Revista de psiquiatría y salud mental (Barcelona) 14 (2021) 90---105 www.elsevier.es/saludmental ORIGINAL ARTICLE Mental health impact of the first wave of COVID-19 pandemic on Spanish healthcare workers: A large cross-sectional survey Jordi Alonso a,b,c,∗ , Gemma Vilagut a,b , Philippe Mortier a,b,∗ , Montse Ferrer a,b,d , Itxaso Alayo a,b , Andrés Aragón-Peña e,f , Enric Aragonès g,h , Mireia Campos i , Isabel D. Cura-González j,k,f , José I. Emparanza l,b , Meritxell Espuga m , Maria João Forjaz n,o , Ana González-Pinto p,q , Josep M. Haro d,q,r , Nieves López-Fresneña s , Alma D. Martínez de Salázar t , Juan D. Molina u,v,w,q , Rafael M. Ortí-Lucas x , Mara Parellada s,q , José Maria Pelayo-Terán y , Aurora Pérez-Zapata z , José I. Pijoan aa,b , Nieves Plana z,b , Maria Teresa Puig ab,ac,d,ad , Cristina Rius ae,b,q,af , Carmen Rodríguez-Blázquez n,af , Ferran Sanz ag,c,ah , Consol Serra ai,aj,b , Ronald C. Kessler ak , Ronny Bruffaerts al , Eduard Vieta am,q , Víctor Pérez-Solà ai,d,q , MINDCOVID Working group1 a Health Services Research Unit, IMIM-Institut Hospital del Mar d’Investigacions Mèdiques, Barcelona, Spain b CIBER Epidemiología y Salud Pública (CIBERESP), Spain c Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain d Universitat Autònoma de Barcelona (UAB), Barcelona, Spain Available online 10 December 2020 ∗ Corresponding author. E-mail address: jalonso@imim.es (J. Alonso). 1 The MINDCOVID Working Group is formed by: Jordi Alonso, Itxaso Alayo, Manuel Alonso, Mar Álvarez, Benedikt Amann, Franco F. Amigo, Gerard Anmella, Andrés Aragón, Núria Aragonès, Enric Aragonès, Ana Isabel Arizón, Angel Asunsolo, Alfons Ayora, Laura Ballester, Puri Barbas, Josep Basora, Elena Bereciartua, Inés Bravo, Ignasi Bolíbar, Xavier Bonfill, Ronny Bruffaerts, Alberto Cotillas, Paula Cristóbal-Narváez, Andrés Cuartero, Concha de Paz, Isabel del Cura-González, Maria Jesús del Yerro, Domingo Díaz, Joan Domènech-Abella, José Luís Domingo, José I. Emparanza, Meritxell Espuga, Patricia Estevan-Burdeus, Mireia Félez-Nobrega, M. Isabel Fernández, Tania Fernández, Montse Ferrer, Yolanda Ferreres, Giovanna Fico, María Joao Forjaz, Rosa García-Barranco, Carles García-Ribera, J. Manuel García-Torrecillas, Araceli Garrido-Barral, Elisa Gil, Marta Gómez, Javier Gómez, Ana González-Pinto, Josep Maria Haro, Margarita Hernando, María Giola Insigna, Milagros Iriberri, Nuria Jiménez, Xavi Jiménez, Amparo Larrauri, Fernando León-Vázquez, Mayte López-Atanes, Nieves López-Fresneña, Carmen López-Rodríguez, Juan Antonio López-Rodríguez, Germán López-Cortacans, Alba Marcos, Jesús Martín, Vicente Martín, Mercedes Martínez-Cortés, Raquel Martínez-Martínez, Alma D. Martínez de Salazar, Isabel Martínez, Marco Marzola, Nelva Mata, Josep Maria Molina, Juan D. Molina, Emilia Molinero, Philippe Mortier, Carmen Muñoz-Ruipérez, Andrea Murru, Lydia Navarro, Beatriz Olaya, Jorge Olmedo-Galindo, Rafael M. Ortí- Lucas, Rafael Padrós, Meritxell Pallejà, Raúl Parra, Julio Pascual, José María Pelayo-Terán, Rosa Pla, Nieves Plana, Coro Pérez-Aznar, Beatriz Pérez-Gómez, Aurora Pérez-Zapata, José Ignacio Pijoan, Elena Polentinos-Castro, Beatriz Puértolas, Maria Teresa Puig, Álex Quílez, María Jesús Quintana, Antonio Quiroga, David Rentero, Cristina Rey, Cristina Rius, Carmen Rodríguez-Blázquez, M. José Rojas-Giraldo, Yamina Romero-Barzola, Gabriel Rubio, Pedro Ruiz, Mercedes Rumayor, Margarita Sáenz, Jesús Sánchez, Ignacio Sánchez-Arcilla, Ferran Sanz, Consol Serra, Victòria Serra-Sutton, Manuela Serrano, Sílvia Solà, Sara Solera, Miguel Soto, Alejandra Tarragó, Natividad Tolosa, Mireia Vázquez, Margarita Viciola, Eduard Vieta, Gemma Vilagut, Sara Yago-González, Jesús Yáñez-Sánchez, Yolanda Zapico, Luís Maria Zorita, Iñaki Zorrilla, Saioa L. Zurbano, and Víctor Pérez-Solà. https://doi.org/10.1016/j.rpsm.2020.12.001 1888-9891/© 2020 The Author(s). Published by Elsevier España, S.L.U. on behalf of SEP y SEPB. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Revista de psiquiatría y salud mental (Barcelona) 14 (2021) 90---105 e Epidemiology Unit, Regional Ministry of Health, Community of Madrid, Madrid, Spain f Fundación Investigación e Innovación Biosanitaria de Atención Primaria, Comunidad de Madrid, Madrid, Spain g Institut d’Investigació en Atenció Primària IDIAP Jordi Gol, Barcelona, Spain h Atenció Primària Camp de Tarragona, Institut Català de la Salut, Spain i Service of Prevention of Labor Risks, Medical Emergencies System, Generalitat de Catalunya, Spain j Research Unit, Primary Care Management, Madrid Health Service, Madrid, Spain k Department of Medical Specialities and Public Health, King Juan Carlos University, Madrid, Spain l Hospital Universitario Donostia, San Sebastián, Spain m Occupational Health Service, Hospital Universitari Vall d’Hebron, Barcelona, Spain n National Center of Epidemiology, Instituto de Salud Carlos III (ISCIII), Madrid, Spain o Health Services Research Network on Chronic Diseases (REDISSEC), Madrid, Spain p Hospital Universitario Araba-Santiago, Vitoria-Gasteiz, Spain q CIBER Salud Mental (CIBERSAM), Madrid, Spain r Parc Sanitari Sant Joan de Déu, Barcelona, Spain s Hospital General Universitario Gregorio Marañón, Madrid, Spain t UGC Salud Mental, Hospital Universitario Torrecárdenas, Almería, Spain u Villaverde Mental Health Center, Clinical Management Area of Psychiatry and Mental Health, Psychiatric Service, Hospital Universitario 12 de Octubre, Madrid, Spain v Research Institute Hospital 12 de Octubre (i + 12), Madrid, Spain w Faculty of Health Sciences, Francisco de Vitoria University, Madrid, Spain x Hospital Clínic Universitari, Valencia, Spain y Hospital El Bierzo, León, Spain z Príncipe de Asturias University Hospital, Alcalá de Henares, Madrid, Spain aa Hospital Universitario Cruces/OSI EEC, Bilbao, Spain ab Department of Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain ac Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain ad CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain ae Agència de Salut Pública de Barcelona, Barcelona, Spain af CIBER Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain ag Research Progamme on Biomedical Informatics (GRIB), Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain ah Instituto Nacional de Bioinformatica - ELIXIR-ES, Barcelona, Spain ai Parc de Salut Mar PSMAR, Barcelona, Spain aj CiSAL-Centro de Investigación en Salud Laboral, IMIM/UPF, Barcelona, Spain ak Department of Health Care Policy, Harvard Medical School, Boston, MA, USA al Center for Public Health Psychiatry, Universitair Psychiatrisch Centrum, KU Leuven, Leuven, Belgium am Fundació Clínic per a la Recerca Biomèdica, Barcelona, Spain Received 28 October 2020; accepted 2 December 2020 Available online 10 December 2020 KEYWORDS Abstract COVID-19 pandemic; Introduction: Healthcare workers are vulnerable to adverse mental health impacts of the Healthcare Workers; COVID-19 pandemic. We assessed prevalence of mental disorders and associated factors during Mental Disorders; the first wave of the pandemic among healthcare professionals in Spain. Need for Care; Methods: All workers in 18 healthcare institutions (6 AACC) in Spain were invited to web-based Disability; surveys assessing individual characteristics, COVID-19 infection status and exposure, and mental Adverse Mental health status (May 5 --- September 7, 2020). We report: probable current mental disorders (Major Health Depressive Disorder-MDD- [PHQ-8≥10], Generalized Anxiety Disorder-GAD- [GAD-7≥10], Panic attacks, Posttraumatic Stress Disorder ---PTSD- [PCL-5≥7]; and Substance Use Disorder ---SUD- [CAGE-AID≥2]. Severe disability assessed by the Sheehan Disability Scale was used to identify probable ‘‘disabling’’ current mental disorders. Results: 9,138 healthcare workers participated. Prevalence of screen-positive disorder: 28.1% MDD; 22.5% GAD, 24.0% Panic; 22.2% PTSD; and 6.2% SUD. Overall 45.7% presented any current and 14.5% any disabling current mental disorder. Workers with pre-pandemic lifetime mental disorders had almost twice the prevalence than those without. Adjusting for all other variables, odds of any disabling mental disorder were: prior lifetime disorders (TUS: OR=5.74; 95%CI 2.53- 13.03; Mood: OR=3.23; 95%CI:2.27-4.60; Anxiety: OR=3.03; 95%CI:2.53-3.62); age category 18- 29 years (OR=1.36; 95%CI:1.02-1.82), caring ‘‘all of the time’’ for COVID-19 patients (OR=5.19; 95%CI: 3.61-7.46), female gender (OR=1.58; 95%CI: 1.27-1.96) and having being in quarantine or isolated (OR= 1.60; 95CI:1.31-1.95). 