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Vol. 16. Núm. S1.
Psycho-COVID: Long-term effects of COVID19 pandemic on brain and mental health
Páginas 1-10 (Enero - Marzo 2023)
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Vol. 16. Núm. S1.
Psycho-COVID: Long-term effects of COVID19 pandemic on brain and mental health
Páginas 1-10 (Enero - Marzo 2023)
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Long-term mental health impact of COVID-19 on primary care health workers in northern Spain: Results from a two-phase longitudinal study
Impacto a largo plazo de la pandemia COVID-19 en la salud mental de profesionales de Atención Primaria en el norte de España; resultados de un estudio longitudinal de doble fase
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Ana Viejo Casasa, Marcos Gómez-Revueltab,c, Urko Merino Garayd, Francisco Ruiz Guerrerob, Mario Ruiz Núñeze, Patricia Fernández Sollab, Roberto Garrastazu Lópezf, Juan Carlos López Carog, Elsa García Rumayorb, Laura Boada Antónb, María Juncal Ruizc,h, Víctor Ortiz-García de la Fozb, Javier Vázquez-Bourgonb,c,
Autor para correspondencia
javier.vazquez@scsalud.es

Corresponding author.
a Pisueña-Cayón Primary Care Centre, Sarón, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
b Department of Psychiatry, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
c Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Seville, Spain
d Santoña Primary Care Centre, Santoña, Spain
e Miera Primary Care Centre, Liérganes, Spain
f Alto Pas Primary Care Centre, Ontaneda, Spain
g Cotolino Primary Care Centre, Castro Urdiales, Spain
h Department of Psychiatry, Hospital Sierrallana, Universidad de Cantabria, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
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Table 1. Socio-demographic and occupational characteristics of the study samples.
Table 2. Long-term differences in self-reported psychological symptoms among primary care health professionals in Cantabria.
Table 3. Long-term differences in quality of life and other self-reported experiences related to COVID-19 pandemic in primary care professionals in Cantabria.
Table 4. Correlation analyses between phase 1 and phase 2 evaluations (self-reported versus psychiatrists evaluations) of Primary Care professionals in Cantabria during the COVID-19 pandemic.
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Vol. 16. Núm S1

Psycho-COVID: Long-term effects of COVID19 pandemic on brain and mental health

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Abstract
Background

COVID-19 pandemic has affected the mental health of the general population, and in particular of health professionals. Primary care personnel are at greater risk due to being highly exposed to the disease and working regularly in direct contact with patients suffering COVID-19. However, there is not sufficient evidence on the long-term psychological impact these professionals may suffer. We aimed to explore the long-term psychological impact of COVID-19 on primary care professionals.

Methods

We applied a two-phase design; a self-reported psychopathology screening (PHQ-9, GAD-7, ISI and IES-R) in phase-1, and a specialised psychiatric evaluation (MINI, HDRS and STAI) in phase-2 to confirm phase-1 results. Evaluations were carried at the beginning of the pandemic (May–June 2020) (n=410) and one year later (n=339). Chi-square, ANOVA and logistic regression tests were used for statistical analyses.

Results

Primary care professionals presented high rates of depression, anxiety and psychological distress, measured by PHQ-9, GAD-7 and IES-R respectively, during the pandemic. Depressive symptoms’ severity (PHQ-9: 7.5 vs 8.4, p=0.013) increased after one year of COVID-19 pandemic. After one year nearly 40% of subjects presented depression. Being women, having suffered COVID-19 or a relative with COVID-19, and being a front-line professional were risk factors for presenting depression and anxiety.

Conclusion

Primary Care professionals in Cantabria present a poor mental health during COVID-19 pandemic, which has even worsened at long-term, presenting a greater psychopathology severity one year after. Thus, it is critical implementing prevention and early-treatment programmes to help these essential professionals to cope with the pandemic.

Keywords:
Psychological impact
COVID-19
Pandemic
Long-term
Resumen
Antecedentes

La pandemia de COVID-19 ha afectado la salud mental de la población general, y en particular de los sanitarios. El personal de atención primaria tiene mayor riesgo por estar más expuesto a la enfermedad y trabajar regularmente en contacto directo con pacientes que padecen COVID-19. Sin embargo, no existe suficiente evidencia sobre el impacto psicológico a largo plazo que pueden sufrir estos profesionales. Nuestro objetivo fue explorar el impacto psicológico a largo plazo de COVID-19 en los profesionales de atención primaria.

Métodos

Se aplicó un diseño en dos fases; un cribado de psicopatología a través de cuestionarios autoaplicados (PHQ-9, GAD-7, ISI e IES-R) en la fase 1, y una evaluación psiquiátrica especializada (MINI, HDRS y STAI) en la fase 2 para confirmar los resultados de la fase 1. Las evaluaciones se realizaron al inicio de la pandemia (mayo-junio de 2020) (n = 410) y un año después (n = 339). Se utilizaron pruebas de X2, ANOVA y regresión logística para los análisis estadísticos.

Resultados

Los profesionales de atención primaria presentaron índices elevados de depresión, ansiedad y malestar psicológico, medidos por PHQ-9, GAD-7 e IES-R, respectivamente, durante la pandemia. La severidad de los síntomas depresivos (PHQ-9: 7,5 vs 8,4; p = 0,013) aumentó tras un año de pandemia COVID-19. Después de un año, casi 40% de los sujetos presentaron depresión. El sexo femenino, haber padecido COVID-19 o tener un familiar con COVID-19 y ser profesional de primera línea fueron factores de riesgo para presentar depresión y ansiedad.

Conclusiones

Los profesionales de Atención Primaria en Cantabria presentaron una mala salud mental durante la pandemia de COVID-19, la cual además empeoró a largo plazo, presentando una mayor gravedad los síntomas un año después. Por lo tanto, es fundamental implementar programas de prevención y tratamiento temprano para ayudar a estos profesionales esenciales a hacer frente a la pandemia.

