QJM: An International Journal of Medicine, 2020, 1–5 doi: 10.1093/qjmed/hcaa207 Review REVIEW The impact of the COVID-19 pandemic on the mental health of healthcare professionals M. D. Braquehais1,2, S. Vargas-Cáceres3, E. Gómez-Durán1, G. Nieva 1,3 , S. Valero1,4, M. Casas1,3 and E. Bruguera1,3 From the 1Galatea Care Programme for Sick Health Professionals, Galatea Clinic, Palafolls Street 17-19, Barcelona 08017, Spain, 2Group of Psychiatry, Mental Health and Addictions, Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig Vall Hebron, 119-129, Barcelona 08035, Spain, 3 Department of Psychiatry, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute (VHIR), CIBERSAM, Universitat Autònoma de Barcelona, Passeig Vall Hebron, 119-129, Barcelona 08035, Spain and 4 Research Centre and Memory Clinic, Fundació ACE Institut Català de Neurociències Aplicades - Universitat Internacional de Catalunya (UIC), Gran Via de Carles III, 85 bis, Barcelona 08028, Spain Address correspondence to M.D. Braquehais, Clı́nica Galatea, Carrer Palafolls, 15-19, 08017 Barcelona, Spain. email: mdbraquehais.paimm@comb.cat Summary Introduction: Healthcare professionals (HPs) have been confronted by unprecedented traumatic experiences during the novel coronavirus disease (COVID-19) pandemic, especially in countries that had not experienced similar epidemic out- breaks in recent years. Aim: To analyze the impact of the COVID-19 pandemic on the mental health of HPs. Method: We comprehensively reviewed the studies published in MEDLINE (PubMed), Web of Science and Google Scholar be- tween December 2019 and May 2020. Results: Most studies report a high prevalence of anxiety and depressive symptoms among HPs that can be associated with: (i) COVID-19 exposure; (ii) epidemiological issues; (iii) material resources; (iv) human resources; and (v) personal factors. The role of certain variables, before, during and after the pandemic, remains unexplored. Longitudinal studies will help eluci- date which factors are associated with a higher risk of developing long-lasting negative effects. Qualitative studies may con- tribute to understanding the influence of individual and social narratives in HPs’ distress. Conclusion: A deeper analysis on the individual, institutional, political and socio-cultural factors, meanings and values influencing HPs distress and resilience during the COVID-19 pandemic is needed. Introduction extended around the world although not all countries have In December 2019, a new severe type of pneumonia, later been equally affected. By 24 May 2020, the World Health known as novel coronavirus disease (COVID-19), was reported Organization (WHO) had been informed of 5 165 481 cases of in Wuhan, Hubei, China. Over the subsequent months, it rapidly COVID-19, including 336 430 deaths.1 C The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. V For permissions, please email: journals.permissions@oup.com 1 2 | QJM: An International Journal of Medicine, 2020, Vol. 0, No. 0 Previous research on other infectious diseases, including the COVID-19 exposure Severe Acute Respiratory Syndrome (SARS), the Middle East re- HPs working in the first line of care, with higher clinical respon- spiratory syndrome (MERS) and the Ebola virus disease, consist- sibilities and those who have been infected have had higher ently showed that many healthcare professionals (HPs) prevalence of anxiety and depressive symptoms.3,8–20 Fear of reported symptoms of anxiety and depression, both during and colleagues, families or themselves being infected has been a after the outbreak, causing a severe impact on their coping abil- major cause of distress.13 However, little is known about some ities, in some cases with long-lasting effects.2,3 related situations that they may have gone through during the In many countries, especially in those that had not experi- pandemic, including HPs that had to be quarantined or those enced recent epidemic outbursts, HPs have been confronted to who needed hospitalization; having to make difficult end-of-life unexpected traumatic experiences during the COVID-19 pan- decisions; and some vicarious trauma experiences, such as demic.4,5 Moreover, many public healthcare systems in western accompanying dying patients when the family could not be pre- societies faced this unprecedented situation with significantly sent due to preventive measures. It would also be useful to ex- reduced material and human resources as a result of the eco- plore the mental status of those in the second line of care and nomic cuts that followed the Great Recession (2008). The situ- the impact of using remote treatment devices on their ation deteriorated further during the COVID-19 epidemic after wellbeing. many HPs became infected and needed to be quarantined, thus reducing the workforce capacity. In Spain, for instance, more than 50 000 HPs have been infected so far, thus needing to be Epidemiology quarantined, and around 10% of them have been hospitalized The likelihood of developing distress is also related to the im- for COVID-19.6 In Italy, more than 10 000 HPs were infected from pact of the pandemic in each territory and to the pandemic March 23 to April 9.3 stage when the study was conducted, with greater suffering The aim of this study is to analyze the current evidence- when the number of cases was increasing.3,8–19 Higher inci- based information about the impact of the COVID-19 pandemic dence rates positively