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G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS Medicina Clínica xxx (xxxx) xxx–xxx www.elsevier.es/medicinaclinica Original article Mental health assessment of Spanish frontline healthcare workers during the SARS-CoV-2 pandemic Pau Sobregrau Sangrà a,b,j,∗ , Thaís Castro Ribeiro c,d , Silvia Esteban-Sepúlveda e,f , Esther García Pagès d , Beatriz López Barbeito a , Jordi Aguiló Llobet g , José Luís Pomar Moya-Prats h , Luís Pintor Pérez b,i,j , Sira Aguiló Mir a a Emergency Department, Hospital Clinic of Barcelona, Barcelona 08036, Spain b Faculty of Psychology, University of Barcelona (UB), Barcelona 080035, Spain c Psychiatry Department, Hospital Clinic of Barcelona, Barcelona 08036, Spain d Networking Biomedical Research Center: Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Universitat Autònoma de Barcelona (UAB), Bellaterra 08193, Spain e Research Group in Nursing Care (GRECI), Hospital del Mar Institute of Medical Research (IMIM), Barcelona 08003, Spain f Consorci Parc de Salut MAR de Barcelona, Hospital del Mar of Barcelona, Barcelona 08003, Spain g Microelectronics and Electronic Systems Department, Universitat Autònoma de Barcelona (UAB), Bellaterra 08193, Spain h Cardiac Surgery Department, The Thorax Institute, Hospital Clinic of Barcelona, Barcelona 08036, Spain i Clinical Institute of Neurosciences (ICN), Hospital Clinic of Barcelona, Barcelona 08036, Spain j Biomedical Research Institute August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Barcelona 08036, Spain a r t i c l e i n f o a b s t r a c t Article history: Background and objective: The Covid-19 pandemic continues challenging health systems globally, expos- Received 3 September 2021 ing healthcare workers to constant physical and psychological stressors. To date, several studies have Accepted 12 November 2021 already shown the catastrophic impact on the mental health of medical personnel during the early period Available online xxx of the pandemic. Nevertheless, literature evidences the dearth of works that evaluate the effect over time, understanding the pandemic as a sustained extreme stressor. The present study examines the effect of Keywords: the pandemic on the mental health of Covid-19 frontline healthcare workers at six months follow-up. SARS-CoV-2 pandemic Material and methods: A total of 141 frontline healthcare workers from two tertiary hospitals were Anxiety symptoms Acute stress symptoms recruited between July and November 2020. Healthcare workers were evaluated psychologically at base- Depression symptoms line and six months follow-up (January to May 2021) using psychometric tests for the assessment of Posttraumatic stress disorder acute stress (VASS, PSS-10, PCL-5), anxiety (STAI) and depression (PHQ-2) Healthcare workers Results: Overall, there was a general worsening of the mental health between the two psychological assessments, especially regarding depression and predisposition to perceiving the situations as a threat. Nurses and nurse aides showed poorer mental health while physicians improved over time. Reduced working hours and higher physical exercise resulted in better mental health among healthcare workers. Women and nursing staff were the most affected by psychological distress at baseline and six months follow-up. Conclusion: Reduced working hours, adequate resting periods, physical exercise, and efficient interven- tion strategies are of utmost importance in preventing, controlling, and reducing psychological distress among healthcare workers when coping with critical scenarios such as the current pandemic. © 2021 The Authors. Published by Elsevier España, S.L.U. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). ∗ Corresponding author. E-mail address: sobregrau@clinic.es (P.S. Sangrà). https://doi.org/10.1016/j.medcli.2021.11.007 0025-7753/© 2021 The Authors. Published by Elsevier España, S.L.U. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Please cite this article as: P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al., Mental health assessment of Spanish frontline healthcare workers during the SARS-CoV-2 pandemic, Med Clin (Barc)., https://doi.org/10.1016/j.medcli.2021.11.007 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx Análisis de la salud mental de trabajadores sanitarios españoles de primera línea durante la pandemia por SARS-CoV-2 r e s u m e n Palabras clave: Antecedentes y objetivo: La pandemia Covid-19 sigue desafiando a los sistemas sanitarios, exponiendo al Pandemia SARS-CoV-2 personal asistencial a estresores físicos y psicológicos. Actualmente, varios estudios han demostrado el Ansiedad impacto catastrófico en la salud mental del personal asistencial durante la primera etapa de la pandemia, Estrés agudo pero pocos han considerado el seguimiento de los síntomas. El presente estudio examina el efecto de la Depresión pandemia en la salud mental del personal sanitario de primera línea a los 6 meses de seguimiento. Estrés postraumático Personal sanitario Material y métodos: Se evaluó psicológicamente a 141 trabajadores sanitarios de primera línea de 2 hospitales terciarios al inicio del estudio (julio-noviembre, 2020) y a los 6 meses (enero-mayo, 2021) medi- ante pruebas psicométricas para el estrés agudo (VASS, PSS-10, PCL-5), la ansiedad (STAI) y la depresión (PHQ-2). Resultados: En general, se observó un empeoramiento de la salud mental entre las 2 evaluaciones