Mental Disorders Among Healthcare Workers During the Coronavirus Pandemic

Introduction:Coronavirus disease 2019 (COVID-19) is a disease that has become a regular part of care by health services. In the beginning, health services faced immense pressure due to new disease exposure, irregular schedules, and high work stress for healthcare workers. Unfortunately, their mental health was not adequately safeguarded, and there are few healthcare units that screen staff for depression and anxiety. Objective: The objective of this study is to describe the prevalence and factors associated with anxiety and depression diagnoses among healthcare workers during the coronavirus pandemic. Materials and methods: A cross-sectional study was conducted in which depression (Beck questionnaire) and anxiety (Hamilton questionnaire) were investigated in health staff, after providing informed consent. This study was carried out during November and December 2022. All workers in all areas of a first-level unit were invited to participate in this research, so no sample calculation or sampling technique was required. Statistical analysis was performed using X2 and Student’s t-test. Results: Among the 232 workers surveyed, the prevalence of mild anxiety, severe anxiety, and certain levels of depression was 42.1%, 33.5%, and 18.9%, respectively. The study revealed that smoking is associated with a higher risk of anxiety diagnosis (OR=4; CI95%=1.3-12.7). A higher score on the Hamilton Anxiety Scale (OR=1.07; CI95%=1.04-1.11) as well as not being permanent staff (OR=3.34; CI95%=1.2-9.3) was found associated with depression diagnosis. Conclusion: The SARS-CoV-2 pandemic increased the stress and pressure on healthcare workers. Thus, early detection, timely treatment, and effective prevention measures are necessary for safeguarding health status and the provision of healthcare services.


Introduction
Although anxiety and depression are common pathologies in the world population, their prevalence in an entire country is unclear due to multiple conditions that affect them, such as the economic, social, and cultural circumstances of the people, as well as individual personality and biological susceptibility.Some studies showed that the prevalence of depression in Mexico in 2018 was close to 13.3%, and for anxiety, it was around 32.6% in 2020; the most frequent risk factors for both diseases are female gender, unemployment, and low socioeconomic level [1,2].Nevertheless, these diseases, which have become relevant in recent years, are also affected by global events like the coronavirus disease 2019 (COVID- 19) pandemic, putting additional pressure on the population, especially on healthcare workers [3].It is not the first time that the world has faced a coronavirus with high mortality and pandemic potential.In 2002, there was an outbreak of Severe Acute Respiratory Syndrome caused by a coronavirus (SARS-CoV) in China, and in 2012 we faced Middle East Respiratory Syndrome (MERS-COV) in Saudi Arabia; these had a high mortality rate for respiratory complications, and these diseases were controlled with efforts of the affected countries and the international community [4].The SARS-CoV-2 has put a strain on health systems around the world.Its rapid expansion and high capacity to cause serious diseases modify the healthcare response, particularly since early identification is extremely difficult [5].
For Mexico, in January 2023, there were 7,342,764 cases and 331,897 confirmed deaths were reported, with a mortality rate of 4.05% during this period [6].In order to avoid high incidence and mortality, hospital conversion was attempted, which consists of increasing the number of useful beds to treat severe forms of the disease and increasing the capacity of existing units to treat the burden of other diseases [7].However, it was not possible to increase the number of physicians, and even several who had chronic illnesses had to take shelter.
The staff of health institutions (non-clinical staff) and healthcare workers (medical, nursing, laboratory, and imaging personnel) are experiencing uncertainty in providing care in a country with a high prevalence of obesity and chronic degenerative diseases, which are important risk factors for mortality [8][9][10].This, coupled with the absence of protective equipment to avoid infection, raises concerns among healthcare workers about getting infected [11].
During the pandemic, the speed at which information about COVID-19 was spread, as well as the constant changes in public policy in Mexico, caused confusion and mistrust among the Mexican population [12].This, combined with the isolation methods hospitals used for severe cases, posed challenges for patient-centered care [13].These challenges were particularly burdensome for the Mexican health system and caused an extreme emotional toll on healthcare workers [14][15][16][17].
When the influenza (H1N1) pandemic occurred in Mexico in 2009, healthcare workers suffered a significant increase in psychological stress related to concerns about their family's health, doubts about their functional abilities, and fear of stigmatization.On top of that, they had to cope with work stress, social isolation, and concerns about their health.Other risk factors reported in the literature include the constant change of information and procedures, media scrutiny, being part of the nursing staff, increased perception of individual risk, lifestyle changes due to the disease, and personal vulnerability; all of this caused many medical personnel to not go to work in 2009, despite their strong sense of duty.The most frequent problems that have been reported in the literature are post-traumatic stress syndrome, anxiety, depression, and burnout syndrome [18].
The Mexican Social Security Institute (or IMSS per its Spanish acronym for Instituto Mexicano del Seguro Social) was the public institution in Mexico that established guidelines in 2021 to protect the mental health of the workers at the units.However, the efforts were focused on treating patients and controlling the spread of COVID-19.Although these support mechanisms were available for workers, it is not known whether they could be implemented completely and correctly or their beneficial effects [19].
Evaluation and measurement of mental illnesses, such as anxiety and depression, are crucial in the workplace to prevent health issues that can affect job performance.Mental health alterations can have both physiological and cognitive effects; the latter can lead to behavioral and emotional disorders.Various studies describe prevalences of these conditions in health personnel as high as 50% for depression and 46% for severe anxiety [20].The overwhelming demand for urgent healthcare during the COVID-19 pandemic has created a stressful environment for workers, leading to feelings of tension, helplessness, and constant frustration.If left unaddressed, these issues can have harmful physical and mental health consequences and can even be fatal, if are not prevented and attended on time.
Therefore, our study aimed to identify the prevalence of personnel with a diagnosis of mental illnesses and the risk factors associated, which can be used in the future to further analyze more effective ways to support them by implementing better strategies for diagnostics, complying with more comprehensive care from the staff themselves.Likewise, we will be able to identify the specific needs of workers and find the most effective way to care for them.In the present study, the prevalence of anxiety and depression was identified among health personnel from different medical and paramedical areas, during the pandemic caused by the COVID-19 disease at a Family Medical Unit (or UMF, per its Spanish acronym for Unidad de Medicina Familiar) of the IMSS, in Xalapa, Veracruz, Mexico.

