Azoulay et al. Ann. Intensive Care (2020) 10:110 https://doi.org/10.1186/s13613-020-00722-3 RESEARCH Open Access Symptoms of burnout in intensive care unit specialists facing the COVID‑19 outbreak Elie Azoulay1* , Jan De Waele2, Ricard Ferrer3,4, Thomas Staudinger5, Marta Borkowska2, Pedro Povoa6,7, Katerina Iliopoulou8, Antonio Artigas9, Stefan J. Schaller10, Manu Shankar Hari11,12, Mariangela Pellegrini13, Michael Darmon1, Jozef Kesecioglu14 and Maurizio Cecconi15 On behalf of ESICM Abstract Background: The COVID-19 pandemic has resulted in an unprecedented healthcare crisis with a high prevalence of psychological distress in healthcare providers. We sought to document the prevalence of burnout syndrome amongst intensivists facing the COVID-19 outbreak. Methods: Cross-sectional survey among intensivists part of the European Society of Intensive Care Medicine. Symptoms of severe burnout, anxiety and depression were collected. Factors independently associated with severe burnout were assessed using Cox model. Results: Response rate was 20% (1001 completed questionnaires were returned, 45 years [39–53], 34% women, from 85 countries, 12 regions, 50% university-affiliated hospitals). The prevalence of symptoms of anxiety and depres- sion or severe burnout was 46.5%, 30.2%, and 51%, respectively, and varied significantly across regions. Rating of the relationship between intensivists and other ICU stakeholders differed significantly according to the presence of anxiety, depression, or burnout. Similar figures were reported for their rating of the ethical climate or the quality of the decision-making. Factors independently associated with anxiety were female gender (HR 1.85 [1.33–2.55]), working in a university-affiliated hospital (HR 0.58 [0.42–0.80]), living in a city of > 1 million inhabitants (HR 1.40 [1.01–1.94]), and clinician’s rating of the ethical climate (HR 0.83 [0.77–0.90]). Independent determinants of depression included female gender (HR 1.63 [1.15–2.31]) and clinician’s rating of the ethical climate (HR 0.84 [0.78–0.92]). Factors independently associated with symptoms of severe burnout included age (HR 0.98/year [0.97–0.99]) and clinician’s rating of the ethi- cal climate (HR 0.76 [0.69–0.82]). Conclusions: The COVID-19 pandemic has had an overwhelming psychological impact on intensivists. Follow-up, and management are warranted to assess long-term psychological outcomes and alleviate the psychological burden of the pandemic on frontline personnel. Keywords: Coronavirus, Pneumonia, Acute respiratory distress syndrome, Exhaustion, Depersonalization, Well-being Introduction demands on healthcare professionals cause psycho- With more than six million confirmed cases worldwide logical stress. Previous pandemics involving quarantine and more than 350,000 deaths between February and have emphasized that healthcare workers might develop May 2020, the COVID-19 pandemic has emerged as an symptoms of post-traumatic stress disorder, anxiety, unprecedented healthcare crisis [1–3]. Increasing work depression, insomnia, and substance use disorders [4]. As the spread and burden of the pandemic varied by geo- graphic regions (https​://www.who.int/chp/about​/regio​ *Correspondence: elie.azoulay@aphp.fr 1 Médecine Intensive et Réanimation, PHP, Hôpital Saint-Louis, Paris ns/en), with overwhelming numbers of severe cases in University, Paris, France some places [5], and only sporadic transmission with few Full list of author information is available at the end of the article © The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat​iveco​ mmons​.org/licen​ses/by/4.0/. Azoulay et al. Ann. Intensive Care (2020) 10:110 Page 2 of 8 in others suggesting that the psychological burden also We collected demographic variables and information varies across regions [6]. regarding personal and professional experience in man- Preliminary reports from countries affected early on aging severe COVID-19 patients. The number of COVID- in the pandemic highlight the high prevalence of psy- 19 patients managed as defined as the number of patients chological burden in healthcare providers outside the for whom the responding physician was providing direct critical care setting [7, 8]. First, in the general popula- care (clinical examination, medical prescription or pro- tion exposed to the health crisis and state of emergency, cedures during day or night shifts). We collected data high levels of loneliness, worry, fatigue, and low distress on the mental health outcomes included symptoms of tolerance were reported during the early weeks of the severe burnout, anxiety, and