psi- cológicas, especialmente en depresión y predisposición a percibir las situaciones como una amenaza. La salud mental del personal de enfermería empeoró con el tiempo, mientras que los médicos mejoraron. La reducción de la jornada laboral y el aumento del ejercicio físico mejoraron la salud mental. Las mujeres y el personal de enfermería fueron los más afectados por el malestar psicológico al inicio y a los 6 meses de seguimiento. Conclusión: Jornadas laborales reducidas, períodos de descanso adecuados, ejercicio físico y estrategias de intervención eficientes son de suma importancia para prevenir, controlar y reducir el malestar psicológico entre el personal sanitario ante escenarios críticos como la pandemia actual. © 2021 Los Autores. Publicado por Elsevier España, S.L.U. Este es un artı́culo Open Access bajo la licencia CC BY (http://creativecommons.org/licenses/by/4.0/). Introduction Nevertheless, far from the meaningful prevalence of psycholog- ical distress during the early stages of the Covid-19 pandemic and Since first detected in Wuhan (China) in December 2019, the the future clinical and occupational implications of a late and poor rapid worldwide spread of the SARS-CoV-2 virus has had a catas- diagnosis across healthcare workers,11 the literature evidences the trophic effect, compromising the mental health and wellbeing of dearth of studies that have considered the follow-up of the symp- the general population, and especially of those on the frontline toms to shed light on whether the elevated anxiety, depression and fighting against the virus.1 PTSS symptoms are sustained, reduced or increased over time.12 In frontline healthcare workers, the lack of resources alongside The present study aimed to examine the effect of the Covid-19 the overcrowded care wards, quarantines, increased workload, use pandemic on the mental health of frontline healthcare workers at of personal protective equipment (PPE), physical exhaustion, and six months follow-up, understanding this worldwide care crisis as fear of transmitting the disease, among others, have become risk a persistent extreme stressor. factors for increased stress, anxiety, depression, sleep problems, and even suicide rate.2 In other words, the wide range of physical, Methods psychological and emotional stressors to which healthcare workers are constantly exposed when coping with the day-to-day situa- Study design tions of the Covid-19 pandemic have challenged and endangered their mental health and life quality,3 thus interfering with the care A prospective, longitudinal and multicentre study with Spanish quality and efficiency of health systems.4 Covid-19 frontline healthcare workers from two tertiary hospi- Although the clinical and socio-economic implications of high tals, the Hospital Clinic of Barcelona and the Hospital del Mar of psychological distress are well documented in the literature, Barcelona. assessing mental health in unprecedented care scenarios such All study procedures complied with the Helsinki declaration for as the current pandemic remains a challenge within the clinical research and received approval from the Ethics Committee Board practice. On the one hand, no precise tools objectively measure of both hospitals. the intensity with which a stressor affects an individual.3 Phys- iological evaluation of symptoms is both complex and invasive, Setting and subjects making follow-up difficult. On the other hand, psychometric ques- tionnaires cannot determine the effect of the stressor on the This study was conducted with 141 Covid-19 frontline health- person’s health or even whether the stressor is being overcome.3,5 care workers from two Spanish tertiary hospitals. The recruitment Furthermore, learning effects and the desirability response bias process comprised the months of July and November 2020 (both often limit psychometric questionnaire results, as with online inclusive). Then, healthcare workers were scheduled consecutively surveys.6 at six months for a follow-up assessment (until May 2021). Signed To date, despite the complexity of assessing psychological informed consent was required to take part in the study. distress, especially in critical scenarios, several works have con- The recruitment process was conducted through internal dif- ducted cross-sectional evaluations of the healthcare worker’s fusion, using the institutional email, across the medical units mental health during the first wave of the Covid-19 pandemic. In designated for the care of Covid-19 patients. The recruitment pro- this regard, study findings relate to the psychological impact on cess also considered healthcare workers from the external units healthcare workers of the 2003 SARS outbreak.7,8 Severe anxiety, (i.e., health hotels) enabled for Covid-19 hospitalisations. depression and posttraumatic stress symptoms (PTSS), with preva- Healthcare workers recruited for the study were grouped lence of these disorders across medical personnel ranging from 9 according to their professional category: physicians, nurses, and to 90%, 5 to 21% and 11% to 16%, respectively.3,9,10 nurse aides. The medical units where the recruitment process was 2 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx considered were the Intensive Care Unit (ICU), Emergency Ser- high psychological burden, and substance abuse (tobacco, alcohol vice and Covid-19 hospitalisation wards. Covid-19 hospitalisation or other drugs). wards included Internal