91 J. Alonso, G. Vilagut, P. Mortier et al. Conclusions: One in seven Spanish healthcare workers screened positive for a disabling men- tal disorder during the first wave of the COVID-19 pandemic. Workers reporting pre-pandemic lifetime mental disorders, those frequently exposed to COVID-19 patients, infected or quaran- tined/isolated, female workers, and auxiliary nurses should be considered groups in need of mental health monitoring and support. © 2020 The Author(s). Published by Elsevier España, S.L.U. on behalf of SEP y SEPB. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). PALABRAS CLAVE Impacto en la salud mental del personal sanitario español de la primera ola de la pandemia COVID-19: un amplio estudio transversal Pandemia de COVID-19; Resumen Trabajadores de la Introducción: Los profesionales sanitarios son vulnerables al impacto negativo en salud mental salud; de la pandemia COVID-19. Evaluamos la prevalencia de trastornos mentales y factores asociados Trastornos mentales; durante la primera oleada de la pandemia en sanitarios españoles. Necesidad de Métodos: Se invitó a todos los trabajadores de 18 instituciones sanitarias españolas (6 CCAA) atención; a encuestas en línea evaluando características individuales, estado de infección y exposición Discapacidad; a COVID-19 y salud mental (5 Mayo --- 7 Septiembre, 2020). Reportamos: probables trastornos Salud mental adversa mentales actuales (Trastorno depresivo mayor TDD [PHQ-8≥10], Trastorno de ansiedad gener- alizada TAG [GAD-7≥10], Ataques de pánico, Trastorno de estrés postraumático TEP [PCL-5≥7]; y Trastorno por uso de sustancias TUS [CAGE-AID≥2]. La interferencia funcional grave (Escala de Discapacidad de Sheehan) identificó los probables trastornos ‘‘discapacitantes’’. Resultados: Participaron 9.138 sanitarios. Prevalencia de cribado positivo: 28,1% TDD; 22,5% TAG, 24,0% Pánico; 22,2% PTE; y 6,2% TUS. En general, el 45,7% presentó algún trastorno mental actual y el 14,5% algún trastorno discapacitante. Los sanitarios con trastornos mentales previos tuvieron el doble de prevalencia que aquellos sin patología mental previa. Ajustando por todas las variables, el trastorno mental incapacitante se asoció positivamente con: trastornos previos (TUS: OR=5.74; 95%CI 2.53-13.03; Ánimo: OR=3.23; 95%CI:2.27-4.60; Ansiedad: OR=3,03; IC 95%: 2,53-3,62); edad 18-29 años (OR=1,36; IC 95%: 1,02-1,82); atender ‘‘siempre’’ a pacientes COVID-19 (OR=5,19; IC 95%: 3,61-7,46), género femenino (OR=1,58; IC 95%: 1,27-1,96) y haber estado en cuarentena o aislado (OR=1,60; IC 95%: 1,31-1,95). Conclusiones: Uno de cada 7 sanitarios españoles presentaron un probable trastorno mental discapacitante durante la primera oleada de COVID-19. Aquéllos con trastornos mentales alguna vez antes de la pandemia, los que están expuestos con frecuencia a pacientes con COVID- 19, los infectados o en cuarentena / aislados, las mujeres y las enfermeras auxiliares deben considerarse grupos que necesitan seguimiento y apoyo de su salud mental. © 2020 El Autor(s). Publicado por Elsevier España, S.L.U. en nombre de SEP y SEPB. Este es un artı́culo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by- nc-nd/4.0/). Introduction concern for the potential impact (acute and longer term) on the mental health of healthcare workers. COVID-19 represents a major health challenge worldwide Several systematic reviews and meta-analyses including and several populations may experience adverse mental studies on health care workers have documented that the health related to the COVID-19 pandemic.1,2 Among them, first wave of the COVID-19 pandemic was associated with front-line healthcare workers are considered an extremely increased depression, anxiety, insomnia, and burnout, as at risk population because of their direct exposure to well as other adverse psychosocial outcomes. Luo et al.,6 infected patients, the limited availability of protective estimated that a quarter of healthcare workers suffered equipment, and the increased workload related to the from anxiety (26%), depression (25%), and that about a third pandemic. Compared to the general community, healthcare suffered substantial stress. Similar figures were reported in workers have about 12 times more risk for a positive other systematic reviews.7---9 In Spain, a number of studies COVID-19 test.3 Although with noticeable regional and have been carried out to assess mental health of healthcare international variations, it is estimated that 10---20% of all workers during the first wave of the COVID-19 pandemic10---15 COVID-19 diagnoses occur in this population segment.4,5 In general, results are consistent with international data, In addition to the risk of contagion and insufficiency of showing high levels of anxiety, depression and stress symp- equipment and health services preparedness there is great toms. 92 Revista de psiquiatría y salud mental (Barcelona) 14 (2021) 90---105 Differences in study design, sample size as well as vari- or higher of the sum score to indicate current MDD. The ation in the assessment of adverse mental health hamper PHQ-8 shows high reliability (>0.8) and good diagnostic comparisons across studies. Importantly, current studies accuracy for Major Depressive Disorder (AUC > 0.90).17 have limited value when it comes to assessing the needs for - Generalized Anxiety Disorder (GAD): evaluated with the care associated with the impact of COVID-19 among health- seven-item Generalized Anxiety Disorder scale (GAD- care workers. There is a necessity of credible and actionable 7), which has a good performance to detect anxiety indicators of mental disorders and their impact which more (AUC > 0.8).18 We used the Spanish version of the GAD-719 directly enable policy makers to allocate adequate resources and considered the cut-off point of 10 or higher to indicate when planning interventions. a current GAD. Here we aimed to estimate the prevalence of clini- - Panic attacks: the number of panic attacks in the 30 days cally significant mental disorders among Spanish healthcare prior to the interview was assessed with an item from the professionals during the first wave of the COVID-19 pan- World Mental Health-International College Student-WMH- demic (March-July, 2020) using a representative sample ICS.20,21 A dichotomous variable was created to indicate and well-validated screeners of common mental disorders. the presence of panic attacks. Specifically, our objectives were to estimate (1) prevalence - Posttraumatic Stress Disorder (PTSD): assessed using the of specific mental disorders, any such disorder, and any 4-item version of the PTSD