correlated with higher prevalence of anx- on the mental health of HPs. iety and depression. Recent experience in similar epidemic outbursts helped to decrease the distress as both HPs and the general population were more familiar with what was likely to Methods occur once the first cases of COVID-19 had been identified. We identified 260 studies published in English and Spanish be- tween December 2019 and May 2020 available in MEDLINE Public health policies (PubMed), Web of Science and Google Scholar. We used the ap- The effect of political issues on HPs’ mental health during the proach recommended by the Preferred Reporting Items for pandemic has not been studied. A wider analysis should include Systematic Reviews and Meta-Analyses (PRISMA) guidelines.7 information on the extent to which each government achieved We chose 232 records, after duplicates were removed, of which data transparency and designed a clear and effective prevention 193 records were excluded based on the review of the title and and treatment plan. Information about the coverage of public abstract. Finally, of the 39 articles remaining, 30 were selected. health systems in each country should also be considered. The search was performed on 7 May 2020 using a broad com- bination of terms: ‘mental health’ OR ‘stress’ OR ‘distress’ OR Material resources ‘emotional exhaustion’ OR ‘burnout’ OR ‘depression’ OR ‘anx- iety’ OR ‘suicide’ OR ‘substance related disorders’ OR ‘addict*’ Shortage of personal protection equipment has been associated OR ‘quarantine’ OR ‘social isolation’ with those related to med- with fear of contagion among HPs, especially among those at ical professionals (‘physicians’ OR ‘medical staff hospital’ OR the first line of care.3,8–20 On the other hand, providing health- ‘doctor’ OR ‘health personnel’ OR ‘nurses’) and terms related to care workers with resting places and giving them adequate time COVID-19 (‘2019-nCoV’ OR ‘SARS-CoV2’ OR ‘2019 novel corona- totake a break and sleep, whether in their work locations or out- virus’). The type of studies selected only included original re- side, i.e. adapted hotels, have contributed to lessen the impact search articles and clinical reports. Editor’s letters, clinical of physical and emotional exhaustion and it even proved to be guidelines, preventive recommendations and reviews were more effective than offering psychological support during the excluded. outburst of the pandemic.14 Differences between working in the public and private health sectors have seldom been analyzed.18 Results Human resources The first studies on the impact of the coronavirus pandemic on Close contact with infected patients and higher level of profes- HPs were developed in China4,8–17 but, as the pandemic spread, sional responsibility increased the likelihood of suffering from other countries started to publish cross-sectional studies ana- mental distress.3,8–20 Higher exposure to COVID-19 was present lyzing the psychological response of healthcare workers to the among those in the first line of care: emergency departments, pandemic.3,18–20 intensive care units, COVID-19 hospitalization units, support Most studies report a high prevalence of anxiety (ranging ambulance services and primary care personnel. HPs with pre- from 30% to 70%) and depressive symptoms (20–40%).3,8–20 vious healthcare working experience were found to be more re- Insomnia, burnout, emotional exhaustion or somatic symptoms silient when faced with stressful situations. Excessive hours on were also similarly reported.3,10–12 duty increased the risk of developing insomnia and emotional In Table 1, we display the factors that may potentially be exhaustion.10,12,17 However, it would also be interesting to related to HPs’ mental distress and highlight those whose role know: the impactof having to rapidly acquire expertise to attend has been analyzed in recently published studies. Risk and pro- COVID-19 patients (for instance, pediatricians working as in- tective factors can be grouped as follows. ternal medicine specialists); the impact on resident or in- M.D. Braquehais et al. | 3 Table 1. Factors related to the impact of the COVID-19 pandemic on healthcare professionals COVID-19 EXPOSURE Epidemiology Health policies Material resources Human resources Personal factors • First line of care • Previous • Public data • Personal protec- • Psychological sup- • Sex (Emergency/Intensive epidemics transparency tion equipment port resources • Age care units/Primary • Incidence (coun- • Government availability • Hours on ward • Social support care/ COVID-19 try/region) global action plan • Time/place to rest • ‘Converted’ medic- • Coping strategies hospitals) • Pandemic stage • Public health • Health system al professionals • Personality traits • COVID 1 strategy capacity (hospi- • Internal residents • Attachment style (quarantined) • Public health sys- tals, intensive care • New teams’ • Having children • Peer infection/ deaths tem coverage units) formation • Pre-morbid mental • Vicarious trauma • Treatment resour- • Reinforcement disorders (type) ces availability staff • Recent physical • Hospitalized for symptoms COVID-19 • Ageing family • End-of-life decisions members • Degree of • Deaths of relatives responsibility • Legal/illegal drug • Second line of clinical misuse care • Alcohol use • Remote teleworking Highlighted factors are those referred to the systematic review selection. training HPs; how they dealt with