Medicine, Infections, Pneumology, Gas- - Electrophysiological signals: assessed with medical-grade devices: troenterology, and health hotels. the NeXus-10 MKII (Mind Media B.V., CD Herten, Netherlands) The inclusion criteria were to be a healthcare worker, have system and the E4 wrist-worn (Empatica Inc., Cambridge, MA) worked at any of the medical services mentioned above, be directly wearable. Together, these devices registered breathing (Resp), involved in managing SARS-CoV-2 patients, and have accepted par- electrodermal activity (EDA), electrocardiography (ECG), photo- ticipation by signing the informed consent. plethysmography (PPG) and body temperature (Temp). All frontline healthcare workers recruited for the study per- formed similar duties regarding the care of Covid-19 patients Psychometric questionnaires required, on average, 15–20 min regardless of the medical unit worked during the period evalu- to be completed. Healthcare workers needed no special education ated. Likewise, all healthcare workers from the two hospitals were or training to complete them independently. assessed under the same premises to reduce performance bias. The flowchart in Fig. 1 shows the recruitment and follow-up of healthcare workers. Procedure Participants were recruited between July and November 2020 (both inclusive) at the medical units designated for the care of Assessment instruments Covid-19 patients. After signing the informed consent, healthcare workers were scheduled for a first assessment [A1] (Fig. 1). The - Subjective perceived stress: assessed with the Visual Analogue estimated time between recruitment and the first evaluation was Scale for stress (VASS).13 The VASS is a visual 100-point scale (0, no more than seven days, and always respecting the availability of not at all; 100, absolutely stressed). Although it has shown reli- each healthcare worker. able discriminative sensitivity and construct validity, the VASS The first assessment was comprised of two different stages: the test is not a diagnostic tool.13 Accordingly, we used the cut-off psychological assessment and the physiological assessment. points obtained in a previous work conducted by our research On the one hand, the psychological assessment consisted of evaluating caregivers of chronic patients (high-stress levels) and administering the five psychometric questionnaires described in controls (low-stress levels).5 A VASS score equal to or below 30 the previous section. Psychometric tests were applied in person and equal or above 31 and 70 indicated low, moderate and high and in the following order: VASS, PSS-10, PCL-5, STAI and PHQ-2. perceived stress, respectively. On the other hand, the physiological assessment consisted of - Stress appraisal: assessed with the 10-item Perceived Stress Scale evaluating different stress-related physiological variables using (PSS-10).14 The PSS-10 is based on a Likert scale, with responses medical-grade technology (i.e., NeXus-10 MKII & E4 wrist-worn). ranging from 0 (never) to 4 (very often). A PSS-10 score equal to The physiological assessment lasted approximately 25 min, and the or below 13, equal to or above 14 and higher than 26 indicated data collected is meant to be analysed in future work. low, moderate and high-stress appraisal, respectively. The PSS- The psychological assessment always preceded the physio- 10 cut-offs used in this work were in line with those observed in logical assessment, and a break was given between the two other Covid-19 studies.15 assessments. - Posttraumatic Stress Symptoms (PTSS): assessed with the Post- Once finalised the first assessment, healthcare workers were traumatic Stress Disorder Checklist for DSM-5 (PCL-5),16 which scheduled at six months for a second assessment [A2]. The second has high internal consistency in measuring posttraumatic stress assessment included the psychological and physiological proce- (PTSS) symptoms (Cronbach’s alpha: 0.94). A total PCL-5 score dures performed in the first assessment (Fig. 1). equal to or higher than 31 was indicative of a possible posttrau- matic stress disorder (PTSD). - Anxiety symptoms: assessed with the State-Trait Anxiety Inven- Statistical analysis tory (STAI).17 The STAI-State (STAI-S) subscale evaluates the current anxiety, while the STAI-Trait (STAI-T) subscale indicates First, a description of all sociodemographic variables and psy- the propensity to be anxious on a personality basis. There are no chological results were performed. Then, statistic tests were normative STAI test values for medical staff. Accordingly, we used applied accordingly. the STAI cut-off scores defined in previous research conducted The Paired Samples T-Test and One-Way repeated measures with caregivers of chronic patients and controls.5 An STAI-S total ANOVA were used to examine differences over time for the sam- score of 10 suggested low anxiety, 37 moderate anxiety, and ple and within groups, respectively. The Wilcoxon signed-rank test higher than 36 severe anxiety. On the other hand, an STAI-T cut- was applied when assumptions for the Paired Samples T-Test were off point of 14, 26 and above 26 indicated low, moderate and high not met. The Independent Samples T-Test and One-Way ANOVA predisposition to perceive situations as a threat, respectively. were used to examine for differences between groups in mental - Depression symptoms: assessed with the Patient Health health at baseline and at six months follow-up, independently. The Questionnaire-2 (PHQ-2).18 A PHQ-2 score equal to or above 3 Mann–Whitney U test and the Kruskal–Wallis test were used when suggested possible Major Depressive Disorder (MDD), with a assumptions for the parametric form of the above tests were not sensitivity of 83% and a specificity of 92%. met. The Bonferroni correction was applied when needed. - Sociodemographic variables: assessed with the clinical and Participants lost to follow-up (23.4%) were not considered in the sociodemographic form. The form included data regarding the final analysis. To exclude the possibility that the loss of participants gender, age, psychiatric history (i.e., affective and anxiety dis- had occurred selectively and thus skewing the final results, a set of orders), physical activity levels, professional category, regular sensitive analyses (i.e., Chi-square tests for comparison of propor- working shift, weekly working hours (i.e., part-time and full- tions and the Independent Samples T-Test, One-Way ANOVA and time), working hours increase, medical service performed during their respective parametric forms when needed) were conducted the pandemic, to be off work due to Covid-19 infection (i.e., sick comparing the 21 participants lost to follow-up against the sample leave), requested help and taken stress-related medication due to finally included in the study. 3 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx Fig. 1. Flowchart of the recruitment and follow-up of healthcare workers. SPSS v.26 for Windows was used for all data analyses. All results were finally included in the study. Twenty-one (1489%) healthcare were interpreted with a 95% confidence interval (CI) and a signifi- workers were lost to follow-up. Nevertheless, sensitive analy- cance level (p-value) of 0.05. ses conducted in this regard revealed no significant differences between those who completed the study and those lost to follow-up Results (p > .05). A description of the clinical and sociodemographic char- acteristics of the sample is shown in Table 1. Demographic and clinical characteristics of the sample According to Table 1, the majority of healthcare workers were women (87.9%), middle-age (39.7%), nurses (60.3%), from the A total of 141 healthcare workers, 77 from the Hospital Clinic morning shift (45.4%) and the Emergency service (42.6%). A total of Barcelona and 64 from the Hospital del Mar of Barcelona, of 84 (59.6%) healthcare workers reported having increased the 4 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx Table 1 Longitudinal quantitative psychological assessment, at baseline Clinical and sociodemographic characteristics of the 141 healthcare workers and six months follow-up included in the study. Healthcare workers (n = 141) Overall, there was an increase in the psychometric tests’ mean n % Mean (S.D.) scores from the first to the second psychological assessment conducted at six months follow-up. Nevertheless, the analysis Age (years) 38.3 (11.3) conducted on the data revealed only significant differences in Gender the STAI-T (T = 3358, Z = −2.20, p = .026) subscale and the PHQ-2 Men 17 12.10 (T = 206.5, Z = −3.32, p < .001) test. Table 2 shows the results of the Women 124 87.90 quantitative psychological evaluation for the sample at the first and Age (groups in years) second assessments and the statistical difference between the two. 18–30 47 33.30 31–45 56 39.70 When changes in mental health were analysed over time 46–62 38 27.00 within each group, the professional category involved signifi- cant differences in the VASS (F(2,138) = 6.477, p = .002) and PSS-10 Psychiatric history No 127 90.10 (F(2,138) = 5.62, p = .005) tests, and both STAI-S (F(2,138) = 5.33, Yes 14 9.90 p = .006) and STAI-T (F(2,138) = 4.40, p = .014) subscales. Nurses Professional category showed significantly worse perceived stress (p = .002), stress Physicians 35 24.80 appraisal (p = .034), anxiety (p = .040) and predisposition to per- Nurses 85 60.30 ceiving situations as a threat (p = .001) from the first to the second Nurse aides 21 14.90 assessment. On the contrary, physicians showed a significant Working shift improvement in perceived stress (p = .027) and anxiety (p = .012) Mornings 64 45.40 at six months follow-up. Afternoons 21 14.90 The hours per week worked also showed significant differ- Nights 37 26.20 ences over time in the VASS (F(1,139) = 3.89, p = .050), PCL-5 On-call 19 13.50 (F(1,139) = 7.92, p = .006) and PSS-10 (F(1, 139) = 5.88, p = .017) tests, Medical service working and the STAI-S (F(1, 139) = 6.33, p = .013) subscale. Part-time health- Covid-19 Wards 50 35.50 Emergency Service 60 42.60 care workers significantly improved PTSS (p = .012), stress appraisal ICU 31 22.00 (p = 023) and anxiety (p = .026) from the first to the second psy- chological assessment. In contrast, full-time healthcare workers Weekly working hours (hours) 18.5–30 13 9.22 significantly worsened the perceived stress (p = .040) at six months 31–40 124 87.90 follow-up. A psychiatric history also suggested increased perceived Over 40 4 2.84 stress and depression, without statistically significant differences Working hours increase (p > .05). No 57 40.40 Cross-sectionally, the analysis conducted on the psychological Yes 84 59.60 data obtained from the baseline (Table 3) and six months follow-up Off work due to Covid-19 (Table 4) assessments, separately, also revealed statistically signif- No 78 55.30 icant differences. Yes 63 44.70 On the one hand, at baseline (Table 3), women had statistically Physical activity significant higher levels of anxiety (t(139) = 2.78, p = .006), predis- Low 17 12.10 position in perceiving situations as a threat (U = 744.5, p = .050) Medium 77 54.60 and depression (U = 686, p = .012) than men. The professional cate- High 47 33.30 gory significantly differed in the PHQ-2 (2 (2) = 11.64, p = .003) test, Request help with the nursing staff showing higher depression than physicians No 121 85.80 (p < .05). Yes 20 14.20 The PSS-10 (F(2, 138) = 6.61, p = .003) and PHQ-2 (2 (2) = 6.12, Under stress-related medication p = .047) tests, and the STAI-S (F(2, 138) = 5.83, p = .017) and STAI-T No 111 78.70 (F(2, 138) = 7.60, p = .006) subscales also showed significant dif- Yes 30 21.30 ferences depending on the levels of physical activity. Healthcare Smoker workers doing medium and high levels of exercise showed statis- No 97 68.80 Yes 44 31.20 tically significant lower stress appraisal, anxiety, predisposition to perceiving situations as a threat and depression than those doing Substance abuse increase (tobacco, alcohol, others) low physical activity (p < .05). No 96 68.10 Yes 45 31.90 Healthcare workers who had been off work due to the Covid-19 infection (U = 1958.5, p = .025) and requested help to overcome the day-to-day pandemic (U = 758.5, p = .004) showed working hours during the period evaluated, while 63 (44.7%) had significantly higher depression than those who were not on sick been off work due to Covid-19 infection. Only 14% reported to leave and requested help, respectively. Healthcare workers who have requested help to overcome the day-to-day situations of the sought help also showed greater PTSS (U = 715.6, p = .004), anxi- pandemic, and another 31.2% were prescribed stress-related medi- ety (U = 872.5, p = .046) and predisposition to perceiving situations cation due to high psychological distress. Almost 10% of the sample as a threat (U = 840, p = .029). The same results were observed reported a previous psychiatric disorder. between medicated and not medicated healthcare workers, with 5 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx Table 2 Results in the quantitative psychological assessment for the sample at baseline and six months follow-up, and differences over time. Healthcare workers (n = 141) Mean Median SD SE p-Value VASS First assessment [A1] 49.60 50.00 22.42 1.89 Second assessment [A2] 52.67 58.00 22.74 1.91 PCL-5 First assessment [A1] 21.38 20.00 12.79 1.08 Second assessment [A2] 21.85 20.00 14.39 1.21 PSS-10 First assessment [A1] 16.97 16.00 5.93 0.50 Second assessment [A2] 16.99 17.00 6.00 0.50 STAI-S First assessment [A1] 25.77 25.00 9.93 0.84 Second assessment [A2] 26.11 25.00 10.92 0.92 STAI-T First assessment [A1] 20.33 19.00 8.38 0.71 * Second assessment [A2] 21.54 20.00 9.37 0.79 PHQ-2 *** First assessment [A1] 1.01 1.00 1.28 0.11 Second assessment [A2] 1.50 1.66 1.14 0.10 Note. * p < .05. ** p < .01. *** p < .001. those under stress-related medication having significantly higher Healthcare workers who sought help showed significantly mean scores in the following tests: PCL-5 (U= 1407, p = .002), higher stress appraisal (2 (2) = 4.35, p = .037), anxiety (2 (2) = 7.72, PHQ-2 (U = 989.5, p < .001), STAI-S (U = 1212, p = .022), and STAI-T p = .005), depression (2 (2) = 7.51, p = .002) and predisposition to (U = 1061.5, p = .002). perceiving situations as a threat (2 (2) = 8.43, p = .004) than those Healthcare workers with smoking habits and substance abuse that did not have sought help. Healthcare workers taking stress- had significantly higher PTSS than non-smokers (U = 1623.50, related medication also had significantly greater perceived stress p = .023) and without substance abuse (U = 1500, p = .003). A psy- (2 (2) = 5.24, p = .022), anxiety (2 (2) = 3.95, p = .047) and predis- chiatric history suggested greater psychological distress without position to perceiving situations as a threat (2 (2) = 6.05, p = .014) statistically significant differences (p > .05). than healthcare workers not medicated due to high psychological On the other hand, at six months follow-up (Table 4), women distress. continued having significantly higher mean scores than men in all Lastly, healthcare workers with tobacco consumption and sub- the psychometric questionnaires (p < .05), except in the PCL-5 test stance abuse also had significantly higher depression (2 (2) = 4.50, (p > .05). p = .034) and PTSS (2 (2) = 7.21, p = .007) than non-smokers and The professional category also involved significant differences in without substance abuse habits. At six months follow-up, a psy- the PCL-5 (2 (2) = 12.26, p = .002) and PHQ-2 (2 (2) = 4.22, p = .023) chiatric history also seemed to involve worse overall psychological tests, and STAI-S (2 (2) = 6.51, p = .039) and STAI-T (2 (2) = 6.14, outcomes without statistically significant differences (p > .05). p = .046) subscales. Nurses had higher PTSS (p = .002), anxiety (p = .042), depression (p = .018), and predisposition in perceiving Discussion situations as a threat (p = .038) than physicians. Likewise, full- time healthcare workers significantly increased perceived stress The current study aimed to investigate the effect of the Covid-19 (U = 534.5, p = .033) and PTSS (U = 559.5, p = .050) than those work- pandemic over time in frontline Spanish healthcare workers. To the ing part-time. best of our knowledge, our study is the first to provide consistent Similar