Materials And Methods
A cross-sectional study was conducted, which included clinical and non-clinical staff from a primary care unit of the IMSS.The inclusion criteria were personnel assigned to the UMF who worked for at least six months from January to December 2022, personnel who were in direct care with patients and, therefore, being at risk for SARS-CoV-2 infection within the UMF.Personnel working for any other public institution other than the IMSS were excluded.The exclusion criteria were personnel who decided not to complete the required questionnaires or decided that their data would be excluded from the research, and personnel who lied about their sociodemographic or work characteristics during data collection.Incorrect or incomplete forms were eliminated from the final grouping to avoid invalidating our study.Of the 490 workers at the unit, 232 met the selection criteria and all were included.There was no dropout.The research was approved by the Institutional Ethics and Research Committee.Our study was carried out between November and December 2022, using the Hamilton Anxiety Rating Scale (HAS) and Beck Depression Inventory (BDI) to explore anxiety and depression, respectively [21,22].Also, the Graffar-Méndez-Castellanos socioeconomic tool was used to complement this work [23].We conducted a survey to gather data on socio-demographic information, comorbidities, weight, and height of the workers.Additionally, a set of 19 Likert-type questions were asked where the workers indicated their level of agreement about their attitude toward  Continuous variables between two independent groups were compared using the Student's t-test and ANOVA for three or more independent groups.The chi-square test was used to compare categorical variables between independent groups.All the statistical tests were two-tailed.Correlation analyses through Spearman's rank correlation coefficient were performed to identify the relationship between the tool scores.The risk factors were identified by calculating the odds ratio (OR) and their 95% confidence intervals through a multivariate analysis of binary logistic regression, where the dependent variable was depression (score at BDI ≥14 points) or anxiety (score at HAS ≥6 points) and the independent variables were gender, marital status, working position, smoking, alcohol use, BDI, and HAS score.Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 29 (Released 2022; IBM Corp., Armonk, New York, United States).