checklist for DSM-5 (PCL- disabling disorder both in the total sample of healthcare 5)22,23 which generates diagnoses that closely parallel professionals and in subsamples of those with/without prior those of the full PCL-5 (AUC > 0.9), making it well-suited lifetime mental disorders; and (2) associations of individual for screening.23 We used the Spanish version of the and professional characteristics, COVID-19 infection status, questionnaire,24 and considered a cut-off point of 7 to and COVID-19 exposure with these mental disorders. indicate current PTSD. - Substance Use Disorder (SUD): evaluated with the CAGE- Methods AID questionnaire, that consists of 4 items focusing on Cutting down, Annoyance by criticism, Guilty feeling, and Study design, population and sampling Eye-openers. The CAGE-AID has been proved useful in helping to make a diagnosis of alcoholism25---27 and Sub- A multicenter, observational cohort study of healthcare stance Use Disorder.28 The questionnaire has been adapted workers was carried out in a convenience sample of 18 health into Spanish. A cut-off point of 2 was considered to indi- care institutions from 6 Autonomous Communities in Spain cate current SUD.29 (i.e., Andalusia, the Basque Country, Castile and Leon, Cat- - Disabling mental disorder: a mental disorder was consid- alonia, Madrid, and Valencia). Institutions were selected to ered ‘‘disabling’’ if the participant reported severe role reflect the geographical and sociodemographic variability in impairment during the past 12 months according to an Spain; most participating centers came from regions with adapted version of the Sheehan Disability Scale.30---32 A high COVID-19 caseloads. Here we report on the baseline 0---10 visual analog scale was used to rate the degree of assessment of the cohort, which consists of de-identified impairment for four domains: home management/chores, web-based self-report surveys administered soon after the work, close personal relationships, and social life. The first COVID-19 outbreak in Spain. Data collection started at scale was labeled as no interference (0), mild (1---3), the time of stabilization in the number of new cases in Spain, moderate (4---6), severe (7---9), and very severe (10) inter- but when health institutions, particularly hospitals, were ference. Severe role impairment was defined as having a under very high demand pressures (May 5 --- September 7, 7---10 rating.33---35 2020). - Prior lifetime mental disorders: lifetime mental disorders In each participating health care institution, institutional prior to the onset of the COVID-19 outbreak were assessed representatives invited all employed hospital workers to using a checklist based on the Composite International participate using the hospitals’ administrative email distri- Diagnostic Interview (CIDI) that screens for self-reported bution lists (i.e., census sampling). No further advertising of lifetime depressive disorder, bipolar disorder, anxiety dis- the survey was done and no incentives were offered for par- orders, panic attacks, alcohol and drug use disorders, and ticipation. The invitation email included an anonymous link ‘‘other’’ mental disorders. to access the web-based survey platform (qualtrics.com). Informed consent was obtained from all participants at the first survey page. Up to two reminder emails were sent within a 2---4 weeks period after the initial invitation. At COVID-19 exposure and infection status the end of the survey, all participants were provided with a We assessed the frequency of direct exposure to COVID-19 detailed list of local mental healthcare resources, including infected patients during professional activity using one 5- coordinates to nearby emergency care for respondents with level Likert type item, ranging from ‘‘none of the time’’ a 30-day suicide attempt. to ‘‘all of the time. We defined frontline healthcare work- ers those reporting being exposed ‘‘all of the time’’ or Measures ‘‘most of the time’’ to COVID-19 patients. We assessed COVID-19 infection status asking whether the respondent Current mental disorders had been hospitalized for COVID-19 infection and/or had - Major Depressive Disorder (MDD): evaluated with the a positive COVID-19 test or medical diagnosis not requir- Patient Health Questionnaire (PHQ-8). We used the Span- ing hospitalization. We also asked whether the respondent ish version of the PHQ-816 with the cut-off point of 10 had been in isolation or quarantine because of exposure to 93 J. Alonso, G. Vilagut, P. Mortier et al. COVID-19 infected person(s), and whether s/he had close status, individual characteristics and current and disabling ones infected with COVID-19. mental disorders were estimated, stratifying by prior life- time mental disorders. Individual characteristics MI were carried out using package mice from R.37,38 Anal- We assessed: age; gender; country of birth; marital status; yses were performed using R v3.4.239 and SAS v9.4.40 having children in care; living situation; and profession into 5 categories: medical doctors, nurses, auxiliary nurses, other Results professions involved in patient care (i.e., midwives; dentists or odontologists; pharmaceutical, laboratory, or radiology Survey response technicians; psychologists, physiotherapists, social work- ers, patient transport), and other professions not involved A total of 9138 healthcare workers participated in the sur- in patient care (i.e., administrative and management per- veys. The response rate is difficult to estimate given that sonnel, logistic support [e.g. food, maintenance, supplies], the survey view rate (i.e., the proportion of hospital workers research-only personnel). that opened the invitation email) is unknown, except for one hospital (26.4%). The survey participation rate (i.e., those Ethical considerations that agreed to participate divided by those that responded to the informed consent on the first survey page) was 89.0%, The study complies with the principles established by and the survey completion rate (i.e., those that completed national and international regulations, including the Decla- the survey among those that agreed to participate) was ration of Helsinki and the Code of Ethics. The study protocol 80.8%. When the denominator used to calculate the response was approved by the IRB Parc de Salut Mar (2020/9203/I) rate is the total number of health care workers listed in and by the corresponding IRBs of all the participat- the email distribution list or the total number of healthcare ing centers. The study is registered at ClinicalTrials.gov workers employed as provided by the hospital representa- (https://clinicaltrials.gov/ct2/show/NCT04556565). tives, the survey response adjusted by achieved sample size is 12.5% (see Supplementary Tables 1 and 2). Statistical analysis Prevalence of current mental disorders: Analyses were restricted to the n = 9146 respondents who completed all mental health items of the questionnaire. An The first two columns of Table 1 show the size and weighted additional n = 8 respondents were excluded because they distribution of the sample studied. Healthcare profession- did not identify with neither male nor female gender. In als were mostly female (77.3%), the larger age group was order to improve representativeness, observed data were 30---49 years (45.8%), just over half were married (53.0%), weighted using raking procedure to reproduce marginal four out of ten were living with children (41.4%), and 57.2% distributions of gender, age and professional category of were living in an apartment. About