Palabras clave:
Impacto psicológico
COVID-19
Pandemia
Largo plazo
Texto completo
Introduction

The COVID-19 pandemic, caused by SARS-CoV-2 virus, has rapidly spread world-wide since the pandemic was declared in the early months of 2020. Given the highly contagious capacity of this new SARS-CoV-2 coronavirus, WHO recommended limiting human-to-human transmission by reducing secondary infections among close contacts and healthcare workers, preventing transmission amplification events, and preventing further international spread.1 The SARS-CoV-2 virus is producing a serious impact on physical health and it entails a significant risk for life with an observed excess mortality.2 Apart from the serious threats to people's physical health and lives that is being caused by the COVID-19 pandemic, the fears, uncertainties and strict measures of quarantine and home-confinement (leading to people isolation) can have a detrimental impact on mental health and would be contributing to an increasing incidence of mental health problems. Several studies have shown from the early phases of the pandemic a wide psychological impact in the general population3–5 in relation to the COVID-19 pandemic. In Spain high rates of depressive and anxiety symptoms were also reported at the beginning of the pandemic,6 having even increased among general population during the pandemic.7

Health professionals are at particular high risk of suffering a psychological effect from the pandemic.8 For instance, a recent study reported that among 994 medical staff working in Wuhan, the majority experienced psychological impact measured by the PHQ-9 scale.9 In the same line, Lai and colleagues10 in their cross-sectional, survey-based study on 1257 healthcare workers, observed that a substantial proportion of participants reported symptoms of depression (50.4%), anxiety (44.6%), insomnia (34.0%), and distress (71.5%). Similarly, in Spain, healthcare staff reported symptoms of anxiety, depression and post-traumatic stress disorder (PTSD).11 However, despite being one of the most affected countries by the pandemic, Spain seemed to have a lower rate of medical staff with psychological problems, according to a survey-based study with healthcare workers of eight different European countries.12

Several risk factors for presenting more severe psychological symptoms have been identified in relation to the COVID-19 pandemic, such as gender (women) and working at the healthcare frontline and in high-exposure units.9,10,13,14 The gender differences are in line with those observed in the general population where female citizens reported higher degrees of the psychological impact of the outbreak, stress, anxiety, and depression.5 Similarly in Spain it has been described an association between being women or working at the front-line, with an increased risk of having a greater psychological impact.11 Age was also described as a risk factor, where younger professionals were the most affected by these symptoms.15

The main objective of this study was to evaluate the psychological impact of COVID-19 pandemic in public health care workers in Primary Care in Cantabria. Secondly, we aimed to explore if there are specific risk factors for a greater psychological impact from COVID-19 exposure. Taking into account the previously described scientific evidence, we hypothesised that primary care health professionals will present psychological symptoms, such as anxiety, depression, insomnia or post-traumatic symptoms, in relation to the COVID-19 pandemic. Furthermore, gender (women), age (younger) and being first-line health professionals will convey a greater risk of presenting a psychological impact.

Material and methods

This work has been carried out in Cantabria (northern Spain), between May 2020 and June 2021.

Design

We designed a prospective longitudinal two-phase study.16,17 The phase 1 consisted in a wide (regional level) screening (self-applied scales) of psychological symptoms among Primary Care professionals. This screening was carried out at baseline, between May and June 2020, and one year later, between May and June 2021. The phase 2 consisted in a more detailed and specialised mental health evaluation of a sub-sample of the study population at baseline.

Study population and survey process

The study was focused on health professionals working at Primary Care in Cantabria (Servicio Cántabro de Salud). After getting institutional approval, the survey was sent to Primary Care personnel through email. A specifically short and quick survey was designed to facilitate completing it. Data from completed surveys were exported to the study database and stored at the IDIVAL centre. After completing the phase-1 survey (screening) subjects were invited to participate in the phase-2 of the study, a specialised mental health examination through personal interviews with trained psychiatrists. Finally, and in order to explore the long-term psychological impact of the pandemic, the Phase 1 (screening survey) was again repeated one year later; subjects who have respond to baseline surveys was invited to participate 1 year later.

All subjects gave written informed consent before participating in the study (for both phases of the study). The study was approved by the Research Ethics Committee of Cantabria (CEIm of Cantabria). Subjects’ data was managed confidentially following national and international regulations.

Clinical evaluationPhase 1: screening through self-reported survey

The phase 1 of the study consisted in a self-reported survey that included a mental health evaluation and an ad-hoc designed questionnaire on socio-demographic and occupational characteristics, a COVID-19 exposure and self-perceived health-related quality of life, on a Likert-type scale (between 1 – minimum- and 7 – highest-scores).

Mental health status was assessed through a set of validated self-rated scales. The 9-item Patient Health Questionnaire (PHQ-9) to evaluate severity of depressive symptoms: minimal/no depression (0–4), mild depression (5–9), moderate depression (10–14), moderately severe depression (15–19) or severe depression (20–27).18 “Probable depression” was defined as a score of 10 or greater on the PHQ-9.19 The 7-item Generalised Anxiety Disorder (GAD-7) to evaluate anxiety severity: minimal/no anxiety (0–4), mild anxiety (5–9), moderate anxiety (10–14), or severe anxiety (15–21).20 “Probable anxiety” was defined as a score of 10 or greater on the GAD-7.21 The 7-item Insomnia Severity Index (ISI) measures insomnia severity: normal (0–7), subthreshold (8–14), moderate insomnia (15–21), or severe insomnia (22–28).22 And the 22-item Impact of Event Scale-Revised (IES-R) evaluates psychological distress to a specific stressful life event (the occurrence of COVID-19 in this case): subclinical (0–8), mild distress (9–25), moderate distress (26–43), and severe distress (44–88).23 In this study scoring over 33 was considered as a cut off for a “probable PTSD case or psychological distress”.24

Suicidality was assessed through the item 9 of the PHQ-9 scale, which evaluates passive thoughts of death or self-injury within the last two weeks, and is often used to screen depressed patients for suicide risk.25

Phase 2 – Specialised mental health evaluation

The second phase of the study consisted in a specialised mental health evaluation carried out by experienced psychiatrists. This mental health assessment included the MINI International Neuropsychiatric Interview26 Spanish version 5.0.0; the MINI is a brief structured diagnostic interview that explores the main psychiatric disorders (from DSM-IV and CIE-10) allowing its identification and diagnostic orientation, while presenting good psychometric properties (inter-observer reliability-kappa value 0.75, test–retest reliability 0.75).