Results
Among the 232 workers surveyed who relatively met all the selection criteria from the UMF, no worker left the study and there were no incomplete questionnaires.Of all the subjects included, 54.7% (127 workers) were women, and the mean age of the workers was 41 ± 8.6 years.Regarding working conditions, the average seniority at IMSS (in any unit) was 16 ± 2.4 years.However, within the unit, the average time was 9 ± 1.8 years.Despite the relatively short time in the UMF, 91.4% (212 workers) are permanent staff.The nursing staff category had the greatest representation, with 39.7% (92 workers), followed by medical personnel with 34.9% (81 workers).Concerning the sociodemographic and anthropometric variables, the average number of children per worker was 1.69 ± 1.3.Seventy-eight percent (181 workers) of the staff had a bachelor's degree or above, 62.5% (145 workers) had a stable partner (with and without civil partnership), the average body mass index (BMI) of the workers was 27.7 ± 4.2 kg/m 2 , 29.2% of the workers were sedentary, and 51.7% (120 workers) practiced mild physical activity, and the average score for the socioeconomic level tool was of 8.9 ± 1.9 which corresponds to the upper-middle stratum (second highest quintile).Regarding cigarette and alcohol use, the prevalences were 18.5% (43 workers) and 21.6% (50 workers), respectively.The tools used to explore mental disorders showed that the mean scores for all workers surveyed were 12.93 ± 10.2 for HAS.The stratified tool showed 42.2% (98 workers) of the workers with minor anxiety and 33.6% (78 workers) with major anxiety.BDI was 8.08 ± 7.4.Similarly, when stratified, 19% (44 workers) have some level of depression.
Table 1 shows the sociodemographic characteristics according to occupation and job category; there was no relevant difference in gender or marital status.Medical personnel are those who have the highest level of education.The sociodemographic and work characteristics, as well as the personal background of the workers, showed significant differences in the screening tests of the tools categorized by diagnosis, non-permanent personnel within the work position, and tobacco use and higher socioeconomic levels were relevant in those with some degree of anxiety.For those who experienced some degree of depression, the association was linked with occupation, less physical activity, and high socioeconomic level.All the associations of the variables are described in Table 2.The comparison of proportions was carried out using the chi-square test.

Characteristic
The categorical variables and their statistical differences regarding the total score of the tools are shown in Table 3.The mean score for the anxiety tool was higher in non-clinical personnel and those who smoke, consume alcohol, and have a high socioeconomic level.Regarding the score of the depression instrument, the highest score was found in those with a high economic level.In the correlation matrix, the total scores for the screening tools were used.Statistically significant differences were found between the HAS score and the BMI (ρ = 0.16) and the BDI score (ρ = 0.57).The BDI score showed a correlation with HAS (ρ = 0.57).The rest of the correlations for all the continuous variables are described in Table 4.  Finally, in the survey applied to workers that explores the attitude, knowledge, needs, and fears about COVID-19, being categorized by the degrees of anxiety and depression, we observed that there were workers who considered they were absent as cases increased; they did not consider they had enough knowledge, and they did not believe that the UMF is prepared to serve the population.They also described their fears of the disease, which included workers' fears, the most prevalent being the risk of infecting their family.The answers to these items are described in Table 5.

