Impact of COVID-19 first wave on the mental health of healthcare workers in a Front-Line Spanish Tertiary Hospital: lessons learned

The emergence of the COVID-19 pandemic has led to a worldwide public health emergency, causing significant psychological challenges in the global healthcare system, particularly during the initial stages of the outbreak³². The results obtained from the present study show a high prevalence of current probable mental disorders and suicidal ideation in a large sample of HCWs from Hospital 12 de Octubre (Spain) during the first wave of the COVID-19 pandemic. Symptoms of MDD were the most frequently reported, followed by GAD, panic attacks, and PTSD. Furthermore, we observed that HCWs with lifetime mental disorders had a notably higher occurrence of adverse mental health. Other specific variables such as gender, age, job position, and direct exposure to infected patients were found to pose a greater risk in the onset of mental disorders.

During the COVID-19 pandemic, HCWs have been confronted with an unprecedented situation that has taken a toll on their mental and physical health³³. Their essential duties required them to make difficult decisions under extreme pressure, thereby placing them at a higher risk of developing mental health disorders^34,35. Previous studies evidencing the impact of the COVID-19 crisis on the mental health of HCWs are in agreement with the findings presented herein^{15,16,36,37,38,39}. A survey carried out in May 2020 by the British Medical Association showed that 45% of UK physicians were experiencing anxiety, depression, stress, or other mental issues due to the COVID-19 pandemic³⁶. In Spain, another survey performed during the first COVID-19 wave (between May 2020 and September 2020), reported that 43.7% of the 2929 primary care professionals (95% confidence interval [CI] = 41.9–45.4) screened positive for a probable mental disorder³⁷. In general, published studies evaluating the psychological toll on HCWs report symptoms of anxiety, depression, insomnia, or distress³⁸. The prevalence of depressive symptoms and anxiety ranges from 8.9 to 50.4% and between 14.5 and 44.6%, respectively. A systematic review and meta-analysis, involving data from 70 studies and 101,017 HCWs, have revealed a pooled prevalence of 30.0% for anxiety, 31.1% for depression and depressive symptoms, 56.5% for acute stress, 20.2% for post-traumatic stress, 44.0% for sleep disorders³⁹. Another systematic review and meta-analysis, including 12 studies related to the psychological impact of the COVID-19 outbreak on HCWs in Asian countries, reported an overall prevalence rate of anxiety, depression, and stress of 34.8%, 32.4% and 54.1%, respectively⁴⁰.

In Spain, MINDCOVID studies were multicenter observational trials that aimed to evaluate the impact of COVID-19 on the mental well-being of HCWs during the first wave^15,16. In line with our findings, almost half of the surveyed workers (45.7%) presented any current mental disorder and 14.5% tested positive for a disabling mental disorder¹⁵. The most frequent probable mental disorders reported were current MDD (28.1%), GAD (22.5%), panic attacks (24.0%), PTSD (22.2%), SUD (6.2%), and any STB (8.4%). Other prevalence rates reported were passive ideation (4.9%), active ideation without plan or attempt (0.8%), and active ideation with plan or attempt (2.7%)^15,16. When comparing our present results (unicenter) with those from the multicenter, nationwide MINDCOVID study¹⁵, prevalence rates of any probable mental disorder, MDD and PTSD are higher (Supplementary Fig. 1). The observed differences may respond to the different casuistry of Spanish hospitals during the first wave. Indeed, the pandemic carried out potentially traumatic moral and ethical challenges (e.g., choosing whom to indicate a ventilator in a situation where there was not for everyone) that exposed HCWs to the risk of developing moral injury^41,42. Although moral injury is not considered a mental disorder yet, it is thought to be associated with PTSD by symptomatology and etiology, since both could be two different responses to trauma^41,42. Thus, the higher prevalence of this PTSD could be attributed to the exposure of HCWs to these moral stressors^41,42.