a fourth (26.4%) were healthcare personnel in each participating institution, as physicians, and 30.6% were nurses, and the majority were well as distribution of personnel across institutions. working in a hospital (54.1%). Almost 80% of participants To optimize survey response time, the Sheehan disabil- were directly involved in patient care, although less than ity scale was assessed in a random 60% of the sample. a half (43.6%) were directly exposed to COVID-19 patients Median missingness per variable was less than 1%. All missing all or most of the time (i.e., frontline workers). Almost a item-level data from the Sheehan scale and from all other fifth (17.4%) had COVID-19, 13.8% had their spouse/partner, variables included in the analysis were handled using mul- children or parents infected with COVID-19, and up to 25.5% tiple imputation (MI) by chained equations with 40 imputed had been isolated or quarantined. An important proportion datasets and 10 iterations. (41.6%) reported pre-pandmic lifetime mental disorder(s). Distribution of individual characteristics and COVID-19 Also in Table 1, the prevalence of current mental disor- infection and exposure variables were obtained for the ders is presented according to the above variables. Overall, whole sample as weighted percentage and standard error. 28.1% met criteria for Major Depressive Disorder, between Prevalence estimates of specific current mental disorders, 22.2% and 24.0% met criteria for anxiety disorders (GAD, any current mental disorder, and any disabling disorder were Panic attacks, or PTSD), and 6.2% met criteria for substance estimated, overall and stratified by individual character- use disorder. In all, almost half of the sample (45.7%) met istics. Chi-square tests from MI pooled using Rubin’s rule criteria for current mental disorder and about one in seven were used to determine significant differences across strata. (14.5%) had a current disabling mental disorder. Adjustment for multiple comparisons was performed using The prevalence of any current mental disorder was sig- the Benjamini---Hochberg procedure36 with a false discovery nificantly higher among healthcare workers with female rate of 5%. Bivariable associations between each individ- gender, younger age, not born in Spain, not being married, ual characteristic and current mental disorders and severe or living with children less than 12 years of age or not hav- mental disorder were estimated for the overall sample, and ing children at home. Auxiliary nurses and nurses showed the separately for individuals with and without a history of prior highest prevalence of current mental disorders (59.5% and lifetime mental disorders. Odds ratios (OR) and MI-based 50.4%, respectively). There was a clear positive trend with 95% confidence intervals (CIs) for each characteristic were higher exposure to COVID-19 patients, and those having the calculated with logistic regression, adjusted by week of sur- disease --- in particular those 112 professionals who had been vey and health center membership. Finally, multivariable hospitalized for COVID-19, having been isolated or quaran- associations between all COVID-19 exposure and infection tined, and whose parents, children or partner were infected 94 Table 1 Prevalence of current probable mental disorders among Spanish healthcare workers, according to individual characteristics, COVID-19 exposure, and prior lifetime disorders. MINCOVID study (N = 9138) (absolute numbers and weighted proportions). Na %b Current MDD Current GAD Current panic Current PTSD Current Any current Any current (n = 2554) (n = 2007) attacks (n = 1946) substance use mental disabling (n = 2064) disorder disorder mental (n = 569) (n = 4118) disorder (n = 1278) %b (SE) %b (SE) %b (SE) %b (SE) %b (SE) %b (SE) %b (SE) Revista de psiquiatría y salud mental (Barcelona) 14 (2021) 90---105 28.1 (0.5)* 22.5 (0.4)* 24.0 (0.5)* 22.2 (0.4)* 6.2 (0.3)* 45.7 (0.5)* 14.5 (0.5)* Gender -Male 1766 22.7 (0.4)* 20.2 (0.9)* 17.1 (0.8)* 17.6 (0.9)* 15.6 (0.8)* 8.3 (0.6)* 36.4 (1.1)* 10.7 (0.9)* -Female 7372 77.3 (0.4) 30.4 (0.6) 24.1 (0.5) 25.8 (0.5) 24.2 (0.5) 5.6 (0.3) 48.5 (0.6) 15.6 (0.6) Age -18---29 years 1188 10.8 (0.3)* 33.7 (1.5)* 27.8 (1.4)* 32.1 (1.5)* 22.9 (1.3)* 9.6 (1.0)* 54.7 (1.6)* 16.6 (1.4)* -30---49 year 4252 45.8 (0.5) 30.2 (0.7) 24.9 (0.7) 25.6 (0.7) 24.1 (0.7) 7.0 (0.4) 49.2 (0.8) 15.4 (0.7) -50 years or more 3698 43.4 (0.5) 24.4 (0.7) 18.7 (0.6) 20.2 (0.7) 20.1 (0.6) 4.5 (0.3) 39.8 (0.8) 13.0 (0.7) Country of birth -Spain 8677 95.4 (0.2)* 27.7 (0.5)* 22.5 (0.5) 23.6 (0.5)* 22.2 (0.5) 6.1 (0.3) 45.4 (0.5)* 14.4 (0.5) -Other 461 4.6 (0.2) 36.0 (2.4) 22.5 (2.1) 31.4 (2.4) 22.5 (2.1) 7.7 (1.3) 53.3 (2.5) 15.3 (2.1) Marital status -Single, divorced or legally separated, or widowed 4465 47.0 (0.5)* 30.8 (0.7)* 22.7 (0.6) 26.5 (0.7)* 23.1 (0.6) 7.6 (0.4)* 48.9 (0.8)* 15.9 (0.7)* -Married 4673 53.0 (0.5) 25.6 (0.6) 22.4 (0.6) 21.7 (0.6) 21.5 (0.6) 5.0 (0.3) 42.9 (0.7) 13.2 (0.7) 95 Having children in care -Younger (<12 ys) children in care 2377 25.9 (0.5)* 27.9 (0.9)* 24.4 (0.9)* 23.6 (0.9)* 22.3 (0.9) 4.7 (0.4)* 46.6 (1.1)* 14.5 (0.9) -Children in care, but >12ys 1328 15.5 (0.4) 24.7 (1.2) 18.1 (1.0) 21.4 (1.1) 21.0 (1.1) 5.7 (0.6) 42.0 (1.4) 12.7 (1.0) -No children in care 5433 58.6 (0.5) 29.1 (0.6) 22.8 (0.6) 24.8 (0.6) 22.5 (0.6) 7.0 (0.4) 46.4 (0.7) 15.0 (0.6) Living situation -House 3724 42.4 (0.5)* 27.6 (0.7) 23.1 (0.7) 22.8 (0.7) 23.3 (0.7)* 4.8 (0.4)* 44.6 (0.8) 14.1 (0.7) -Apartment 5383 57.2 (0.5) 28.4 (0.6) 22.0 (0.6) 24.8 (0.6) 21.3 (0.6) 7.2 (0.4) 46.5 (0.7) 14.7 (0.7) -Other 31 0.4 (0.1) 37.0 (8.5) 31.9 (8.1) 32.9 (8.5) 41.7 (8.7) 6.8 (4.7) 53.1 (9.0) 23.6 (8.9) Profession -Physician 2953 26.4 (0.5)* 22.4 (0.9)* 17.0 (0.8)* 14.3 (0.7)* 13.8 (0.7)* 6.8 (0.5)* 35.9 (1.0)* 9.6 (0.7)* -Nurse 2746 30.6 (0.5) 31.2 (0.9) 25.6 (0.8) 24.2 (0.8) 25.1 (0.8) 5.5 (0.4) 50.4 (1.0) 16.9 (0.9) -Auxiliary nurse 881 13.6 (0.4) 38.9 (1.4) 30.8 (1.3) 39.6 (1.4) 35.1 (1.4) 4.9 (0.6) 59.5 (1.4) 19.8 (1.4) -Other profession involved in patient care 960 9.2 (0.3) 21.7 (1.4) 17.2 (1.3) 21.6 (1.5) 18.1 (1.3) 7.8 (0.9) 40.0 (1.7) 11.3 (1.3) -Other profession not involved in patient care 1598 20.3 (0.4) 26.5 (1.0) 22.0 (1.0) 26.8 (1.1) 22.1 (1.0) 6.6 (0.6) 44.9 (1.2) 15.0 (1.1) Workplace setting -Hospital 5207 54.1 (0.5)* 28.9 (0.7)* 22.7 (0.6) 25.1 (0.6)* 23.2 (0.6)* 6.8 (0.4)* 47.1 (0.7)* 14.9 (0.6) -Primary Care 2772 35.2 (0.5) 27.9 (0.8) 22.8 (0.8) 22.8 (0.8) 21.6 (0.7) 5.2 (0.4) 44.5 (0.9) 14.0 (0.9) -Others 1159 10.7 (0.3) 24.7 (1.4) 20.6 (1.3) 22.0 (1.4) 19.2 (1.3) 6.5 (0.8) 43.0 (1.6) 13.8 (1.4) Frontline work during COVID-19 -Frontline 4180 43.6 (0.5)* 36.2 (0.8)* 29.7 (0.7)* 30.3 (0.8)* 28.6 (0.7)* 6.4 (0.4) 54.9 (0.8)* 18.3 (0.8)* -Not-frontline 4958 56.4 (0.5) 21.8 (0.6) 16.9 (0.5) 19.1 (0.6) 17.3 (0.5) 6.0 (0.3) 38.6 (0.7) 11.6 (0.6) Table 1 (Continued) Na %b Current MDD Current GAD Current panic Current PTSD Current Any current Any current (n = 2554) (n = 2007) attacks (n = 1946) substance use mental disabling (n = 2064) disorder disorder mental (n = 569) (n = 4118) disorder (n = 1278) %b (SE) %b (SE) %b (SE) %b (SE) %b (SE) %b (SE) %b (SE) Frequency of direct exposure to COVID-19 patients -All of the time 2256 23.0 (0.5)* 39.7 (1.1)* 34.3 (1.1)* 32.5 (1.1)* 32.4 (1.0)* 7.1 (0.6) 58.7 (1.1)* 18.8 (1.1)* -Most of the time 1924 20.7 (0.4) 32.3 (1.1) 24.7 (1.0) 27.9 (1.1) 24.5 (1.0) 5.7 (0.6) 50.7 (1.2) 17.7 (1.1) -Some of the time 2617 30.2 (0.5) 26.1 (0.9) 20.3 (0.8) 22.4 (0.8) 22.3 (0.8) 6.1 (0.5) 44.7 (1.0) 13.4 (0.9) -A little of the time 1183 14.1 (0.4) 19.1 (1.1) 14.7 (1.0) 16.1 (1.1) 13.6 (1.0) 6.8 (0.7) 34.5 (1.4) 11.1 (1.0) -None of the time 1158 12.0 (0.4) 14.4 (1.1) 11.3 (1.0) 14.2 (1.1) 8.9 (0.9) 4.8 (0.7) 28.1 (1.4) 7.6 (1.0) COVID-19 infection history -Having been hospitalized for COVID-19 112 1.2 (0.1)* 38.4 (4.6)* 33.9 (4.5)* 27.7 (4.3)* 25.5 (4.1) 7.8 (2.6)* 55.6 (4.7)* 24.8 (4.7)* J. Alonso, G. Vilagut, P. Mortier et al. -Positive COVID-19 test or medical COVID-19c 1576 16.2 (0.4) 32.8 (1.2) 25.6 (1.1) 26.5 (1.2) 23.3 (1.1) 4.6 (0.6) 49.2 (1.3) 16.4 (1.1) -None of the above 7450 82.6 (0.4) 27.0 (0.5) 21.8 (0.5) 23.4 (0.5) 22.0 (0.5) 6.5 (0.3) 44.9 (0.6) 14.0 (0.6) Isolation or quarantine because of COVID-19 -Having been isolated or quarantined 2444 25.5 (0.5)* 33.9 (1.0)* 26.0 (0.9)* 27.6 (0.9)* 24.3 (0.9)* 6.1 (0.5) 51.8 (1.1)* 17.9 (1.0)* -Not having been isolated or quarantined 6694 74.5 (0.5) 26.1 (0.5) 21.3 (0.5) 22.7 (0.5) 21.5 (0.5) 6.2 (0.3) 43.7 (0.6) 13.3 (0.6) Close ones infected with COVID-19 -Partner, children, or parents 1396 13.8 (0.4)* 35.7 (1.4)* 28.7 (1.3)* 25.6 (1.3) 26.2 (1.2)* 5.7 (0.7)* 51.4 (1.4)* 17.1 (1.2) 96 -Other family, friends or othersd 5532 58.5 (0.5) 27.6 (0.6) 22.2 (0.6) 24.0 (0.6) 21.4 (0.6) 6.8 (0.4) 46.0 (0.7) 14.1 (0.6) -None of the above 2210 27.7 (0.5) 25.4 (0.9) 20.1 (0.8) 23.1 (0.9) 21.9 (0.8) 5.0 (0.5) 42.5 (1.0) 14.1 (0.9) Lifetime mental disorders before onset COVID-19 outbreak -Lifetime mood disorder 1009 11.2 (0.3) * 50.1 (1.6)* 39.2 (1.5) * 38.6 (1.6) * 36.2 (1.5) * 10.9 (1.0) * 70.4 (1.4) * 31.1 (1.9) * -No lifetime mood disorder 8129 88.8 (0.3) 25.3 (0.5) 20.4 (0.5) 22.1 (0.5) 20.5 (0.5) 5.6 (0.3) 42.6 (0.6) 12.4 (0.5) -Lifetime anxiety disorder 3241 35.9 (0.5) * 40.0 (0.9) * 32.6 (0.8) * 38.4 (0.9) * 30.9 (0.8) * 9.5 (0.5) * 63.6 (0.9) * 21.9 (1.0) * -No lifetime anxiety disorder 5897 64.1 (0.5) 21.4 (0.5) 16.9 (0.5) 15.9 (0.5) 17.4 (0.5) 4.3 (0.3) 35.8 (0.6) 10.3 (0.5) -Lifetime substance use disorder 124 1.4 (0.1) * 61.0 (4.4) * 41.8 (4.4) * 40.2 (4.6) * 42.0 (4.4) * 62.8 (4.4) * 90.1 (2.8) * 30.5 (4.9) * -No lifetime substance use disorder 9015 98.6 (0.1) 27.6 (0.5) 22.3 (0.4) 23.7 (0.5) 22.0 (0.4) 5.4 (0.2) 45.1 (0.5) 14.3 (0.5) -Other lifetime mental disorder 257 2.8 (0.2) * 38.8 (3.1) * 25.4 (2.7) 29.2 (2.9) 28.1 (2.8) * 9.5 (1.9) * 58.1 (3.1) * 26.0 (3.5) * -No other lifetime mental disorder 8881 97.2 (0.2) 27.8 (0.5) 22.4 (0.4) 23.8 (0.5) 22.1 (0.4) 6.1 (0.3) 45.4 (0.5) 14.2 (0.5) -Any lifetime mental disorder 3771 41.6 (0.5)* 39.5 (0.8)* 31.3 (0.8)* 36.1 (0.8)* 30.0 (0.8)* 9.2 (0.5)* 62.3 (0.8)* 21.6 (0.9)* -No lifetime mental disorder 5367 58.4 (0.5) 20.0 (0.6) 16.3 (0.5) 15.3 (0.5) 16.7 (0.5) 4.0 (0.3) 33.9 (0.7) 9.4 (0.5) Number of prior lifetime mental disorders -Zero 5367 58.4 (0.5)* 20.0 (0.6)* 16.3 (0.5)* 15.3 (0.5)* 16.7 (0.5)* 4.0 (0.3)* 33.9 (0.7)* 9.4 (0.5)* -Exactly one 2999 33.0 (0.5) 35.4 (0.9) 27.9 (0.8) 33.7 (0.9) 27.0 (0.8) 7.3 (0.5) 58.1 (0.9) 18.0 (0.9) -Two or more 771 8.6 (0.3) 55.0 (1.8) 44.1 (1.8) 45.6 (1.9) 41.4 (1.8) 16.6 (1.3) 78.0 (1.5) 35.3 (2.2) * Pooled Chi-square test from multiple imputations statistically significant after adjustment for multiple comparisons with Benjamini-Hochberg (false discovery rate 0.05). a Unweighted numbers. b Weighted percentage (using post-stratification weights obtained with raking procedure). c The category ‘‘positive COVID-19 test or medical COVID-19 diagnosis’’ excludes those having been hospitalized for COVID-19. d The category ‘‘other family, friends or others’’ excludes having a partner, children, or parents infected with COVID-19. Revista de psiquiatría y salud mental (Barcelona) 14 (2021) 90---105 100 adjusting by week of the survey and by healthcare cen- 90 ter. Table 2 also shows these associations, stratifying by 80 prior lifetime mental disorders. Columns 3---4 present data 70 62.3 for those with no mental disorders prior to the COVID-19 60 50 pandemic and columns 5---6 refer to those reporting mental 39.5 40 31.3 36.1 33.9 disorders before the first wave of the COVID-19 pandemic. In 30 30 20 general, all the above-mentioned variables under study with 16.3 15.3 16.7 20 9.2 any current (disabling) mental disorders were significan- 10 4 tly associated with both new onset and persistence/relapse 0 mental disorders. However, the association of hospitaliza- MDD GAD Panic PTSD SUB Any current Attacks mental tion due to COVID-19 with any current disabling disorder disorder was only significant for those with previous mental disor- New Onset Persistence/Recurrence ders. Among those with previous mental disorders, previous SUD and previous depression were most strongly associated Figure 1 Current prevalence of probable mental disorders with current persisting/relapsing mental disorders. among Spanish healthcare workers during the first wave of the Table 3 presents multivariable analyses of the asso- COVID-19 pandemic, according to pre-pandemic lifetime men- ciations described above, adjusting by all individual tal disorders. MINDCOVID study (n = 9138). characteristics, COVID-19 exposure factors, and healthcare Green bar: workers with no pre-pandemic mental disorders (new center and week of interview. Being female, and between onset); Red Bar: workers with lifetime history of mental disor- ages 18---29 and being 30---49 were significantly associated ders (persistence/recurrence). with any and with any disabling current mental disorder. MDD: Major Depressive Disorder; GAD: Generalized Anxiety Dis- Being a physician and a nurse was consistently associated order; PTSD: Post-Stress Traumatic Disorder; SUB: Substance with significantly lower odds of current mental disorders, Use Disorder. while being an auxiliary nurse with previous mental disorders showed high (but not significant) ORs of current disabling with COVID-19. Prior lifetime mental disorders were strongly mental disorders. Being a frontline healthcare worker was associated with presenting current mental disorder (espe- a very important risk factor of any current and any dis- cially those reporting previous substance use disorder or abling disorder, as it was also having been in quarantine or depression). The higher the number of prior lifetime mental isolated. The factors most strongly associated with current disorders reported, the more likely the prevalence of any disabling mental disorders were previous substance use dis- current disorder. Similar prevalence differences were found orders, anxiety disorder and depression disorders. Having when considering current disabling mental disorders. more than one previous disorder was no longer statistically significant in the multivariate analysis. Current mental disorders according to prior lifetime mental disorders Discussion Fig. 1 shows current prevalence of mental disorders accord- Our results document a high prevalence of current men- ing to pre-COVID-19 pandemic lifetime mental disorders. tal disorders, with almost half of respondents screening Prevalence was consistently lower among workers without positive on at least one of the five well-established screen- prior mental disorders (new onset), i.e., approximately half ers for common mental disorders. Most important, 1 in than among workers with prior mental disorders (persis- 7 met criteria for a current disabling mental disorder. To tent/relapsing). the best of our knowledge, this is the first study to con- Fig. 2 shows current prevalence of any mental disorders sider both symptom screening and disability as indicator (both disabling and non-disabling), according to pre-COVID- of adverse mental health during the COVID-19 pandemic. 