To evaluate depression severity we used the 17-item version of the Hamilton Depression Rating Scale (HDRS).27 Each item is rated between 0 and 2 points in some cases, and between 0 and 4 in others, ranging the total score between 0 and 52 points. Different specific indices have been defined: (a) Melancholy index, made up of items 1 (depressed mood), 2 (feeling of guilt), 7 (work and activities), 8 (inhibition), 10 (psychic anxiety) and 13 (general somatic symptoms); (b) Anxiety index, made up of items 9 (agitation), 10 (psychic anxiety) and 11 (somatic anxiety); and (c) Sleep disturbance index, formed by the three items referring to insomnia (i.e.: 4, 5, 6). The HDRS has good psychometric properties, with good internal consistency (Cronbach's alpha between 0.76 and 0.92), intra-class correlation coefficient of 0.92, and inter-observer reliability between 0.65 and 0.9.

Finally, we used the State-Trait Anxiety Inventory (STAI) to assess anxiety.28 The STAI assess anxiety as a state (momentary, transitory) and anxiety as a trait (as a more stable condition). It is made up of 40 items divided into 2 subscales: trait and state, with Likert-type responses from 0 to 3.

Previous personal psychiatric history and prescription of psychiatric treatments, and substance use (tobacco and alcohol) were explored specifically during this clinical interview.

Statistics

Chi-square and ANOVA analyses were performed to compare qualitative and quantitative variables between the two groups. Binary logistic regression was run to determine the effect of gender (women), age, being first-line health worker, and COVID-19 direct exposure (having had COVID-19 and/or having had a relative with COVID-19) on presenting a probable depression (PHQ-910) or anxiety (GAD-710). The Statistical Package for Social Science (SPSS) version 23.0 (IBM Corp., Armonk, NY, USA) was used for statistical analyses. All statistical tests were two-tailed and significance was determined at the 0.05 level.

ResultsEnrolment and sample description

A total of 410 healthcare workers participated in this survey at baseline, and 339 one year after (Table 1), almost reaching the 20% of the target population. At both time-points, a majority of participants were women (72.9 and 71.9%, respectively). Most of the subjects were Medical doctors (43.6 and 47.5%) or nurses (27.9% and 27.1%) and they majorly work in primary care teams (57.1% and 47.2%) while 33.6% work in primary care emergency walk-in teams. The mean age of the study sample was 48 years at both time-points. As shown in Table 1 we found no significant differences in the sociodemographic and occupational characteristics between both time-points.

Table 1.

Socio-demographic and occupational characteristics of the study samples.

  Baseline1 yearTotal     
  N=410N=339N=749     
  Mean  SD  Mean  SD  Mean  SD  Statistic  Value  p 
Age  48.2  10.3  48.0  9.6  48.1  10.0  t  0.292  0.770 
  N  N  N       
Gender (women)  299  72.9  244  71.9  543  72.5  X2  0.062  0.803 
Civil status              Fisher  3.719  0.289 
Single  75  18.4  45  13.3  120  16.1       
Married or couple  296  72.5  264  77.9  560  75.0       
Divorced or widowed  37  10  30  8.9  67       
Educational level              X2  1.702  0.427 
Secondary education or lower  45  11  31  9.2  76  10.2       
University education  363  89.0  308  90.9  671  89.8       
Occupation              X2  8.540  0.481 
Doctor  178  43.6  161  47.5  339  45.4       
Nurse  114  27.9  92  27.1  206  27.6       
Administrative  35  8.6  29  8.6  64  8.5       
Emergency sanitary technician  27  6.6  28  8.3  55  7.4       
Physiotherapist  16  3.9  14  4.1  30  4.0       
Midwife  17  4.1  2.4  25  3.4       
Social worker  12  2.9  1.5  17  2.3       
Cleaning service  2.2  0.6  11  1.5       
Place of work              X2  7.760  0.051 
Primary care team  233  57.1  160  47.2  393  52.6       
Primary care emergency team  125  30.6  122  36.0  247  33.1       
061 Ambulance service team  26  6.4  29  8.6  55  7.4       
Other  24  5.9  28  8.3  52  7.0       
Residential area              X2  1.414  0.814 
Urban area (>10,000 inhabitants)  212  52.0  177  52.2  389  52.1       
Small urban area (2,000–10,000)  131  32.1  104  30.7  235  31.5       
Rural area (<2,000 inh.)  65  15.9  58  17.1  123  16.4       
Prevalence of self-reported psychological symptoms among primary care health professionals and long-term differences

Participants reported important depressive symptomatology, with 30% of them reporting a score of probable depression at the beginning of the COVID-19 pandemic (Table 2). This rate significantly increased after 1 year, reaching up to 39% of the participants. This change was in parallel with a significant increase in the mean PHQ-9, from 7.5 to 8.4 (p=0.013). We observed no significant changes in the mean GAD-7 or in the proportion of subjects reaching a score suggestive of “probable anxiety disorder”, which remained around 30% of the study population. Insomnia, as reported through the ISI, was very common among primary care health workers, although we found no significant differences after 1 year of COVID-19 pandemic. Mean IES-R score did not differ at 1 year compared to baseline self-evaluation. Despite this, it is noteworthy to highlight that around 20% of primary care professionals reached a scoring suggestive of “probable PTSD” at both time-points.