Discussion
Despite the various measures taken by the IMSS, healthcare workers showed a high prevalence of mental disorders (75.6% anxiety, and 18.9% depression), which may explain why interventions were not identifiable or affordable for workers or they became insufficient [19].Something relevant about this work is that the workers consider that the UMF has provided them with enough information about the disease, however, they are afraid of the disease, of suffering from a serious form, of infecting others, and to a lesser extent of isolation.
The identified prevalence in healthcare workers seemed to be higher than that in the general population, which may be caused by the type of work and that the people had to deal with coronavirus.A study carried out by Li et al., (2020), in China with the support of social networks among the general population, identified an overall prevalence of 11.69% prior to the news of the national dissemination of SARS-CoV-2 (January 20, 2020) and 12.76% after this period [24].Meanwhile, depression prior to this period was 14.87% and later 15.27% [24].Our study helps to provide clarity about mental health, showing lower figures before the disease emerged, while when compared with the present study, it is observed that the diseases in the general population are much lower than those among health personnel during the pandemic (75.8% for anxiety and 19% for depression).
Another study, in China, that allows comparison with the general population is the one carried out by Huang and Zhao (2020), which found the prevalence of anxiety as 35.1% and depression as 20.1%, which did not change according to gender, being only higher in those under 35 years old [25].A much higher prevalence of anxiety can be observed in Mexican workers, even than in those who identified themselves as health workers in China; however, the prevalence of depression in this study was higher than that of the personnel studied (19%), and even greater than that reported by Li et al., (2020), something important to mention is that the studies carried out in China are separated by approximately 30 days, which implies that as the disease and information progress, the mental health of the population begins to suffer consequences [24].
Several papers have reported this aspect among health workers during the COVID-19 pandemic.For example, the study by Lai et al., (2020), carried out in various hospitals in China identified a prevalence of 50.4% depression and 44.6% anxiety, in contrast to our study, which only reported lower depression levels (19%) [26].Interestingly, Lai et al., (2020) carried out their study during the beginning of the pandemic, so it is assumed that as time went by, new therapeutic, diagnostic, and preventive resources appeared, and in general, more information about the disease.Personnel in Mexico should have a reduction in these alterations, something that apparently turns out to be incorrect.The study also reported differentiated prevalences according to subgroups, with anxiety more frequent in women, which aligned with the findings of the present study (although there was no statistical significance).
Healthcare workers also showed different prevalences according to the type of healthcare unit level where they worked.In this regard, the study by Huang et al., (2020), carried out at a tertiary hospital, found a prevalence of 23.04% for anxiety, with female staff being the most affected (25.67%), as well as a higher score on the anxiety detection instrument in nursing staff [27].In this study, a lower prevalence than that described by Lai et al. was identified in a similar population, whose difference was the level of care in the health unit where they work [26].The present study identified a higher prevalence of anxiety in Mexican workers, with women being the most affected.However, the nursing staff was the one that obtained the lowest score in the anxiety instrument, being surpassed by the medical staff and non-clinical staff.
Closer to our population is what was identified by Dosil Santamaría et al., (2020), in their study carried out in Spain in healthcare personnel, in which prevalences of 37% of anxiety and 27.4% of depression were described, and those over 36 years old are the most affected (similar to what was identified by Huang and Zhao (2020), and 44.4% felt fear of contagion and these, in turn, were the population with a higher prevalence rate of mental disorders [25,28].When compared with what was found in the present study, the prevalence of anxiety continues to be higher in the Mexican population, while depression is much higher in Spanish workers.Interestingly, of the population in this work, 59.65% said they were afraid of COVID-19, and the diagnosis of anxiety was higher (p < 0.01).
In Latin America, we can address these alterations.The study by Magaña-Salazar et al., (2020), carried out in El Salvador on workers at a second-level hospital (which included clinical and non-clinical staff), identified a prevalence of depression of 9.1%, 51.2% had minor anxiety and 13.2% had major anxiety [29].When compared with the population of the present study, a higher prevalence of major anxiety was observed (33.5%), although it was slightly lower in the anxiety rating (42.1%) and twice the proportion of workers with depression (18.9%).The personnel with the greatest impact on their mental health, according to Magaña-Salazar et al., (2020), were the nursing and non-clinical personnel, something that could not be identified in the Mexican nursing personnel but was the case for the non-clinical personnel [29].
To compare what was found in similar health units and populations, we have the study by Rubio-Morales et al., (2021), carried out in a UMF in Ciudad Obregón, Sonora, Mexico, in which greater anxiety was found in 7.7% of workers, and 6.9% moderate and high depression, something quite different from what was found in the present study, where the prevalence was much higher in a population subjected to the same working

TABLE 1 : Demographic and occupational characteristics of healthcare staff
*Unmarried category included widowed and divorced participants

TABLE 4 : Correlation matrix for depression and anxiety scores and categorical variables
*p-value less than 0.05.The Spearman rho correlation coefficient test was used.All hypothesis tests were two-tailed.UMF: Unidad de Medicina Familiar; IMSS: Instituto Mexicano del Seguro Social

TABLE 5 : Severity categories for depression and anxiety distributed by questions asked to staff and comparison test
Totally disagree + partially disagree + neither agree nor disagree, 2: partially agree + totally agree.P value less than 0.05.All hypothesis tests were two-tailed.The comparison of proportions was carried out using the chi-square test.UMF: Unidad de Medicina Familiar; IMSS: Instituto Mexicano del Seguro Social Binary logistic regression models were used, where the screening tools were separated into dichotomous results, in which smoking was found to be a risk factor for anxiety (OR 4 95% CI 1.3-12.7).A higher score on HAS (OR 1.07 95% CI 1.04-1.11)andnotbeing permanent staff (OR 3.34 95% CI 1.2-9.3)werefound to be risk factors for depression.The models are described in Table6. 1:*