depression, using the Hos- COVID-19 pandemic. They were significantly associated pital Anxiety and Depression Scale (HADS) and Maslach with depression, anxiety, and stress symptoms [4, 9]. Sec- Burnout Inventory (MBI). The HADS is a 14-item auto ond, this psychological burden appears to be higher in questionnaire that includes 7 items about symptoms of healthcare providers, especially in those who are younger, anxiety, and 7 items on depression [19]. MBI consists less experienced, and amongst those working in frontline of a 22-item questionnaire on the three components of [10]. Increased working hours, the number of Covid-19 burnout: emotional exhaustion (9 items), depersonaliza- patients cared for, and limited logistic support are asso- tion (5 items), and personal achievement (8 items). Par- ciated with the highest prevalence of mental burden ticipants were classified as having symptoms of anxiety or [10]. In a systematic review of 13 studies (33,062 par- depression when the corresponding subscale was > 7 [20] ticipants), the pooled prevalence of anxiety and depres- and high levels of burnout when the MBI was > −9 [15]. sion was 23.2%, and 22.8%, respectively [11]. In a study Visual analog scales were used by respondents to rank of healthcare providers exposed to COVID-19 patients, their relationship with ICU physicians, nurses, adminis- half of them self-perceived burnout [12]. In another study trators, the quality of the decision-making and the ethi- of 376 healthcare professionals in Italy, more than 1 out cal climate. The ethical climate was defined as “individual of 3 showed a high score of emotional exhaustion, and 1 perceptions of the organization that influences attitudes out of 4 reported high levels of depersonalization, while and behaviour and serves as a reference for employee around 15% reported low levels of personal accomplish- behavior” [21]. ment [13]. However, not all these studies captured the As ESICM has members worldwide, we summa- three major burnout domains, namely, emotional exhaus- rized the demographic characteristics and categorized tion, depersonalization, and personal accomplishment the respondents from 85 countries, into 12 different [14, 15], using valid instruments. regions, as previously described [22]. Continuous vari- It is well recognized that the COVID-19 pandemic is ables are described as median (interquartile range [IQR]) putting healthcare professionals working in critical care and are compared between groups using the non-par- under extreme pressure [7, 16]. Aside from the disrup- ametric Wilcoxon rank-sum test. Categorical variables tion of healthcare delivery in highly affected regions, the are expressed as frequency (percentages) and are com- scarcity of resources such as personal protective equip- pared between groups using Fisher’s exact test. Factors ment, ICU beds, and ventilators, increase this psycholog- independently associated with mental health outcomes ical burden [17]. Although features such as exhaustion, were assessed using Cox model. Conditional stepwise psychological disturbances, and stigmatization are to be variable selection was performed with 0.2 as the critical expected, they are seldom documented [18]. Notably, P-value for entry into the model, and 0.1 as the P-value the prevalence of burnout using a validated screening for removal. Interactions and correlations between the tool has never been reported in healthcare professionals explanatory variables were carefully checked. Statistical working in critical care. In this context, to document the analyses were performed with R statistical software, ver- prevalence of mental health outcomes in ICU specialists sion 3.4.3 (available online at http://www.r-proje​ct.org/). facing the COVID-19 outbreak, we performed an online A P-value < 0.05 was considered significant. survey on behalf of the European Society of Intensive Care Medicine (ESICM). Results Methods Among ESICM members, 5660 opened the e-mail This web-based survey endorsed by ESICM collected advertising for the survey, 1132 (20%) responded, data between April 30 and May 25, 2020, using an online including 1001 complete answers for demographic ques- questionnaire sent through the ESICM members’ list tions (Table 1), 848 complete responses for the Hospital (https​://www.surve​ymonk​ey.com/r/F2FFC​6S). Online Anxiety and Depression Scale (HADS) and 846 complete consent was obtained from the participants. responses for the Maslach Burnout Inventory (MBI). Azoulay et al. Ann. Intensive Care (2020) 10:110 Page 3 of 8 Table 1 Characteristics of responding physicians Numbers (%) or median (interquartile Total, 1001 respondents ranges) Age 45 (39–53) Female gender 342 (34.2%) Single 170 (17%) Number of children 2 (0–2) Religiosity (0 not at all—100 very religious) 26 (1–61) Current smoker 97 (9.7%) Sleeping pills intake 374 (37.4%) Excessive alcohol intake (self-report) 121 (12.1%) Live in a city > 1 million inhabitants 403 (40.3%) Work in a university-affiliated hospital 551 (55.1%) Number of ICU beds baseline/during the 20 (11–36)/35 (20–60) surge Number of night shifts per month 5 (3–6) Number of COVID-19 patients managed 30 (14–60) Ratings (0 poor–10 excellent) Relationship with doctors 8 (7–9) Relationship with nurses 9 (8–9) Relationship with administrators 7 (5–8) Relationship with referring physicians 8 (7–9) Quality of the decision-making 8 (7–9) Ethical climate 8 (7–9) Mental health outcomes Hospital anxiety and depression scale, anxi- 7 (4–9) ety subscale N = 848 respondents Presence of symptoms of anxiety 395 (46.6%) Hospital anxiety and depression scale, 4 (2–7) depression subscale Fig. 1 Maslach and Burnout Inventory in 846 ICU specialists. The Presence of symptoms of depression 256 (30.2%) three domains of the instrument, namely emotional exhaustion, depersonalization, and personal accomplishment, are displayed Maslach burnout inventory −8 (−21 to 8) separately. Symptoms of emotional exhaustion are mild or severe in N = 846 respondents 29.9% and 23.0% of the respondents. Symptoms of depersonalization Presence of severe burnout 439 (51.8%) are mild or severe in 34.3% and 23.0% of the respondents. Symptoms Emotional exhaustion sub score 18 (10–29) of personal accomplishment are mild or severe in 35.2% and 31.4% of Depersonalization sub score 8 (4–12) the respondents. Overall, prevalence of severe burnout was reported Personal accomplishment sub score 35 (29–40) in 51.8% (439/846) of the respondents Respondents (45 years [39–53], 34% female) were mostly from Middle Europe (25%), Southern Europe relationship between ICU specialists and other ICU spe- (23%), the United Kingdom (12%), South America (9%), cialists, nurses, administrators, or primary physicians Northern Europe (8.1%), Eastern Europe (5.3%), Mid- were significantly different according to the presence of dle-East (5%), North America (4.7%), Asia (3.3%), India (2.7%), Australia–New Zealand (1.3%) or Africa (0.6%); 54% were living in a city of > 1 million inhabitants, and 55% were working in a University-affiliated hospital. Fig. 2 Physician’s ranking (from 0 [very poor relationship] to 10 37.2% intensivists took sleeping pills, 12% reported hav- [excellent relationship]) of their relationship with other ICU specialists, ing excessive alcohol intake, and 9.7% were smoking. nurses, administrators, or with referring physicians. They have also ranked the quality of the decision-making and the ethical climate Regarding the mental health outcomes of ICU spe- in their ICU. Results are presented according to the presence of cialists during the COVID-19 outbreak, the prevalence symptoms of anxiety (a), the presence of symptoms of depression of symptoms of anxiety, depression, and severe burn- (b), or the presence of symptoms of severe burnout (c). This figure out were 46.5%, 30.2%, and 51%, respectively (Fig. 1). displays the results in the 848 ICU specialists returning complete Ranking (VAS from 0 [poor] to 10 [excellent]) of the HADS. *** indicates P value < 0.0001 Azoulay et al. Ann. Intensive Care (2020) 10:110 Page 4 of 8 a 10 Respondents with or without symptoms of anxiety a Respondents with or without symptoms of anxiety P=0.001 P<0.0001 p<0.0001 P<0.0001 100 9 *** *** 80 Visual Analog Scale *** Visual Analog Scale *** 60 8 *** 40 20 7 *** 0 6 COVID-19 is COVID-19 is COVID-19 is a COVID-19 is a more challenging more challenging source of conflicts source of conflicts professionally emotionally with my team with my family 5 Relationship Relationship Relationship Relationship Quality of the Ethical with other ICU with nurses with with referring decision Climate specialists administrators physicians making b Respondents with or without symptoms of depression P=0.02 P<0.0001 P<0.0001 P<0.0001 100 80 b 10 Visual Analog Scale Respondents with or without symptoms of depression 60 9 40 *** *** 20 *** Visual Analog Scale *** 8 *** 0 COVID-19 is COVID-19 is COVID-19 is a COVID-19 is a 7 more challenging more challenging source of conflicts source of conflicts *** professionally emotionally with my team with my family 6 c Respondents with or without symptoms of severe burnout P=0.17 P=0.001 P<0.0001 P<0.0001 100 5 Relationship Relationship Relationship