Table 2.

Long-term differences in self-reported psychological symptoms among primary care health professionals in Cantabria.

  Baseline1 yearTotal     
  N=410N=339N=749     
  Mean  SD  Mean  SD  Mean  SD  Statistic  Value  p 
PHQ-9 total  7.5  4.6  8.4  5.8  7.9  5.2  t  −2.487  0.013 
GAD-7 total  7.1  4.6  7.2  5.4  7.2  5.0  t  −0.329  0.743 
ISI total  8.5  5.5  8.2  5.8  8.4  5.6  t  0.597  0.551 
IES-R total  20.3  16.7  19.7  18.3  20.0  17.4  t  0.463  0.643 
  N  N  N  Statistic  Value  p 
PHQ-9              X2  17.930  0.003 
No depression – minimal  123  30.1  105  30.9  228  30.5       
Mild depression  161  39.5  102  30.1  263  35.2       
Moderate depression  88  21.6  77  22.7  165  22.1       
Moderately severe depression  32  7.8  38  11.2  70  9.4       
Severe depression  1.0  17  5.0  21  2.8       
Probable depression (PHQ-910)  124  30.4  132  38.9  256  34.3  X2  6.003  0.014 
Probable anxiety (GAD-710)  124  30.4  112  33.0  236  31.6  X2  0.600  0.439 
ISI              X2  2.595  0.458 
No insomnia  194  47.5  162  47.8  356  47.7       
Insomnia, subclinical  145  35.5  122  36.0  267  35.7       
Insomnia, moderate severity  64  15.7  46  13.6  110  14.7       
Insomnia, severe  1.2  2.7  14  1.9       
IES-R              X2  2.198  0.532 
Absence  257  63.0  225  66.4  482  64.5       
Clinical issue  65  15.9  44  13.0  109  14.6       
Probable PTSD  14  3.4  2.4  22  2.9       
Severe problem  72  17.6  62  18.3  134  17.9       
Probable PTSD case or psychological distress (IES-R>33)  81  19.9  68  20.1  149  19.9  X2  0.005  1.000 

Abbreviations: PHQ-9: Patient Health Questionnair-9; GAD-7: Generalised Anxiety Disorder-7; ISI: Insomnia Severity Index; IES-R: Impact of Event Scale-Revised; PTSD: posttraumatic stress disorder.

Regarding suicidality, the proportion of subjects having passive suicidal thoughts increased from baseline to 1-year follow-up (7.1% vs 11.2%, x2=3.815, p=0.051). At baseline, 27 participants (7.1%) reported having had thoughts of death or self-injury in the previous 2 weeks “several days” (5.4%), “more than half the days” (1.5%), or “nearly every day” (0.2%). While at 1-year follow-up 38 subjects (11.2%) informed having passive suicidal thoughts in the last 2 weeks “several days” (8.0%), “more than half the days” (1.5%), or “nearly every day” (1.7%).

Risk factors for self-reported psychological impact during COVID-19

Associations analyses showed a significant relation between presenting a PHQ-9 of probable depression (10 or above) with gender (39% of women vs 21.8% of men; X2=19.496, p<0.001), being first-line health worker (35.4% versus 25.3 of non-first line professionals; X2=3.335, p=0.085) and having suffered COVID-19 (52.6% vs 32.8%; X2=9.236, p=0.003). Age was not significantly associated with presenting depression (p>0.05). Similarly, we observed a significant association between reporting a probable anxiety disorder (GAD-7 of 10 or above) and gender (34.9% of women vs 22.8% of men; X2=10.140, p=0.001), being first-line health worker (32.8% versus 21.7% of non-first line professionals; X2=4.240, p=0.045), having suffered COVID-19 (45.6% vs 30.4%; X2=5.613, p=0.025) and having a close relative who had suffered COVID-19 (43.8% vs 30.5%; X2=4.787, p=0.035). We observed a tendency towards statistical significance when exploring the associations between age and anxiety (F=3.815; p=0.051); those subjects with anxiety (GAD-710) were younger (mean age 47 years) than those without anxiety (mean age 48.6 years).

Logistic regression analyses showed gender (women) (b=0.914, z=4.686, p<0.001), having suffered COVID-19 (b=0.895, z=0.019, p=0.005) and being first-line professionals (b=0.672, z=2.432, p=0.015) as predictive factors for “probable depression”. Similarly, the results showed that gender (women) (b=0.914, z=4.686, p<0.001), age (b=−0.017, z=−2.115, p=0.034) and being first-line professionals (b=0.788, z=2.713, p<0.007) were predictive factors for “probable anxiety”. However, both models showed a small R2 Nagelkerke (0.065 and 0.053 respectively), not allowing a full explanation of the variability.

Health workers’ perceived quality of life and other self-perceived reports related to the COVID-19 pandemic

As shown in Table 3, the mean self-perceived quality of life and health status were good (above 4=“normal”). However, these items were scored significantly lower after 1 year of the pandemic, reflecting a statistically significant decrease in the self-perceived health status and quality of life of health workers in the study. In line with this, primary care professionals perceived that their health status and quality of life had worsened compared to before the COVID-19 pandemic. Participants also reported a perception of having been clearly exposed to SARS-CoV-2 at their work. Participants perceived not having had access to the appropriate individual protection equipment and having received poor institutional support during the pandemic. However, these perceptions significantly improved 1 year after. It is noteworthy the significant increase of primary care professionals having suffered from COVID-19 after 1 year of the pandemic breakout.

Table 3.

Long-term differences in quality of life and other self-reported experiences related to COVID-19 pandemic in primary care professionals in Cantabria.

