, in addition to frontline healthcare providers like doctors, nurses, and paramedic staff specifically respiratory and intensive care units [16].

It was discovered that 36.7% of participants had severe levels of PTSD symptoms, and 56.8% of participants exhibited PTSD symptoms as in studies from China (53.8%) [17]. New York, US (57%) Italy (55%) [18]

Spain (56.6%) [19] and the UK (60.6%) Chinese nurses (16.8%), Mexican nurses (27.7%), Italian nurses (36.7%) [17]. Additionally, a recent research review revealed that 11.4% to 74.4% of HCPs experience PTSD symptoms [20].

Table 1: Characteristics of the selected research studies.

There is abundant evidence from cross-sectional research indicating frontline HCWs who come forward to join the COVID-19 outbreak response team underwent increased workload and burnout to a very high degree [21-26].

This review presented findings regarding mental health issues among HCWs during the COVID-19 pandemic. HCWs experienced a variety of things, including an increased workload and a shortened rest schedule, anxiety, and insomnia, which increased their susceptibility to high levels of stress.

The review showed that mental health issues such as depression, PSTD, burnout, and anxiety might arise among HCWs during the COVID-19 pandemic; however, other causes may also increase the possibility of depression, anxiety, traumatic stress insomnia, and burnout. Along with COVID-19 among other reasons like HCW imbalance work and life, physical health of staff, and workplace environment may provoke such illnesses overall.

Furthermore, this review is an effort to add more value to the present literature. Patient advocacy groups and charitable foundations have been noted to advocate for millions of the affected people who had no voice for their incapacitating conditions more than healthcare institutions and decision-makers in the field of global health. Numerous social media platforms are working around the clock to generate money for research, create clinician groups, and encourage the government to support its efforts to combat COVID-19. However, still, there is a need to focus on healthcare staff too who never stood behind in to win the battle against Corona Virus.

To our knowledge, the study has many significant points there are very fewer studies conducted on this eye- opening fact in Pakistan, but it has several limitations such as the data collected from secondary sources, which should be ideally conducted on primary respondents too for identifying the potential risks for psychological impact. Meanwhile, the study emphasized causality only which also needs to be considered further in the future.

CONCLUSION

In this systematic review, we conclude that among healthcare providers, a great threat of developing psychological distress, sleep quality, and insomnia during the COVID-19 pandemic exists. The review emphasized the importance of the mental health of frontline healthcare personnel, during the COVID-19 Pandemic

situation with a greater chance to develop depression, anxiety, traumatic stress, burnout, and insomnia among frontline healthcare workers in Pakistan.

Our review underlines the requirement for intervention and further longitudinal study designs directed at prevention, treatment, and effective ways to delineate the causation of mental health outcomes in healthcare workers. Hence, to prevent such risks policymakers should develop strategies to take preventive actions for the well-being and performance of healthcare providers.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

The authors have contributed substantially to the design, contributed to study for important intellectual content, and drafting of the manuscript.

REFERENCES

020-0372-4

https://doi.org/10.15585/mmwr.mm6915e6

https://doi.org/10.15537/smj.2021.42.3.20200812