Relationship Quality of the Ethical with other ICU with nurses with with referring decision Climate 80 administrators physicians making Visual Analog Scale specialists 60 c 10 Respondents with or without symptoms of severe burnout 40 20 9 *** *** *** 0 *** Visual Analog Scale *** 8 COVID-19 is COVID-19 is COVID-19 is a COVID-19 is a more challenging more challenging source of conflicts source of conflicts professionally emotionally with my team with my family 7 Fig. 3 Physician’s ranking (from 0 [less challenging than non-COVID *** patients] to 100 [more challenging than non-COVID patients]) of how the pandemic has been a professional and emotional challenge, and 6 whether it was a source of intra-team or intra-family conflict. Results are presented according to the presence of symptoms of anxiety (a), the presence of symptoms of depression (b), or the presence of 5 symptoms of severe burnout (c) Relationship Relationship Relationship Relationship Quality of the Ethical with other ICU with nurses with with referring decision Climate specialists administrators physicians making Azoulay et al. Ann. Intensive Care (2020) 10:110 Page 5 of 8 Fig. 4 Prevalence and adjusted prevalence of anxiety, depression and severe burnout in the 12 participating regions Fig. 5 World map displaying the prevalence (graphs in the left) and the adjusted odds ratio (OR, graphs in the right) of symptom of anxiety, depression and severe burnout across regions symptoms of anxiety (Fig. 2, panel a), depression (Fig. 2; Respondents were asked to compare their COVID-19 panel b) or severe burnout (Fig. 2, panel c). Similarly, experience to general ICU non-COVID patients in a 0 physicians with either of these symptoms provided signif- (less challenging than non-COVID patients) to 100 (more icantly lower scores to the ethical climate or the quality of challenging than non-COVID patients) scale. Overall, the the decision-making ratings (Fig. 2). scores reported were (75 [55–88]) for the professional Azoulay et al. Ann. Intensive Care (2020) 10:110 Page 6 of 8 challenge, (80 [59–93]) for the emotional challenge, (32 inhabitants (HR 1.40 [1.01–1.94]), and clinician’s rating [8–61]) for the intra-team conflicts, and (12 [0–50]) for about the ethical climate (HR 0.83 [0.77–0.90]). Factors the intra-family conflicts. To the question of whether independently associated with symptoms of depression this experience would make them see their professional were female gender (HR 1.63 [1.15–2.31]) and clinician’s career differently, ICU specialists provided a score of 50 rating about the ethical climate (HR 0.84 [0.78–0.92]). (4–75). Figure 3 shows the distribution of the scores in Factors independently associated with symptoms of ICU specialists with and without symptoms of anxiety severe burnout included age (HR 0.98/year [0.97–0.99]) (panel a), depression (panel b), or severe burnout (panel and clinician’s rating about the ethical climate (HR 0.76 c). [0.69–0.82]). By univariable analysis, factors associated with symp- toms of anxiety were female gender (41.2% in those Discussion with symptoms of depression vs. 27.9% in those with- The novel SARS-CoV-2 pandemic has resulted in an out), younger age (44.5 [38–52] vs. 47 [40–54], years overall surge in new cases of anxiety, depression and P = 0.0002), living in city of > 1 million inhabitants (50.2% burnout in critical care health care workers. Determi- vs. 42.1%, P = 0.02), and higher religiosity (35 [4–66] vs. nants of mental health outcomes included clinician’s 19 [0–57], P = 0.001). Factors associated with the preva- characteristics (age, gender, religiosity), ICU char- lence of symptoms of depression were female gender acteristics (region, located in a large city, university- (42.4% in those with symptoms of depression vs. 30.5% affiliated), and how critical care specialists ranked the in those without, P = 0.0008), younger age ((44 [38–51] ethical climate in their ICU. vs. 46 [39–54], P = 0.004), being single (21.4% vs. 15.1%, Given the highly contagious nature of SARS-CoV-2, P = 0.03), living in city of > 1 million inhabitants (63.6% occupational hazards have been associated with more vs. 49.5%, P = 0.0003), and higher religiosity (36 [5–67] emotional impact in physicians who work on the front- vs. 21 [0–59], P = 0.002). Working in a university-affili- line [10]. However, this study, including ICU specialists ated hospital was associated with a lower prevalence of managing critically ill COVID-19 patients, did not con- symptoms of anxiety (42% vs. 52%, P = 0.007) but did not firm that exposure to the disease or the physical