  Basal1 yearTotal     
  N=410N=339N=749     
  Mean  SD  Mean  SD  Mean  SD  Statistic  Value  p 
How is your overall health status today?a  5.5  1.1  4.9  1.2  5.2  1.2  t  6.299  <0.001 
How has it changed compared to before COVID-19?b  3.8  1.0  3.6  1.2  3.7  1.1  t  1.311  0.190 
How is your current quality of life?a  5.0  1.3  4.5  1.3  4.8  1.3  t  4.704  <0.001 
How has it changed compared to before COVID-19?b  3.4  1.1  3.6  1.3  3.5  1.2  t  −2.262  0.024 
Do you consider that you have been exposed to SARS-CoV-2 due to the performance of your work?c  5.9  1.2  6.0  1.2  5.9  1.2  W  66,360.0  0.315 
Do you consider that you have been exposed to SARS-CoV-2 out of work?c  3.9  1.6  4.2  1.5  4.0  1.6  t  −2.563  0.011 
Do you consider that you have had access to appropriate individual protection equipment?c  3.5  1.7  4.4  1.9  3.9  1.8  t  −7.197  <0.001 
Have you felt supported by the institution you work for?c  3.0  1.6  3.4  1.7  3.2  1.7  t  −3.595  <0.001 
  N  N  N  Statistic  Value  p 
Have you been sick from COVID-19? (Yes)  15  3.7  42  12.4  57  7.6  X2  19.943  <0.001 
Have you lived with COVID-19 patients? (Yes)  13  3.2  51  15.0  64  8.6  X2  33.235  <0.001 
a

Likert-type scale 1–7 (1=Very poor, 7=Excellent).

b

Likert-type scale 1–7 (1=Much worse, 7=Much better).

c

Likert-type scale 1–7 (1=Disagree, 7=Strongly agree).

We observed a significant association between presenting depression or anxiety and most of quality of life and self-perceived experiences’ variables. Thus, those subjects reporting depression or anxiety, presented a significantly poorer health-related quality of life than those without depression or anxiety (see Supplementary material 1). Moreover, depression and anxiety were significantly associated with a perception of poorer institutional support and poorer access to appropriate individual protection equipment.

Phase-2 results and correlations between phase 1 and phase 2 evaluations

Phase-2 of the study was carried out at baseline, on a representative subgroup of 57 subjects (Supplementary material 2). We observed moderate correlations between the specialised psychopathological evaluations from phase-2 and the self-reported psychological symptoms from phase-1 (Table 4). Seventeen (29.8%) participants in the phase-2 reported having a past history of psychiatric issues. Based on the MINI structured interview 25% of subjects presented at baseline (phase 2) a diagnosis of depression and/or anxiety disorder, whereas only 8.8% (n=5) admitted having sought help in the previous weeks. 28.1% (n=16) were on psychopharmacological treatment (4 on antidepressants, 3 on anxiolytics and 9 on hypnotic medications) and 3 (5.3%) on psychological treatment. Regarding substance use, 17.5% of participants reported smoking tobacco and 49.1% having consumed alcohol in the previous year. In comparison to pre-pandemic use, 50% had increased during the COVID-19 pandemic the amount of tobacco smoked, and 28.1% reported having increased the alcohol used.

Table 4.

Correlation analyses between phase 1 and phase 2 evaluations (self-reported versus psychiatrists evaluations) of Primary Care professionals in Cantabria during the COVID-19 pandemic.

  ISI totalGAD-7_TotalIES-R totalSTAI stateSTAI trait
  N  r  p  N  r  p  N  r  p  N  r  p  N  r  p 
PHQ-9 total  408  0.706  <0.001  408  0.755  <0.001  408  0.651  <0.001  54  −0.247  0.072  54  0.208  0.132 
ISI total        408  0.657  <0.001  408  0.653  <0.001  54  −0.238  0.082  54  0.075  0.589 
GAD-7_Total              408  0.717  <0.001  54  0.107  0.442  54  0.270  0.048 
IES-R total                    54  −0.224  0.103  54  0.275  0.044 
STAI state                          56  0.140  0.303 
STAI trait                               
STAI total                               
HAMD total                               
HAMD total – melancholy                               
HAMD total – anxiety                               
  STAI totalHAMD totalHAMD total – melancholyHAMD total – anxietyHAMD total – insomnia
  N  r  p  N  r  p  N  r  p  N  r  p  N  r  p 
PHQ-9 total  54  0.006  0.965  55  0.517  <0.001  55  0.484  <0.001  55  0.450  0.001  55  0.326  0.015 
ISI total  54  −0.087  0.530  55  0.441  <0.001  55  0.369  0.006  55  0.238  0.081  55  0.469  <0.001 
GAD-7_Total  54  0.265  0.053  55  0.477  <0.001  55  0.411  0.002  55  0.457  <0.001  55  0.263  0.052 
IES-R total  54  0.070  0.615  55  0.339  0.011  55  0.378  0.004  55  0.402  0.002  55  0.161  0.241 
STAI state  56  0.681  <0.001  56  −0.075  0.581  56  −0.160  0.240  56  0.036  0.790  56  −0.004  0.974 
STAI trait  56  0.820  <0.001  56  0.099  0.468  56  0.288  0.032  56  0.309  0.020  56  −0.054  0.690 
STAI total        56  0.030  0.828  56  0.121  0.376  56  0.250  0.063  56  −0.043  0.754 
HAMD total              57  0.835  <0.001  57  0.711  <0.001  57  0.629  <0.001 
HAMD total – melancholy                    57  0.640  <0.001  57  0.277  0.037 
HAMD total – anxiety                          57  0.234  0.080 

Abbreviations: PHQ, Patient Health Questionnaire; ISI, Insomnia Severity Index; GAD, General Anxiety Disorder; IESR, Impact of Event Scale-Revised; STAI, State-Trait Anxiety Inventory; HAMD, Hamilton Depression Rating Scale.