new teams specially created Therefore, during the pandemic, the majority of them have during the pandemic; and the psychological impact on re- experienced unpleasant emotions, including fear, hyper-arousal, inforcement staff (including retired HP that had reincorporated intrusive memories and insomnia, as well as some related to during the pandemic). sadness or emotional exhaustion. The more they were exposed to unexpected life-threatening situations or uncertainty, the more mental distress they were likely to experience. However, Personal factors most HPs have chosen to take care of patients with COVID-19 Most studies point to an increased risk for women of having infections despite the risk to themselves and their families. worse physical and mental health during the pandemic.3,8–15,17,19 During the COVID-19 pandemic, many have been infected, Younger HPs were more afraid of contagion while older HPs needing to be quarantined or even hospitalized. From previous were also worried about the risk of death.3 Middle-aged HPs experiences, we learnt that those quarentined tend to feel more seemed to be more protected against distress. However, fear of anxious, frustrated, helpless and isolated than non-healthcare being infected, either themselves or their relatives, was higher workers.2 Their main fear is the infection risk to themselves or among those having children although little is known about their family members, especially when children are involved those in charge of ageing relatives or who have had deaths from and they feel guilty and powerless as they cannot help their COVID-19 in their families. Social support has been consistently peers. regarded as a protective factor that reduces the risk of experi- With respect to the long-lasting mental health consequen- encing mental distress during the pandemic.3,8,10 Some person- ces of the pandemic, we know that posttraumatic stress symp- ality traits, such as neuroticism, feeling loneliness, having toms, depression and alcohol or substance misuse were previous mental disorders or physical complaints, have been reported by HPs months and years after the SARS outbreak, found to increase the likelihood of suffering from anxiety or de- mainly among those with high-risk exposure or who needed to pressive symptoms, while extraversion, self-efficacy or parental be quarantined, although it was lower among those with altru- attachment style have been found to foster resilience.3,12,15,20 istic acceptance of risk during the outbreak or with higher social On the other hand, little is known yet about self-treatment with support.22,23 legal drugs (e.g. sedatives, opiates), alcohol or illegal drug use In fact, a big concern is that HPs may be reluctant to ask for among HPs during the COVID-19 pandemic as a maladaptive help if needed. Self-treatment, denial, rationalization or mini- coping strategy and the risk of developing substance use mization may be initial defense mechanisms used to confront disorders. stressful situations but may result in not seeking appropriate help when developing a mental disorder. During the COVID-19 outbreak, this tendency might have changed.9,24 The social rec- Discussion ognition HPs are receiving during this pandemic together with The COVID-19 has confronted many HPs with unexpected, life- the the mass and social media diffusion of their testimonies threatening experiences for which they had not been trained. could help to lower the internal psychological barriers to seek- Although they are used to witnessing trauma and to regularly ing professional aid if necessary. However, when it comes to se- dealing with loss,21 the high morbidity and mortality rates of vere mental disorders, self-stigmatizing attitudes may persist. this pandemic, the shortage in personal protective equipment, Easy access to medication or potentially lethal means may in- the fear of they or their family members becoming infected, the crease the risk of not asking for help in such circumstances. absence of an effective treatment/vaccine on the immediate Psychological assistance provided to HPs during the pandemic25 horizon and the new restrictive public health policies activated should be extended afterwards for cases at higher risk of devel- in most countries, have changed their normal scenario. oping mental disorders. 4 | QJM: An International Journal of Medicine, 2020, Vol. 0, No. 0 Longitudinal studies should help ascertain the long-lasting 6. Ministerio de Sanidad y Consumo de Espan ~ a. Informe sobre consequences of the acute distress among HPs facing this pan- la situación de la COVID-19 en Espan ~ a. https://www.isciii.es/ demic. More ambitious research strategies, using big data ana- QueHacemos/Servicios/VigilanciaSaludPublicaRENAVE/Enfer lysis, may shed some light into how proximal factors (related to medadesTransmisibles/Documents/INFORMES/Informes%20 HPs experience) and distal factors (linked to institutional, polit- COVID-19/COVID-19%20en%20Espa%C3%B1a.%20Situaci%C3 ical or socio-cultural issues) have influenced HPs’ mental health %B3n%20en%20Sanitarios%20a%2021%20de%20mayo%20de during the COVID-19. Despite the importance of quantitative %202020.pdf (24 May 2020, date last accessed). analysis, qualitative research may contribute to draw a more ac- 7. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA curate picture of individuals and socio-cultural narratives Group. 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