to the results obtained in the first assessment, the lev- results from face-to-face psychological assessments, with the main els of physical activity entailed significant differences in both the finding being the overall worsening of healthcare workers’ men- STAI-S (2 (2) = 8.25, p = .016) and STAI-T (2 (2) = 7.85, p = .020) sub- tal health between the first and second psychological assessments scales. Healthcare workers with low physical activity levels had conducted at six months follow-up, especially regarding depression significantly higher anxiety (p = .033) and a predisposition to per- and predisposition to perceiving situations as a threat.19 ceive situations as a threat (p = .026) than those with high physical Another relevant finding was that nurses showed a meaning- activity levels. ful worsening of stress, anxiety and depression between the first At six months follow-up, significant differences in the VASS and second psychological assessment. Nurse aides also appeared to (2 (2) = 6.42, p = .040) and PSS-10 (2 (2) = 6.57, p = .037) tests were show the same tendency as nurses, without differences over time found depending on the medical unit healthcare workers worked. being significant. Instead, physicians presented a general improve- Healthcare workers from Covid-19 hospitalisation wards showed ment at six months follow-up, significantly decreasing perceived significantly higher perceived stress than those working at the stress and anxiety. A possible contributing factor to these differ- Emergency Service (p = .044). Likewise, healthcare workers from ences in mental health depending on the professional category the ICU service showed worse stress appraisal than those working might be the added care and contact nurses and nurse aides usually at the Emergency Service (p = .036). have with the ill patient compared to physicians. 6 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx Table 3 Results of the quantitative psychological assessment at baseline. VASS PCL-5 PSS-10 STAI-S STAI-T PHQ-2 N Mean S.D. Mean S.D. Mean S.D. Mean S.D. Mean S.D. Mean S.D. Gender Men 17 40.53 21.57 17.82 12.39 14.24 4.88 19.65 8.60 16.18 7.46 .35 .79 Women 124 50.84 22.33 21.87 12.81 17.35 5.98 26.61 9.84 20.90 8.37 1.10 1.31 ** p-Value * * Psychiatric history No 127 48.80 23.53 20.22 12.42 16.05 6.35 24.45 10.89 17.34 7.39 .073 .93 Yes 14 56.77 15.88 23.69 13.31 17.31 6.45 26.23 10.51 24.31 7.41 1.38 1.66 p-Value Professional category Physicians 35 53.83 22.77 18.00 13.12 17.46 7.45 25.23 12.53 19.51 9.33 .46 .95 Nurses 85 47.78 21.65 22.65 12.51 16.62 5.43 25.59 8.73 20.71 8.36 1.16 1.33 Nurse aides 21 49.90 24.93 21.90 12.92 17.57 5.13 27.43 10.03 20.14 6.98 1.29 1.35 p-Value .** Weekly working hours Part-time 13 48.00 31.26 23.69 16.46 19.62 6.74 28.00 13.19 23.38 11.42 1.08 1.50 Full-time 128 49.76 21.48 21.15 12.41 16.70 5.80 25.55 9.58 20.02 8.01 1.00 1.26 p-Value Working shift Mornings 64 50.98 21.88 20.52 13.03 17.05 5.88 24.89 9.84 20.19 8.53 .91 1.16 Afternoons 21 54.86 19.43 24.29 14.21 15.90 5.61 28.86 11.21 21.43 6.79 1.29 1.49 Nights 37 43.59 23.74 22.68 11.02 17.08 5.52 25.38 8.46 21.05 8.11 1.30 1.49 On-call 19 50.79 23.90 18.58 13.61 17.68 7.39 26.11 11.48 18.16 10.09 .47 .70 p-Value Physical activity Low 17 60.00 24.10 27.35 15.43 21.47 6.34 33.18 11.70 26.82 10.32 1.71 1.65 Medium 77 49.16 21.57 21.16 12.15 16.79 5.54 25.05 8.97 20.32 7.86 1.06 1.33 High 47 46.55 22.56 19.60 12.43 15.64 5.73 24.28 9.82 17.98 7.32 .66 .89 ** ** p-Value * * Medical service working Covid-19 wards 50 52.92 19.44 18.82 11.99 17.06 6.41 25.32 9.26 20.98 8.87 1.24 1.33 Emergency service 60 47.42 24.45 21.93 12.04 16.67 5.81 25.10 10.02 19.80 8.08 .88 1.14 ICU 31 48.45 22.88 24.45 14.89 17.42 5.48 27.81 10.84 20.29 8.37 .87 1.43 p-Value Off work due to Covid-19 No 78 49.18 24.15 21.41 13.43 16.65 6.19 24.96 10.74 19.54 8.11 .85 1.29 Yes 63 50.11 20.25 21.35 12.05 17.37 5.60 26.78 8.82 21.30 8.67 1.21 1.25 p-Value * Request help No 121 49.00 23.25 20.11 12.41 16.64 5.96 25.15 10.14 19.73 8.31 .87 1.15 Yes 20 53.20 16.52 29.10 12.62 18.95 5.43 29.55 7.78 23.95 8.13 1.85 1.66 ** ** p-Value * * Under stress-related medication No 111 49.00 22.37 19.80 12.69 16.49 5.99 24.97 10.27 19.25 8.22 .77 1.04 Yes 30 51.80 22.82 27.23 11.56 18.77 5.41 28.73 8.05 24.30 7.90 1.87 1.68 ** ** *** p-Value * Working hours increase No 57 48.96 22.52 22.04 13.18 16.93 5.80 26.26 10.51 20.75 8.24 1.07 1.21 Yes 84 50.02 22.47 20.94 12.57 17.00 6.04 25.44 9.57 20.04 8.52 .96 1.33 p-Value Smoker No 97 50.04 22.69 19.71 12.33 16.71 6.02 25.29 10.24 19.98 8.52 .90 1.14 Yes 44 48.61 22.04 25.07 13.15 17.55 5.75 26.84 9.26 21.09 8.13 1.25 1.53 p-Value * Substance abuse No 96 49.64 22.65 19.01 11.15 17.06 6.03 25.32 9.87 20.33 8.05 .95 1.16 Yes 45 49.51 22.17 26.44 14.61 16.78 5.76 26.73 10.11 20.31 9.15 1.13 1.52 ** p-Value Note. * p < .05. ** p < .01. *** p < .001. 