strain affect the prevalence of symptoms of depression. Age and associated with the surge were the leading factors for female gender were also associated with a higher preva- symptoms of severe burnout, anxiety, and depression lence of severe burnout (45 [37–51] vs. 47 years [40–55], [10, 12, 13]. The number of COVID-19 patients man- P = 0.0001, and 38.2% vs. 30.1%, P = 0.02). Clinicians with aged, the number of night shifts per month, or time symptoms of anxiety, depression, or severe burnout were since the last vacation at the time of the surge were not more frequently smoking or taking sleeping pills, whereas associated with either symptom. alcohol consumption was not affected. The number of The substantial variation in the prevalence of burn- COVID-19 patients managed was not associated with the out across regions calls for attention [23]. Indeed, the prevalence of the psychological burden. pandemic exposed ICU specialists to the inadequacy of The prevalence of symptoms of anxiety, depression, and national stockpiles in personal protective equipment, burnout varied significantly across regions (Figs. 4 and ventilators, staff, and drugs [24–26]. National responses, 5). For anxiety, Middle Europe, East Europe, Asia, and including lockdown timing and duration, have varied also Scandinavia were in the 30–40% range, Australia–New worsening the psychological pressure on the personnel. Zealand, South America, North America, the UK, and Moreover, the lack of established policies for patient’s tri- South Europe in the 50–60%, and India, Middle-East and age and management has increased the burden on health Africa in the > 60% range. For depression, Middle Europe, care workers [27]. Each professional society has issued Australia–New Zealand, Scandinavia, and East Europe guidelines potentially mismatching with local procedures were in the 20–40% range, the UK, North America, Asia, or with recommendations from other specialties, with South America South Europe, and the Middle East in the no effort to align such guidelines. Last, as the pandemic 30–50%, and Africa was 80%. For severe burnout, Aus- occurred heterogeneously and asynchronously through- tralia–New Zealand, India, Middle Europe, and Scan- out the world, both the COVID-19 burden and the effects dinavia were in the 20–40% range, East Europe, North of the lockdown were captured at different time points America, Asia, South America, the UK, South Europe, from the disease peak [4]. and the Middle East were in the 50–70% range. Even though anxiety and depression have not been By multivariable analysis, factors independently associ- assessed using the HADS, this study reports a prevalence ated with symptoms of anxiety were female gender (HR of burnout in ICU physicians of 52%. These results sug- 1.85 [1.33–2.55]), working in a university-affiliated hos- gest then that the SARS-CoV-2 pandemic has generated pital (HR 0.58 [0.42–0.80]), living in a city of > 1 million more burnout than what could have been expected. For Azoulay et al. Ann. Intensive Care (2020) 10:110 Page 7 of 8 instance, in the systematic review from van Mol et al. relation with the pandemic and including all healthcare [28], reported rates of burnout in ICU physicians were professionals are warranted. about 30% when the MBI was used [29–32]. In summary, the pandemic has had an overwhelming Moral distress from suboptimal decision-making, dif- impact on ICU specialists. With about half the ICU phy- ficulties in involving the relatives, and the perception of sicians having symptoms of severe burnout and anxi- inappropriate care may be a cornerstone for the develop- ety as well as 30% with symptoms of depression, we can ment of psychological burden in ICU specialists. Moral consider that COVID-19 has generated a mental health distress is an ethical root cause of clinician burnout [21], emergency. The lack of knowledge and experience about translating in low clinician well-being, job dissatisfaction, the disease was most probably a source of anxiety. Cli- and job turnover [33]. During the pandemic, tough deci- nicians ranked this burden as the most significant pro- sions for patients lacking decision-making capacity had fessional and emotional challenge when compared to to be made without any relative [34]. Clinicians struggled non-COVID-19 patients. These mental health prob- to balance substituted judgment with their views on the lems may be generated by a failure to triage appropri- best interests of the patient, creating a climate for sub- ately, manage and make decisions for the patients and optimal decision-making [35]. In this