19 pandemic prior lifetime mental disorders. Among workers Such a combination is potentially more valid and useful without prior mental disorders, the prevalence of any men- for services planning purposes, than descriptive informa- tal disorder (new onset) was almost 34% and one in four tion on psychological symptoms.41,42 We also found that of those were disabling mental disorders (Fig. 2A). Among prevalence of adverse mental health was significantly more healthcare workers with any prior lifetime disorder, the frequent among healthcare workers with prior mental dis- prevalence of current disorders (persistence/relapse) was orders. Finally, we found that being a female, having a high much higher (61%) and more frequently disabling (i.e., one frequency of exposure to COVID-19 patients, and having in three) (Fig. 2B). quarantined or isolated are risk factors for both any current disorder and any disabling disorder. Factors associated with current mental disorders Comparison with other studies Table 2 shows bivariate associations of individual character- istics, personal COVID-19 exposure and prior lifetime mental The prevalence estimates of MDD (28.1%) and GAD (22.5%) disorders with any current mental disorder and with any cur- we found are within the range of meta-analytic reports rent disabling mental disorder. The first two columns present of healthcare workers studied in predominantly Asian the associations for the overall sample (n = 9138) that had healthcare settings.6,8,9 PTSD prevalence (22.2%) is also been presented in Table 1 in the form of Odds Ratios, once similar to a recent meta-analysis (20.7%).5 Substance use 97 J. Alonso, G. Vilagut, P. Mortier et al. A. Helthcare workers with no pre-pandemic lifetime mental disorders (New Onset). 50 years or more 20.3 8 30-49 year 27.2 10.5 18-29 years 31.9 11.4 Female 26.6 10.4 Male 18.3 6.4 Total 24.8 9.1 0 10 20 30 40 50 60 70 80 90 100 Non-Disabling Disabling B. Helthcare workers with any pre-pandemic lifetime mental disorder Persistence/Recurrence). 50 years or more 37.1 20.9 30-49 year 42.9 22 18-29 years 44.2 22 Female 41.2 22.4 Male 38.6 18.2 Total 40,7 21,5 0 10 20 30 40 50 60 70 80 90 100 Non-Disabling Disabling Figure 2 Current prevalence of any probable mental disorders (disabling and non-disabling) among Spanish healthcare workers during the first wave of the COVID-19 pandemic, according the pre-pandemic lifetime mental disorders and individual characteristics. MINDCOVID study (n = 9138). disorder was present in 6.2% of our sample. Only a few need to closely monitor the extent to which these needs studies have reported empirical estimates of this disorder are adequately met. during the COVID-19 pandemic and we were unable to find An important finding of our study is the strong association any specific data among healthcare workers. Our results sug- of prior lifetime disorders with any current disabling mental gest that this disorder has a considerably lower prevalence disorder (with odds ratios ranging from 1.53 to 8.25). This than found in the general adult populations of the US43 and result, which is consistent with our clinical experience dur- France.44 ing the first wave of the pandemic, strongly suggests that To the best of our knowledge, no previous report has healthcare workers with such a history must be considered presented data on the prevalence of any mental disorder a group at especially high risk. Adequate mental health mon- and any disabling mental disorder among healthcare work- itoring and support measures should be made accessible and ers during the COVID-19 pandemic. The prevalence in our uptake of treatment use in this high-risk group should be a study (i.e., 45.7% of the responding healthcare workers meet focus of further research. criteria for any of the five assessed disorders) is somewhat higher than the 40.9% of ≥1 adverse mental or behavioral Strengths and limitations health symptom in the adult US population.43 More impor- tantly, 1 in 7 presented a current disabling mental disorder, pointing to the high interference of adverse mental health Strengths of our study include the large number of par- on, professional, domestic, personal, and social activities. ticipating institutions from the most affected regions of Our results suggest that there are large mental healthcare Spain; the use of institutional mailing lists as the a reli- needs to meet among healthcare professionals. There is able sampling framework; data representative for a large 98 Table 2 Bivariate associations between individual characteristics, COVID-19 exposure, and pre-pandemic lifetime (LT) mental disorders with any probable current mental disorders and current disabling. Spanish healthcare workers, MINDCOVID study (N=9138). ALL (n = 9138) No prior LT mental disorders Prior LT mental disorder (new onset) (n = 5367) (persistence relapse) (n = 3771) Any current mental Any current Any current mental Any current Any current mental Any current disorder (n = 4118) disabling mental disorder (n = 1818) disabling mental disorder (n = 2300) disabling mental Revista de psiquiatría y salud mental (Barcelona) 14 (2021) 90---105 disorder (n = 1278) disorder (n = 485) disorder (n = 793) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) Gender --- female (vs. male) 1.60 (1.44---1.78)* 1.77 (1.46---2.14)* 1.74 (1.50---2.02)* 1.96 (1.43---2.70)* 1.32 (1.12---1.56)* 1.45 (1.11---1.88)* Age -18---29 years 1.77 (1.53---2.05)* 1.61 (1.27---2.03)* 1.89 (1.54---2.34)* 1.73 (1.17---2.56)* 1.36 (1.09---1.69)* 1.22 (0.89---1.67) -30---49 year 1.48 (1.35---1.62)* 1.39 (1.19---1.63)* 1.55 (1.37---1.76)* 1.51 (1.19---1.91)* 1.35 (1.17---1.57)* 1.25 (1.00---1.57) -50 years or more Ref. Ref. Ref. Ref. Ref. Ref. Country of Birth --- Spain (vs. Other) 0.74 (0.60---0.91)* 0.85 (0.61---1.19) 0.80 (0.60---1.06) 0.93 (0.54---1.62) 0.69 (0.49---0.97)* 0.83 (0.51---1.35) Marital status --- married (vs. single, 0.81 (0.74---0.88)* 0.77 (0.67---0.89)* 0.88 (0.78---0.99)* 0.88 (0.70---1.10) 0.86 (0.75---0.99)* 0.82 (0.67---1.00) divorced or legally separated, or widowed) Having children in care -Younger (<12 ys) children in care 1.04 (0.94---1.15) 1.01 (0.86---1.18) 1.17 (1.02---1.34)* 1.18 (0.91---1.51) 1.00 (0.85---1.18) 0.96 (0.76---1.21) 99 -Children in care, but >12ys 0.86 (0.76---0.97)* 0.81 (0.66---0.99)* 0.89 (0.75---1.06) 0.80 (0.58---1.10) 0.90 (0.74---1.10) 0.89 (0.66---1.18) -No children in care Ref. Ref. Ref. Ref. Ref. Ref. Living situation -House 0.78 (0.38---1.61) 0.53 (0.19---1.43) 0.74 (0.23---2.40) 0.45 (0.09---2.29) 1.16 (0.45---3.00) 0.79 (0.21---3.00) -Apartment 0.85 (0.41---1.75) 0.56 (0.20---1.53) 0.80 (0.25---2.57) 0.47 (0.09---2.40) 1.17 (0.45---3.02) 0.78 (0.20---3.01) -Other Ref. Ref. Ref. Ref. Ref. Ref. Profession -Physician 0.63 (0.55---0.71)* 0.50 (0.40---0.62)* 0.66 (0.55---0.79)* 0.47 (0.33---0.68)* 0.64 (0.52---0.78)* 0.53 (0.39---0.73)* -Nurse 1.17 (1.03---1.32)* 1.16 (0.95---1.42) 1.41 (1.19---1.68)* 1.29 (0.94---1.77) 1.03 (0.85---1.26) 1.10 (0.83---1.45) -Auxiliary nurse 1.74 (1.48---2.03)* 1.73 (1.35---2.22)* 1.81 (1.45---2.26)* 1.62 (1.09---2.41)* 1.72 (1.33---2.23)* 1.79 (1.26---2.56)* -Other profession involved in patient 0.78 (0.66---0.93)* 0.65 (0.48---0.88)* 0.71 (0.55---0.91)* 0.60 (0.37---0.98)* 0.88 (0.67---1.15) 0.70 (0.47---1.06) care -Other profession not involved in Ref. Ref. Ref. Ref. Ref. Ref. patient care Workplace setting -Hospital 1.10 (0.95---1.28) 1.08 (0.85---1.38) 1.06 (0.86---1.30) 1.07 (0.71---1.61) 1.15 (0.91---1.47) 1.14 (0.81---1.60) -Primary Care 1.14 (0.95---1.36) 1.14 (0.82---1.57) 1.22 (0.94---1.58) 1.24 (0.73---2.10) 1.08 (0.82---1.44) 1.11 (0.71---1.74) -Other Ref. Ref. Ref. Ref. Ref. Ref. Table 2 (Continued) ALL (n = 9138) No prior LT mental disorders Prior LT mental disorder (new onset) (n = 5367) (persistence relapse) (n = 3771) Any current mental Any current Any current mental Any current Any current mental Any current disorder (n = 4118) disabling mental disorder (n = 1818) disabling mental disorder (n = 2300) disabling mental disorder (n = 1278) disorder (n = 485) disorder (n = 793) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) Frontline work during COVID-19 1.82 (1.66---1.99)* 2.00 (1.72---2.32)* 1.97 (1.73---2.23)* 2.44 (1.89---3.14)* 1.77 (1.54---2.04)* 1.86 (1.53---2.27)* Frequency of direct exposure to COVID-19 patients -All of the time 3.30 (2.78---3.91)* 3.88 (2.85---5.28)* 4.37 (3.37---5.68)* 5.78 (3.37---9.94)* 3.11 (2.41---4.01)* 3.68 (2.47---5.47)* -Most of the time 2.53 (2.14---3.01)* 3.27 (2.39---4.47)* 3.04 (2.32---3.97)* 4.35 (2.48---7.64)* 2.42 (1.89---3.10)* 3.04 (2.04---4.54)* -Some of the time 2.01 (1.71---2.37)* 2.24 (1.63---3.07)* 2.49 (1.93---3.21)* 2.70 (1.54---4.74)* 1.88 (1.48---2.38)* 2.21 (1.49---3.29)* -A little of the time 1.31 (1.09---1.58)* 1.57 (1.13---2.20)* 1.44 (1.08---1.91)* 1.74 (0.96---3.16) 1.42 (1.08---1.86)* 1.73 (1.11---2.70)* -None of the time Ref. Ref. Ref. Ref. Ref. Ref. J. Alonso, G. Vilagut, P. Mortier et al. COVID-19 infection history -Having been hospitalized for 1.41 (0.96---2.06) 2.05 (1.23---3.41)* 1.05 (0.59---1.85) 1.83 (0.82---4.09) 1.65 (0.90---3.02) 2.18 (1.04---4.57)* COVID-19 -Positive COVID-19 test or medical 1.07 (0.95---1.20) 1.12 (0.93---1.34) 1.03 (0.88---1.21) 1.10 (0.82---1.48) 1.11 (0.92---1.34) 1.14 (0.88---1.47) COVID-19 diagnosisa -None of the above Ref. Ref. Ref. Ref. Ref. Ref. Having been isolated or quarantined 1.35 (1.22---1.49)* 1.52 (1.31---1.77)* 1.27 (1.10---1.45)* 1.52 (1.20---1.92)* 1.41 (1.20---1.65)* 1.56 (1.25---1.94)* 100 because of COVID-19 Close ones infected with COVID-19 -Partner, children, or parents 1.25 (1.08---1.44)* 1.19 (0.95---1.48) 1.51 (1.25---1.84)* 1.41 (1.01---1.96)* 0.99 (0.79---1.25) 0.97 (0.70---1.34) -Other family, friends or othersb 1.09 (0.98---1.20) 0.98 (0.83---1.16) 1.24 (1.08---1.42)* 1.03 (0.78---1.35) 0.95 (0.81---1.11) 0.90 (0.71---1.14) -None of the above Ref. Ref. Ref. Ref. Ref. Ref. Lifetime mood disorder before onset 3.18 (2.75---3.68)* 4.88 (4.02---5.94)* n.a. n.a. 1.61 (1.38---1.89)* 2.41 (1.95---2.98)* COVID-19 outbreak Lifetime anxiety disorder before onset 3.15 (2.87---3.45)* 3.72 (3.19---4.34)* n.a. n.a. 1.52 (1.26---1.84)* 1.44 (1.08---1.92)* COVID-19 outbreak Lifetime substance use disorder before 11.55 (6.18---21.56)* 12.69 (6.17---26.11)* n.a. n.a. 6.02 (3.21---11.28)* 6.20 (2.91---13.19)* onset COVID-19 outbreak Other lifetime mental disorder before 1.62 (1.26---2.09)* 2.32 (1.64---3.30)* n.a. n.a. 0.79 (0.61---1.03) 1.04 (0.72---1.50) onset COVID-19 outbreak Any lifetime mental disorder before 3.21 (2.93---3.51)* 3.97 (3.40---4.63)* n.a. n.a. n.a. n.a. onset COVID-19 outbreak Having two or more lifetime mental 4.72 (3.95---5.65)* 7.34 (5.85---9.21)* n.a. n.a. 2.52 (2.09---3.05)* 3.79 (2.98---4.84)* disorders (vs. zero or exactly one) Note: OR, odds ratio; 95%CI, 95% confidence interval; n.a., not applicable. All analyses adjust for time of survey (weeks), hospital membership and all predictors shown in the rows. * Statistically significant (˛ = 0.05). a The category ‘‘positive COVID-19 test or medical COVID-19 diagnosis’’ excludes those having been hospitalized for COVID-19. b The category ‘‘other family, friends or others’’ excludes having a partner, children, or parents infected with COVID-19. Table 3 Multivariable associations between individual characteristics, COVID-19 exposure, and prior lifetime (LT) mental disorders with probable current mental disorders and current disabling mental disorders. Spanish healthcare workers, MINDCOVID study (N = 9138). ALL (n = 9138) No prior LT mental disorders Prior LT mental disorder (new onset) (n = 5367) (persistence/relapse) (n = 3771) Any current mental Any current Any current mental Any current Any current mental Any current disorder (n = 4118) disabling mental disorder (n = 1818) disabling mental disorder (n = 2300) disabling mental disorder (n = 1278) disorder (n = 485) disorder (n = 793) Revista de psiquiatría y salud mental (Barcelona) 14 (2021) 90---105 aOR (95%CI) aOR (95%CI) aOR (95%CI) aOR (95%CI) aOR (95%CI) aOR (95%CI) Gender - female (vs. male) 1.45 (1.29---1.63)* 1.58 (1.27---1.96)* 1.54 (1.31---1.81)* 1.77 (1.27---2.46)* 1.36 (1.13---1.63)* 1.50 (1.12---2.01)* Age -18---29 years 1.53 (1.28---1.82)* 1.36 (1.02---1.82)* 1.82 (1.43---2.32)* 1.67 (1.07---2.61)* 1.23 (0.95---1.59) 1.17 (0.80---1.71) -30---49 year 1.46 (1.30---1.64)* 1.34 (1.09---1.64)* 1.49 (1.27---1.74)* 1.39 (1.04---1.87)* 1.42 (1.19---1.70)* 1.30 (0.98---1.74) -50 years or more Ref. Ref. Ref. Ref. Ref. Ref. Marital status --- married (vs. single, 1.05 (0.95---1.17) 1.02 (0.85---1.23) 1.09 (0.94---1.26) 1.09 (0.84---1.42) 1.01 (0.86---1.19) 0.98 (0.77---1.26) divorced or legally separated, or widowed) Having children in care -Younger (<12 ys) children in care 0.97 (0.85---1.11) 1.01 (0.81---1.26) 1.00 (0.84---1.20) 1.03 (0.74---1.42) 0.93 (0.76---1.13) 0.99 (0.73---1.33) -Children in care, but >12 ys 0.96 (0.84---1.11) 0.89 (0.70---1.13) 0.95 (0.78---1.14) 0.82 (0.57---1.16) 0.99 (0.80---1.24) 0.95 (0.68---1.32) -No children in care Ref. Ref. Ref. Ref. Ref. Ref. 101 Profession -Physician 0.45 (0.39---0.53)* 0.34 (0.26---0.44)* 0.45 (0.37---0.55)* 0.30 (0.20---0.45)* 0.45 (0.36---0.56)* 0.36 (0.25---0.52)* -Nurse 0.77 (0.67---0.90)* 0.73 (0.57---0.92)* 0.82 (0.67---0.99)* 0.69 (0.48---0.98)* 0.70 (0.56---0.87)* 0.73 (0.53---1.01) -Auxiliary nurse 1.12 (0.94---1.34) 1.07 (0.80---1.42) 1.11 (0.87---1.41) 0.92 (0.60---1.40) 1.13 (0.85---1.50) 1.18 (0.79---1.78) -Other profession involved in 0.67 (0.55---0.80)* 0.54 (0.39---0.75)* 0.59 (0.45---0.77)* 0.50 (0.30---0.82)* 0.75 (0.56---1.00) 0.57 (0.36---0.92)* patient care -Other profession not involved in Ref. Ref. Ref. Ref. Ref. Ref. patient care Frequency of direct exposure to COVID-19 patients -All of the time 3.98 (3.27---4.85)* 5.19 (3.61---7.46)* 4.40 (3.31---5.85)* 6.62 (3.70---11.85)* 3.53 (2.66---4.68)* 4.27 (2.70---6.76)* -Most of the time 3.10 (2.54---3.76)* 4.53 (3.17---6.48)* 3.15 (2.36---4.20)* 5.00 (2.77---9.01)* 3.08 (2.34---4.06)* 4.26 (2.70---6.71)* -Some of the time 2.50 (2.08---3.01)* 2.96 (2.07---4.23)* 2.74 (2.09---3.60)* 3.25 (1.82---5.82)* 2.24 (1.73---2.90)* 2.71 (1.74---4.20)* -A little of the time 1.55 (1.27---1.90)* 1.93 (1.33---2.80)* 1.60 (1.19---2.14)* 2.06 (1.13---3.78)* 1.53 (1.15---2.03)* 1.81 (1.12---2.92)* -None of the time Ref. Ref. Ref. Ref. Ref. Ref. COVID-19 infection history -Having been hospitalized for 1.06 (0.69---1.64) 1.42 (0.76---2.65) 0.92 (0.50---1.71) 1.48 (0.60---3.65) 1.23 (0.64---2.39) 1.38 (0.57---3.34) COVID-19 -Positive COVID-19 test or medical 0.82 (0.70---0.95)* 0.76 (0.60---0.96)* 0.77 (0.63---0.93)* 0.69 (0.48---1.01) 0.88 (0.70---1.11) 0.83 (0.60---1.14) COVID-19 diagnosisa Table 3 (Continued) ALL (n = 9138) No prior LT mental disorders Prior LT mental disorder (new onset) (n = 5367) (persistence/relapse) (n = 3771) Any current mental Any current Any current mental Any current Any current mental Any current disorder (n = 4118) disabling mental disorder (n = 1818) disabling mental