Discussion

Our study shows high rates of depression, anxiety, insomnia and psychological distress, measured by PHQ-9, GAD-7, ISI and IES-R respectively, during the first months of the pandemic, in primary care professionals. This self-reported psychopathology correlated with a specialised clinical evaluation carried out in a representative subsample of participants. One year later, we observed a significant increase in the mean score in the depression scale PHQ-9 together with a significant increase in the percentage of subjects with a PHQ-9 score suggestive of depression, reaching up to 40% of the participants. The scoring in all the other scales increased, although the differences did not reach statistical significance.

These results are in line with previous evidence showing that health care professionals have experienced during the early phases of the COVID-19 pandemic, a clinically relevant psychological impact, measured by self-applied scales.9,10 These results have been also seen in Spain where healthcare staff reported symptoms of PTSD, stress, anxiety or depression.11,12 Similarly, previous stressful epidemics, such as the SARS-CoV in 2003, the Ebola (2014) or the MERS-CoV outbreak in 2015, already highlighted that healthcare professionals where specially at high risk of developing psychological symptoms and mental health disorders such as anxiety, depression and PTSD.13,29–31

It is important to acknowledge that the psychological impact produced by previous community crises precipitated new psychiatric symptoms in people without mental illness and also aggravated the condition of those with pre-existing mental illness.32 Thus, the psychological impact has been reflected in the incidence of psychiatric morbidities varying from depression, anxiety and PTSD symptoms, to delirium, psychosis and even suicidality.32 This is also important since common mental health disorders, such as anxiety and depression, are known to have detrimental effects on other (physical) health measures.33

As a result of these effects, it has been suggested that in the forthcoming months, the health system will suffer a shortage of health professionals due to mental exhaustion.34 Moreover, these mental health problems among health professionals could also affect their clinical performance and decision making ability, jeopardising the health system capacity of fighting the COVID-19 pandemic.35 Ultimately, psychological exhaustion seemed to directly affect the professionals’ quality of life, their level of satisfaction and their working performance while working.11 In our study, participants reported having mean scores in self-perceived health status and quality of life just above “normal” (4 in a 1–7 Likert-type scale) at both time points, but with a significantly decrease in both perceptions after 1 year follow-up. Moreover, participants reported that their health status and quality of life had become worse compared to how it was before the COVID-19 pandemic. This poor self-perceived health status and quality of life were associated with a poorer mental health, with more severe anxiety and depressive symptoms.

Several individual risk factors for a greater psychological impact have been identified; gender (women), younger age and working at the frontline or in high-exposure units.9,10,13,14 Although healthcare workers from none-high exposure units may also present psychological distress during the pandemic,36 probably through vicarious traumatisation.37 Similar results have been found in Spain, where being women, younger or working at the front-line, were associated with a greater psychological impact.11,15 Our results are partially in line with these previous evidences; in our sample, being women and working in front-line position were risk factors for presenting depression and anxiety. However, and contrary to what we expected, younger age presented only a weak association with anxiety. Interestingly, we did find significant associations between a greater psychological impact (depression or anxiety) and having suffered COVID-19 or having a family member with COVID-19.

Isolation and the lack of social support could be determining factors in coping with this traumatic event.13,38 The high pressure, including overwork, frustration, discrimination, a high risk of infection, but also the fear of being infected and infecting others, were underlying factors of a greater risk or presenting stress, anxiety and depressive symptoms in healthcare professionals.30,35,39 Other factors influencing the psychological distress are those related to the efficacy of the health system during the pandemic, such as the availability of local medical resources, efficiency of the regional public health system, and prevention and control measures taken against the epidemic situation.4 One of the main complaints raised by health professionals in this respect is the lack of appropriate training for providing mental health care in this context.40 On the contrary, the perception of an effective coordination and access to safe environment and individual protection equipment has been identified as protective factors; inadequate protection from contamination has been related to mental health problems such as stress, anxiety, depressive symptoms, and insomnia,35 while professionals who had access to well-equipped and structured environment showed a better psychological adaptation to previous epidemics.13 In this sense, we observed that those primary care professionals with greater severity of depressive and anxiety symptoms significantly perceived a poorer institutional support and deficient access to individual protection equipment during the pandemic; although a causative relation between these factors cannot be established from our data, and there may be a bidirectional effect.

Several limitations must be highlighted in our study. The main limitation is that since we lack a psychological evaluation from a pre-pandemic period, we cannot infer a causal relation between the COVID-19 pandemic and the observed psychological symptoms among the participants. However, we cannot obviate the significant impact the COVID-19 pandemic has entailed, with a clear effect on mortality, global health, health systems’ workload, and social changes including isolation and loneliness, all of them risk factors for presenting a worse mental health. Therefore, we could assume that the poor mental health observed among primary care health workers in Cantabria in this study, during the first stages of COVID-19 pandemic, was at least partially, related to the pandemic itself.

At 1-year follow-up, we sent the electronic survey to the same group of primary care health workers subjects, asking them to respond to it only if having done so at baseline, in an attempt to evaluate the same individuals at both time-point. However, since the electronic surveys were anonymous, we cannot assure that we evaluated the same sample of individuals at both time-points. Despite of this, both samples were similar in all the socio-demographic and occupational characteristics. Other limitations are that the study followed a non-probabilistic “snowball sampling” and the limited sample size. However, it is noteworthy that the study sample was almost the 20% of the target population. Finally, suicidality was measured by means of the PHQ-9 item 9, which evaluates passive thoughts of suicide. Although this is a way of evaluating risk of suicide, it would be recommended using a more specific and complete tool for suicide risk (e.g.: the Columbia Suicide Severity Rating Scale). Similarly, a better description and analysis of substance use would be desirable. Further studies should look into other relevant aspects in the evaluation of the psychological impact of health workers, not included in the present study, such as burnout syndrome. On the other hand, the study has some strengths. The main strength is its two-phase design which provides an empirical validation of the self-reported symptoms (phase 1); previous studies have been exclusively survey-based, and although the self-reported scales they used have been previously validated, they could have missed some clinical information. Therefore, we provide a “clinical validation” of our self-reported evaluation (phase-1) through specialist evaluations carried out by psychiatrists in the phase-2 of the study. We included in the study all the professions working at primary care in Cantabria, and not only doctors and nurses as in other studies. Thus, the data is more representative of the study population. Finally the study includes a subject-centred approach, with measures of self-perceived quality of life, exposure to SARS-CoV-2/COVID-19 and other self-perceived experiences related to the pandemic, that have not been extensively explored in previous studies.