study, the quality the lack of an optimal ethical climate, more than the of the decision-making was associated with the preva- exposure to the disease or the physician strain form the lence of symptoms of anxiety, depression, and burnout. surge. Physicians follow-up, and management are war- Ethical climate should also be recognized as an essential ranted to assess long-term psychological outcomes of contributor that either alleviates or exacerbates moral the COVID-19 outbreak and alleviate the psychological distress [33]. Here again, the ranking of ethical climate burden of the pandemic on exhausted professionals. was an independent predictor of anxiety, depression, and Acknowledgements severe burnout. However, studies are needed to ascertain We are indebted to Dominique de Boom, Nicolas Vander Elst, and Guy Fran- whether the ethical climate could be a surrogate of opti- cois from the ESICM office for their fast and high-quality support to prepare mal teamwork in the setting of the COVID-19 pandemic this survey and its diffusion. where many difficult decisions were also made in the ED Authors’ contributions or the wards. All authors contributed to the study design. All authors read and approved the This study has several limitations. First, as an online final manuscript. study with a 20% response rate, these results might Funding appear as biased. However, burnout syndrome has not None. been assessed in the setting of the COVID-19 pan- Availability of data and materials demic. Moreover, with 1001 respondents from 85 coun- Fully available upon request. tries and 12 regions, this is among the most extensive studies assessing severe burnout in ICU healthcare Ethics approval and consent to participate All participants agreed online to complete the survey. workers and intensivists. Second, the survey focused on frontline clinicians managing the COVID-19 pandemic, Consent for publication with no control group of COVID-19 naïve physicians. All participants consented. As the study was embedded in a COVID-19 survey, cli- Competing interests nicians working in places not involved in the pandemic Authors declare no conflict of interest in relation with this survey. have considered themselves as non-concerned by the Author details subject. However, the lack of association between the 1 Médecine Intensive et Réanimation, PHP, Hôpital Saint-Louis, Paris University, number of COVID-19 patients managed and the psy- Paris, France. 2 Department of Critical Care Medicine, Ghent University Hospi- chological burden suggests that other non-professional tal, 9000 Gent, The Netherlands. 3 Shock, Organ Dysfunction, and Resuscitation Research Group (SODIR), Instituto de Investigación de Vall d’Hebron, Barce- factors contributed to the mental alterations. Third, lona, Spain. 4 Departmento de Medicina Intensiva, Hospital Universitario de as half the respondents were from university-affiliated Vall d́Hebron, Centro de Investigación Biomédica en Red (CIBER) de Enferme- hospitals, a selection bias should be considered. Fourth, dades Respiratorias, Barcelona, Spain. 5 Department of Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna General Hospital, Vienna, the data could not be captured when all of the partici- Austria. 6 NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Por- pating countries were at the peak of the pandemic. Psy- tugal. 7 Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco chological symptoms may vary over time and this could Xavier, CHLO, Estrada Do Forte Do Alto Do Duque, 1449‑005 Lisbon, Portugal. 8 Hellenic Army, ICU Nurse Manager General Military Hospital, Athens, explain part of the regional variability. Last, the restric- Greece. 9 Critical Care Center, Sabadell Hospital, University Institute Parc Taulí, tion of this study to ICU physicians only provides only Autonomous University of Barcelona, Ciberes, Barcelona, Spain. 10 Department a partial picture of what post-COVID-19 psychological of Anesthesiology and Intensive Care, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. 11 School of Immunol- burden is. Studies assessing mental health outcomes in ogy and Microbial Science, Kings College London, London, UK. 12 Guy’s and St Thomas’ NHS Foundation Trust, ICU Support Offices, St Thomas’ Hospital, Azoulay et al. Ann. Intensive Care (2020) 10:110 Page 8 of 8 London, UK. 13 Department of Surgical Sciences and Central Intensive Care 17. Gold JA. Covid-19: adverse mental health outcomes for healthcare work- Unit, Department of Anesthesia, Operation, and Intensive Care and Depart- ers. 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