disorder (n = 2300) disabling mental J. Alonso, G. Vilagut, P. Mortier et al. disorder (n = 1278) disorder (n = 485) disorder (n = 793) aOR (95%CI) aOR (95%CI) aOR (95%CI) aOR (95%CI) aOR (95%CI) aOR (95%CI) -None of the above Ref. Ref. Ref. Ref. Ref. Ref. Having been isolated or quarantined 1.36 (1.20---1.54)* 1.60 (1.31---1.95)* 1.34 (1.13---1.59)* 1.64 (1.20---2.25)* 1.41 (1.16---1.71)* 1.60 (1.21---2.11)* because of COVID-19 Lifetime mood disorder before 2.53 (2.04---3.15)* 3.23 (2.27---4.60)* n.a. n.a. 2.91 (1.29---6.57)* 4.46 (1.65---12.03)* onset COVID-19 outbreak 102 Lifetime anxiety disorder before 2.82 (2.53---3.13)* 3.03 (2.53---3.62)* n.a. n.a. 3.36 (1.49---7.58)* 4.30 (1.61---11.43)* onset COVID-19 outbreak Lifetime substance use disorder 8.25 (4.22---16.11)* 5.74 (2.53---13.03)* n.a. n.a. 9.17 (3.67---22.92)* 7.23 (2.60---20.08)* before onset COVID-19 outbreak Other lifetime mental disorder 1.53 (1.15---2.05)* 2.06 (1.35---3.13)* n.a. n.a. 1.77 (0.80---3.89) 2.69 (1.07---6.76)* before onset COVID-19 outbreak Having two or more lifetime mental 0.93 (0.69---1.24) 1.17 (0.76---1.79) n.a. n.a. 0.78 (0.33---1.83) 0.83 (0.29---2.36) disorders (vs. zero or exactly one) AUC 0.73 0.77 0.68 0.72 0.69 0.73 OR, adjusted Odd Ratio; CI, 95% Confidence Interval; ref, reference category; AUC, Area under the curve. SE, Standard Error, n.a. not applicable. Each column represents a separate regression model, each time adjusting for time of survey (weeks), hospital membership, and all. * Statistically significant (˛ = 0.05). a The category ‘‘positive COVID-19 test or medical COVID-19 diagnosis’’ excludes those having been hospitalized for COVID-19. Revista de psiquiatría y salud mental (Barcelona) 14 (2021) 90---105 number of healthcare workers; and including the criterion of Spanish healthcare workers during the first wave of the severe interference to identify disabling mental disorders. COVID-19 pandemic, with 1 in 7 presenting a disabling These strengths support the robustness and relevance of our mental disorder. Prevalence of adverse mental health results. was significantly more frequent among healthcare workers Nevertheless, the study has some limitations that deserve reporting lifetime mental disorders before the pandemic, careful consideration. First, we had a low response rate. which identifies a group in need of current monitoring and Despite important advantages of institutional email lists, adequate support, especially as the pandemic is entering these email accounts appear not to be checked by a in successive waves. Other healthcare workers that should large majority of employees (<27%) and their utilization be monitored include with a high frequency of exposure to might differ by professional category. In addition, invitations COVID-19 patients, who had been infected or have been reminders were limited to a maximum of 2 due to institu- quarantined or isolated, as well as female workers, and tional requirements. It is possible that healthcare workers auxiliary nurses. with mental health problems were more likely to partici- pate. But it is also likely that the most stressed workers did Transparency statement not have time to respond. In order to improve representa- tiveness, we have carefully weighted the observed data as to The lead author (JA) states that this manuscript is an exactly reproduce the gender, age and professional category honest, accurate, and transparent account of the study distribution of healthcare personnel in each participating being presented, that no important aspect of the study has institution. been omitted, and that differences from the study that Second, the study was cross-sectional in nature, pre- was initially planned have been explained (and if relevant, cluding the inference of any causal impact of the COVID-19 recorded). pandemic on the mental health of healthcare workers. Nev- ertheless, we used clear and relevant recall periods to make sure the symptoms were present after the onset of the Contributors pandemic and we collected information on pre-pandemic lifetime mental disorders. JA, GV, and PM reviewed the literature. JA, GV, PM, MF, EA, Third, measures used to assess mental disorders in our VPS, JMH, RCK, and RB conceived and designed the study. study are based on self-reports and not on clinical diagnoses. EA, JDM, NL, TP, JMPT, JIP, JIE, ME, NP, AGP, CR, EA, ICG, Nevertheless, there is good evidence of acceptable sensitiv- AAP, MC, APZ, EV, CS, and VPS acquired the data. GV, IA, and ity and specificity of the assessment for the current score PM cleaned and analyzed the data. JA, GV, and PM drafted cutoffs used here for current major depression disorder,45 the initial version of the manuscript. All authors reviewed generalized anxiety disorder18 and post-traumatic stress the initial draft and made critical contribution to the inter- disorders.23 These measures are among the most frequently pretation of the data and approved the manuscript. The used in epidemiologic studies which allows comparability of corresponding authors attest that all listed authors meet results. For lifetime disorders we used a list of disorders authorship criteria and that no others meeting the criteria which have been shown to have acceptable agreement with have been omitted. clinical evaluations.46 The high prevalence of both lifetime and current mental disorders found in our study suggests Funding that a part might include false positive cases; and some of the real cases may have a mild disorder. It is for this This work was supported by Instituto de Salud Carlos III reason that we: (a) use the term ‘‘probable’’ disorder to (Ministerio de Ciencia e Innovación)/FEDER (COV20/00711); refer to workers screening positive using the recommended ISCIII (Sara Borrell, CD18/00049) (PM); FPU (FPU15/05728)); cut-off scores for screening; and (b) consider disabling cur- ISCIII (PFIS, FI18/00012); Generalitat de Catalunya rent mental disorders to be a better estimate of the needs (2017SGR452). for mental healthcare in this population, since it includes functional limitation, according to DSM-5 indications.41,42 Conflict of interest statement Healthcare workers with disabling current mental disor- der in our study had much more frequent (between 2 EV reports personal fees from Abbott, personal fees from and three times more) mental comorbidity, current suici- Allergan, personal fees from Angelini, grants from Novar- dal ideation, poor perceived (data not presented, available tis, grants from Ferrer, grants and personal fees from upon request). Janssen, personal fees from Lundbeck, personal fees from Finally, we have not studied here the use of services Sage, personal fees from Sanofi, outside the submitted for mental disorders, a really important complement to the work. JDM reports personal fees from Janssen, personal issue of need for care. This issue requires specific analyses fees and non-financial support from Otsuka, personal fees that we plan to address in the immediate future. and non-financial support from Lundbeck, personal fees from Angelini, personal fees and non-financial support from Conclusions Accord, outside the submitted work. In the past 3 years, RCK was a consultant for Datastat, Inc, Sage Pharmaceuti- Notwithstanding these limitations, our study shows a high cals, and Takeda. All other authors reported no conflict of prevalence of probable current mental disorders among interest. 103 J. Alonso, G. Vilagut, P. Mortier et al. Acknowledgments Spanish Health professionals. 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