The study contributes to the evidence of an association between the COVID-19 pandemic and mental health on primary care health professionals, and sheds light on the possible risk factors associated with a greater psychological repercussion of the pandemic. Thus, it improves the knowledge for the development and implementation of prevention and early intervention programmes to alleviate the psychological distress of these at-risk essential workers.41 In this sense, a wide range of psychological interventions have been implemented and made available to health professionals during the COVID-19 pandemic,42 although only a few have shown some efficacy in reducing the psychological distress and psychopathology associated with the COVID-19 pandemic.43

Conclusions

We observed a temporal relation between COVID-19 pandemic and a significantly poor mental health among primary care professionals in Cantabria, which has even significantly worsened at long-term, presenting a greater symptoms’ severity one year after. These findings are clinically relevant since they provide further evidence on the possible long-term psychopathological impact of COVID-19 pandemic on primary care health professionals. It also sheds light on the possible risk factors that might be associated with a greater psychological repercussion of the pandemic.

Funding disclosures

The present study was carried out at the Hospital Marqués de Valdecilla, University of Cantabria, Santander, Spain, under the following grant support: Instituto de Investigación Sanitaria ValdecillaPRIMVAL20/08, INT/A21/10 and INT/A20/04.

Conflict of interest

The authors report no conflicts of interest in producing this manuscript.

Acknowledgements

The authors wish to thank all the colleagues from Primary Care network in Cantabria (Servicio Cántabro de Salud) for their participation in the study, the Primary Care Directorate for supporting the study, and the Colegio Oficial de Médicos de Cantabria for helping to disseminate the surveys.

Appendix A
Supplementary data

The following are the supplementary data to this article:

References
[1]
World Health Organization. Coronavirus disease (COVID-2019) situation report #87. 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/ [accessed 17.4.20].
[2]
N. Islam, D.A. Jdanov, V.M. Shkolnikov, K. Khunti, I. Kawachi, M. White, et al.
Effects of covid-19 pandemic on life expectancy and premature mortality in 2020: time series analysis in 37 countries.
BMJ, 375 (2021), pp. e066768
[3]
L. Duan, G. Zhu.
Psychological interventions for people affected by the COVID-19 epidemic.
Lancet Psychiatry, 7 (2020), pp. 300-302
[4]
J. Qiu, B. Shen, M. Zhao, Z. Wang, B. Xie, Y. Xu.
A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations.
Gen Psychiatr, 33 (2020), pp. e100213
[5]
C. Wang, R. Pan, X. Wan, Y. Tan, L. Xu, C.S. Ho, et al.
Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.
Int J Environ Res Public Health, 17 (2020),
[6]
L. Garcia-Alvarez, L. de la Fuente-Tomas, M.P. Garcia-Portilla, P.A. Saiz, C.M. Lacasa, F. Dal Santo, et al.
Early psychological impact of the 2019 coronavirus disease (COVID-19) pandemic and lockdown in a large Spanish sample.
J Glob Health, 10 (2020), pp. 020505
[7]
A. Planchuelo-Gomez, P. Odriozola-Gonzalez, M.J. Irurtia, R. de Luis-Garcia.
Longitudinal evaluation of the psychological impact of the COVID-19 crisis in Spain.
J Affect Disord, 277 (2020), pp. 842-849
[8]
A. Fiorillo, P. Gorwood.
The consequences of the COVID-19 pandemic on mental health and implications for clinical practice.
Eur Psychiatry, 63 (2020), pp. e32
[9]
L. Kang, S. Ma, M. Chen, J. Yang, Y. Wang, R. Li, et al.
Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study.
Brain Behav Immun, 87 (2020), pp. 11-17
[10]
J. Lai, S. Ma, Y. Wang, Z. Cai, J. Hu, N. Wei, et al.
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
JAMA Netw Open, 3 (2020), pp. e203976
[11]
M. Dosil, N. Ozamiz-Etxebarria, I. Redondo, M. Picaza, J. Jaureguizar.
Psychological symptoms in health professionals in Spain after the first wave of the COVID-19 pandemic.
Front Psychol, 11 (2020), pp. 606121
[12]
S. Hummel, N. Oetjen, J. Du, E. Posenato, R.M. Resende de Almeida, R. Losada, et al.
Mental health among medical professionals during the COVID-19 pandemic in eight European countries: cross-sectional survey study.
J Med Internet Res, 23 (2021), pp. e24983
[13]
S.M. Lee, W.S. Kang, A.R. Cho, T. Kim, J.K. Park.
Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients.
Compr Psychiatry, 87 (2018), pp. 123-127
[14]
V.A. Naushad, J.J. Bierens, K.P. Nishan, C.P. Firjeeth, O.H. Mohammad, A.M. Maliyakkal, et al.
A systematic review of the impact of disaster on the mental health of medical responders.
Prehosp Disaster Med, 34 (2019), pp. 632-643
[15]
L. Luceno-Moreno, B. Talavera-Velasco, Y. Garcia-Albuerne, J. Martin-Garcia.
Symptoms of posttraumatic stress, anxiety, depression levels of resilience and burnout in Spanish health personnel during the COVID-19 pandemic.
Int J Environ Res Public Health, 17 (2020),
[16]
J.E. White.
A two stage design for the study of the relationship between a rare exposure and a rare disease.
Am J Epidemiol, 115 (1982), pp. 119-128
[17]
R. Tao, D. Zeng, D.Y. Lin.
Optimal designs of two-phase studies.
J Am Stat Assoc, 115 (2020), pp. 1946-1959
[18]
R.D. Kocalevent, A. Hinz, E. Brahler.
Standardization of the depression screener patient health questionnaire (PHQ-9) in the general population.
Gen Hosp Psychiatry, 35 (2013), pp. 551-555
[19]
K. Kroenke, R.L. Spitzer, J.B. Williams.
The PHQ-9: validity of a brief depression severity measure.
J Gen Intern Med, 16 (2001), pp. 606-613
[20]
B. Lowe, O. Decker, S. Muller, E. Brahler, D. Schellberg, W. Herzog, et al.
Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population.
Med Care, 46 (2008), pp. 266-274
[21]
R.L. Spitzer, K. Kroenke, J.B. Williams, B. Lowe.
A brief measure for assessing generalized anxiety disorder: the GAD-7.
Arch Intern Med, 166 (2006), pp. 1092-1097
[22]
C.M. Morin, G. Belleville, L. Belanger, H. Ivers.
The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response.
Sleep, 34 (2011), pp. 601-608
[23]
DSW. The impact of event scale: revised. Springer Science+Business Media; 2007.
[24]
M. Creamer, R. Bell, S. Failla.
Psychometric properties of the Impact of Event Scale-Revised.
Behav Res Ther, 41 (2003), pp. 1489-1496
[25]
S. Kim, H.K. Lee, K. Lee.
Which PHQ-9 items can effectively screen for suicide? Machine learning approaches.
Int J Environ Res Public Health, 18 (2021),
[26]
D.V. Sheehan, L.Y. Harnett-Sheehan, K. Janavs, J. Weiller, E. Bonora, L.I. Keskiner, et al.
Reliability and validity of the mini international neuropsychiatric interview (mini): according to the SCID-P.
Eur Psychiatry, 12 (1997), pp. 232-241
[27]
J.A. Ramos-Brieva, A. Cordero-Villafafila.
A new validation of the Hamilton Rating Scale for Depression.
J Psychiatr Res, 22 (1988), pp. 21-28
[28]
C.D. Spielberger, R.L.R.E.L. Gorsuch.
Manual for the state-trait inventory.
Consulting Psychological Press, (1970),
[29]
J.M. Shultz, F. Baingana, Y. Neria.
The 2014 Ebola outbreak and mental health: current status and recommended response.
JAMA, 313 (2015), pp. 567-568
[30]
J. Shigemura, R.J. Ursano, J.C. Morganstein, M. Kurosawa, D.M. Benedek.
Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations.
Psychiatry Clin Neurosci, 74 (2020), pp. 281-282
[31]
S. Srivatsa, K.A. Stewart.
How should clinicians integrate mental health into epidemic responses?.
AMA J Ethics, 22 (2020), pp. E10-E15
[32]
C.S. Ho, C.Y. Chee, R.C. Ho.
Mental health strategies to combat the psychological impact of coronavirus disease 2019 (COVID-19) beyond paranoia and panic.
Ann Acad Med Singap, 49 (2020), pp. 155-160
[33]
G.J. Rubin, S. Wessely.
The psychological effects of quarantining a city.
BMJ, 368 (2020), pp. m313
[34]
J.A. Martinez-Lopez, C. Lazaro-Perez, J. Gomez-Galan, M.D.M. Fernandez-Martinez.
Psychological impact of COVID-19 emergency on health professionals: burnout incidence at the most critical period in Spain.
J Clin Med, 9 (2020),
[35]
L. Kang, Y. Li, S. Hu, M. Chen, C. Yang, B.X. Yang, et al.
The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus.
Lancet Psychiatry, 7 (2020), pp. e14
[36]
Y. Liang, M. Chen, X. Zheng, J. Liu.
Screening for Chinese medical staff mental health by SDS and SAS during the outbreak of COVID-19.
J Psychosom Res, 133 (2020), pp. 110102
[37]
Z. Li, J. Ge, M. Yang, J. Feng, M. Qiao, R. Jiang, et al.
Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control.
Brain Behav Immun, 88 (2020), pp. 916-919
[38]
B.O. Rodriguez, T.L. Sanchez.
The psychosocial impact of COVID-19 on health care workers.
Int Braz J Urol, 46 (2020), pp. 195-200
[39]
P. Del Pozo-Herce, R. Garrido-Garcia, I. Santolalla-Arnedo, V. Gea-Caballero, P. Garcia-Molina, R. Ruiz de Vinaspre-Hernandez, et al.
Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus.
Int J Environ Res Public Health, 18 (2021),
[40]
Y.T. Xiang, Y. Yang, W. Li, L. Zhang, Q. Zhang, T. Cheung, et al.
Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed.
Lancet Psychiatry, 7 (2020), pp. 228-229
[41]
L.E. Sovold, J.A. Naslund, A.A. Kousoulis, S. Saxena, M.W. Qoronfleh, C. Grobler, et al.
Prioritizing the mental health and well-being of healthcare workers: an urgent global public health priority.
Front Public Health, 9 (2021), pp. 679397
[42]
A. Priede, I. Lopez-Alvarez, D. Carracedo-Sanchidrian, C. Gonzalez-Blanch.
Mental health interventions for healthcare workers during the first wave of COVID-19 pandemic in Spain.
Rev Psiquiatr Salud Ment (Engl Ed), 14 (2021), pp. 83-89
[43]
B. Rodriguez-Vega, A. Palao, A. Munoz-Sanjose, M. Torrijos, P. Aguirre, A. Fernandez, et al.
Implementation of a mindfulness-based crisis intervention for frontline healthcare workers during the COVID-19 outbreak in a public general hospital in Madrid, Spain.
Front Psychiatry, 11 (2020), pp. 562578
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