7 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx Table 4 Results of the quantitative psychological assessment at six months follow-up. VASS PCL-5 PSS-10 STAI-S STAI-T PHQ-2 N Mean S.D. Mean S.D. Mean S.D. Mean S.D. Mean S.D. Mean S.D. Gender Men 17 38.71 16.21 15.41 9.80 12.71 3.79 17.06 7.43 14.82 5.90 .89 .73 Women 124 54.58 22.88 22.73 14.72 17.58 6.01 27.35 10.76 22.46 9.40 1.59 1.16 ** ** *** ** p-Value * Psychiatric history No 127 48.02 20.79 18.69 11.57 14.46 5.87 22.54 11.38 19.11 8.64 1.33 1.22 Yes 14 48.85 25.91 21.66 15.33 15.92 5.96 23.39 10.90 22.00 9.59 1.46 1.20 p-Value Professional category Physicians 35 45.14 23.16 15.29 13.18 15.86 6.39 21.77 10.80 18.11 8.43 1.06 1.12 Nurses 85 55.68 22.04 24.16 14.12 17.79 5.82 27.40 10.66 23.02 9.85 1.69 1.15 Nurse aides 21 53.00 22.99 23.43 14.67 15.67 5.76 28.14 10.73 21.24 7.56 1.51 .95 ** p-Value * * * Weekly working hours Part-time 13 38.77 26.25 15.38 15.29 16.38 7.42 22.92 12.37 22.00 11.70 .075 .089 Full-time 124 54.08 21.98 22.51 14.19 17.05 5.86 26.44 10.76 21.49 9.16 1.42 1.23 p-Value * * Working shift Mornings 64 52.20 24.69 19.69 15.93 16.56 6.00 24.19 11.30 20.56 9.57 1.37 1.16 Afternoons 21 52.76 21.16 23.57 12.99 17.29 5.91 28.52 12.34 22.43 10.61 1.58 1.34 Nights 37 53.32 21.72 25.30 12.28 17.95 6.00 28.05 9.66 23.68 8.36 1.68 1.01 On-call 19 52.84 21.09 20.53 13.65 16.26 6.31 26.16 9.88 19.68 8.98 1.53 1.09 p-Value Physical activity Low 17 59.88 22.95 22.82 17.78 20.35 6.96 32.12 12.40 25.06 11.61 1.79 1.29 Medium 77 54.73 21.06 23.00 13.29 16.86 5.63 26.34 9.93 22.23 8.46 1.53 1.02 High 47 46.68 24.38 19.62 14.85 16.00 5.92 23.57 11.25 19.13 9.54 1.36 1.26 p-Value * * Medical service working Covid-19 wards 50 57.58 22.83 21.08 15.23 17.72 6.62 26.74 11.63 21.70 9.62 1.49 1.15 Emergency service 60 47.55 20.36 21.77 12.40 15.55 5.37 24.83 9.95 20.97 8.67 1.51 1.09 ICU 31 54.65 25.50 23.26 16.79 18.61 5.64 27.58 11.62 22.39 10.47 1.50 1.25 p-Value * * Off work due to Covid-19 No 78 51.79 23.29 21.18 15.09 16.94 6.12 25.42 11.15 20.97 9.21 1.42 1.21 Yes 63 53.75 22.18 22.68 13.54 17.06 5.88 26.97 10.66 22.24 9.60 1.61 1.04 p-value Request help No 121 51.26 22.89 21.18 14.63 16.55 6.00 25.07 10.82 20.60 9.08 1.37 1.05 Yes 20 61.15 20.26 25.90 12.39 19.70 5.31 32.40 9.51 27.20 9.34 2.29 1.34 ** ** ** p-value * Under stress-related medication No 111 50.61 22.31 21.03 14.81 16.81 6.15 25.14 11.13 20.71 9.57 1.51 1.16 Yes 30 60.27 23.08 24.90 12.43 17.67 5.44 29.70 9.43 24.60 8.04 1.47 1.06 p-value * * * Working hours increase No 57 49.72 21.16 21.54 13.91 16.25 5.33 25.44 10.77 21.58 9.90 1.54 1.14 Yes 84 54.67 23.67 22.06 14.78 17.50 6.39 26.57 11.06 21.51 9.06 1.48 1.15 p-value Smoker No 97 52.16 23.88 20.95 15.16 16.74 5.96 25.41 11.36 21.21 9.55 1.37 1.18 Yes 44 53.77 20.21 23.84 12.45 17.55 6.10 27.66 9.82 22.27 9.03 1.80 .98 p-value * Substance abuse No 96 51.05 23.38 19.42 12.83 16.80 5.54 25.22 10.72 21.50 9.19 1.41 1.16 Yes 45 56.11 21.14 27.04 16.21 17.40 6.92 28.02 11.22 21.62 9.87 1.71 1.07 ** p-value Note. * p < .05. ** p < .01. *** p < .001. 8 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx Consistent with early studies in which reduced working hours addition, the Emergency Service generally attends patients only appeared as a resilience factor in critical contexts,21,22 our study during the first 24 h after being medically admitted, as opposed showed that healthcare workers on a part-time basis had a general to days or weeks (or even months) as in the Covid-19 and ICU hos- improvement over time in psychological distress. On the contrary, pitalisation units, which may also lead to a lower psychological full-time healthcare workers appeared to deteriorate their men- burden. tal health between the first and second psychological assessment, At six months follow-up, to have requested help and been taking having significantly higher stress appraisal. Together, these results stress-related medication continued increasing the overall levels of emphasise the importance of maintaining managing standards psychological distress,28 and the psychiatric history also suggested in medical centres to foster shorter shifts and guarantee enough worse psychological outcomes without statistically significant dif- resting periods to reduce the risk and vulnerability of healthcare ferences. These latter results added to the fact that substance abuse workers against psychological burden and professional burnout in resulting from the pandemic accounted for almost 32% of the sam- critical care scenarios as the current pandemic.4,23 ple, increasing PTSS significantly, underlines the crucial importance The literature also extensively shows in a wide range of clinical of designing new effective intervention strategies to control, reduce contexts that a psychiatric history predisposes to future psychi- and prevent the worsening of mental health of all healthcare work- atric disorders and comorbidities, especially when an extreme life ers when coping with critical scenarios as the current pandemic. event (i.e., Covid-19 pandemic) triggers it.24 In line with this, our Nevertheless, considering the lack of specialists the current work seemed to reinforce this argument by suggesting a notable pandemic has brought with it, together with the cost-benefit of exacerbation of stress, anxiety and depression from the first to the individualised sessions and mental health stigmatisation among second assessment in healthcare workers with a previous psychi- healthcare workers, online psychotherapies could improve the atric disorder. Despite this, the differences in psychological distress accessibility and availability of mental health services in high- over time were not significant for this group. A possible explana- demand contexts. In addition, online psychotherapies also aid in tion for the lack of statistical significance could be an insufficiently reducing the spread of the virus that naturally occurs in face-to- long follow-up. Another explanation could be using psychological face