Regarding potential factors associated with probable mental disorders, our study pointed out a higher vulnerability of young individuals (aged between 18 and 29 years), female gender, and those with lifetime mental disorders (p < 0.05). Sociodemographic factors, such as gender and age have been previously related to a higher risk³⁸. Female sex has been associated with a increased risk of mental disorders in several studies analyzing the impact of the COVID-19 pandemic on the mental health of HCWs^{43,44,45,46,47}. A recent meta-analysis conducted by Lee and colleagues including 401 studies, has reported higher odds of probable mental health disorders in women, in particular depression, anxiety, PTSD and insomnia⁴⁸. Multiple explanations or mechanisms have been proposed to explain these differences, including potential response bias (e.g., males may experience greater difficulty in recognizing and expressing psychological distress) as well as various biological, social, and demographic factors^49,50. Therefore, although age and gender appear to be risk factors, this should be considered with caution. Moreover, the existence of a previous mental disorder has been identified as a predictor of other mental issues, such as depression and anxiety, during COVID-19⁵¹. Also, some studies have indicated that the COVID-19 pandemic could have a negative impact on current mental disorders⁵². Given that all HCWs were exposed to a high risk of developing or aggravating psychiatric symptoms, those with prior or current mental disorders would have been more vulnerable during the COVID-19 pandemic.

The limited availability of personal protective equipment, the continuous exposure to infected patients, the rate of deaths, the absence of specific treatments, overwhelming workload are other factors contributing to the development of these mental issues⁵³. Additionally, HCWs’ rising anxiety about the spread of COVID-19 may be linked to the misinformation that circulated during the initial wave of the pandemic and the concern that they may be a possible risk of contagion to their partner and family^43,54. Furthermore, herein it was observed that some job positions, specifically auxiliary nurses, have a higher risk of mental disorders (p < 0.05). Maunder et al.⁵⁵ studied the trend of burnout and psychological distress among HCWs from the fall of 2020 to the summer of 2021 and also found that nurses mostly reported the highest rates of burnout. Similarly, Fattori et al.⁵⁶ observed that nurses and health assistants had higher risks of scoring above cut-offs than physicians (OR = 4.72 and 6.76 respectively). Differences between public and private healthcare sectors has been also analyze previously. According to a recent study by Pabón-Carrasco, HCWs employed in publicly healthcare institutions reported a lower perceived risk of COVID-19 transmission compared to their counterparts in private institutions during the first wave⁴³. However, anxiety levels were higher in public employed HCWs compared to those reported by those privately employed (more than 25% and ~ 20%, respectively). Both groups had high levels of anxiety, despite private sector was not considered first-line⁴³.

Some limitations of our study should be considered. First, its cross-sectional design, without similar information collected before the pandemic, does not allow us to infer the causality of the impact of the COVID-19 pandemic on the mental health of HCWs, nor to estimate the true magnitude of change in the prevalence of probable mental disorders. Furthermore, it is worth mentioning that during the first wave of the pandemic, psychological support was offered on demand to those professionals who requested it voluntarily at the hospital. Additionally, group interventions were conducted to alleviate symptoms at the onset. It would have been interesting to assess the impact of these interventions as a protective factor; however, we lack this data, which constitutes an additional limitation and possible bias.

Second, the response rate was lower than expected. It is possible that those experiencing mental health issues were more willing to participate or stressed workers did not have time to respond. However, weighting data has attempted to counteract this limitation. Third, this study’s assessments are based on self-reports from HCWs and not clinically diagnosed mental disorders. It is for this reason that we describe them as probable mental disorders.

Importantly, our approach has been used in most epidemiological studies, allowing for comparisons of results^21,23,57. A more detailed analysis of proximal factors would have been interesting for linking the probable mental disorders with pandemic-related stressors.

Despite the above-mentioned limitations, we are confident to conclude that, during the first wave of the COVID-19 pandemic, HCWs of this large Spanish university hospital have presented a high prevalence of probable mental disorders, especially depression, PTSD, panic attack and anxiety. Younger individuals and those with lifetime mental disorders have been more vulnerable to experiencing them.

Based on our results, it appears to be expected that there is a significant demand for mental healthcare services among healthcare professionals in this Hospital that needs to be addressed. Our results, like others, highlight the significance of closely monitoring the psychological well-being of HCWs and facilitating their access to psychological assistance.

Understanding this data can also be relevant when selecting profiles of professionals who should be especially protected in high-stress situations, in order to care for their emotional well-being, such as those workers with a history of mental health issues or other vulnerability factors.

Future studies are needed to determine the evolution of the psychological impact of the COVID-19 pandemic over time in HCWs to implement appropriate therapeutic interventions.