therapies.33 Online Cognitive Behaviour Therapy (ICBT) has assessment instruments not designed to assess mental health in the shown efficacy in a broad range of clinical settings: from psychi- context of the pandemic as a sustained stressor over time. In either atric patients with substance abuse or severe disorders to patients case, these results call for an increment in the control and follow-up with chronic pain, among others.34,35 Accordingly, ICBT may be an of healthcare workers to prevent their mental health exacerbation interesting mental health strategy to combat the psychological bur- and consequently compromising their efficiency and care quality den associated with unprecedented health contexts as the current in future pandemics. pandemic. On the other hand, the levels of psychological distress found This study has some limitations. Firstly, the lack of a con- in the cross-sectional analysis were within the range of previ- trol group prevented comparing front-line healthcare workers and ously published works conducted in medical personnel.25 In other second-line healthcare workers (not directly involved in the care words, at baseline, women showed worse psychological distress of Covid-19 patients). Secondly, using psychometric questionnaires than men and nurses and nurse aides were at higher risk of poorer that were not designed to evaluate anxiety, depression and acute mental health than physicians, with depression being significantly stress in the context of the pandemic as a stressor maintained over worse across the nursing staff. Higher physical activity levels pos- time and without diagnostic capacity, as in the VASS test, may limit itively influenced healthcare workers’ mental health, improving the interpretation of the results as some cases of psychological dis- stress, anxiety, depression.26 Healthcare workers who were off tress may have been underdiagnosed. Lastly, the inability to assess due to Covid-19 infection, requested help and took stress-related off work healthcare workers may hinder illustrating the real impact medication showed worse mental health deterioration.27 Tobacco of the pandemic on healthcare workers’ mental health. Even with consumption and substance abuse followed the same tendency, these limitations, our findings are consistent with previously pub- worsening healthcare workers’ mental health,28 namely PTSS. A lished works. In addition, our work sheds light on likely upcoming history of psychiatric disorder also seemed to involve poorer men- mental health consequences on healthcare workers and their wors- tal health, without observing significant differences. ening in the long-term if the situation is not rapidly resolved or Also consistent with early investigations,29–31 women contin- coped efficiently. We strongly encourage future research to include ued having greater psychological distress at six months follow-up long comprehensive follow-ups of healthcare workers. Also, to con- than men. Nurses and nurse aides also had poorer mental health sider including a control group and other relevant study cohorts than physicians, being these differences better explained due to (i.e., second front-line healthcare workers and those in quarantine the closer contact and longer care nursing staff usually have with due to Covid-19 infection and could not be assessed) that allow patients.20 Not surprisingly, we found that working full-time (i.e., additional comparisons. longer hours) significantly increased the PTSS and perceived stress compared to working part-time. Again, these results emphasise the need to reduce the working hours to guarantee adequate resting periods to decrease the impact of prolonged stress exposure at both Conclusion personal and care levels.30 Just as in the baseline psychological assessment, the less physi- In line with results obtained in previous cross-sectional inves- cal activity healthcare workers reported daily, the poorer mental tigations, the present work shows that the yet ongoing Covid-19 health they presented.26 Working in Covid-19 hospitalisation pandemic continues to cause a general deterioration of the men- wards and ICUs was related overall to greater psychological dis- tal health of frontline healthcare workers, especially regarding tress than working at the Emergency Service, being the levels depression and the predisposition to perceiving the day-to-day of acute stress significantly lower in this latter group.32 These experiences of the pandemic as a threat. In addition, while differences between Covid-19 hospitalisation wards and ICU and nurses and nurse aides showed poorer psychological outcomes at Emergency Services are probably because, in most cases, the latter six months follow-up, physicians showed overall greater mental refers to the connecting unit between the initial phase of the disease health, significantly reducing perceived stress and anxiety. Work- and the patient’s worsening (i.e., the Covid-19 ward and ICU ser- ing part-time during the follow-up period enhanced healthcare vices), which would entail a relatively lower emotional burden. In workers’ wellbeing more than those working full-time. At baseline 9 G Model MEDCLI-5870; No. of Pages 10 ARTICLE IN PRESS P.S. Sangrà, T.C. Ribeiro, S. Esteban-Sepúlveda et al. Medicina Clínica xxx (xxxx) xxx–xxx and six months follow-up, women, nurses, and nurse aides were at 13. Lesage FX, Berjot S, Deschamps F. 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