Psychological distress in healthcare workers

We know that healthcare workers are at a greater risk of burnout, however you choose to define it. This study examines the impact of COVID-19 on the psychological distress of frontline workers.

Roberts T, Daniels J, Hulme W, Hirst R, Horner D, Lyttle MD, Samuel K, Graham B, Reynard C, Barrett MJ, Umana E. Psychological Distress and Trauma in Doctors Providing Frontline Care During the COVID-19 Pandemic in the United Kingdom and Ireland: A Prospective Longitudinal Survey Cohort Study.

Background

This study aimed to assess the prevalence and extent of psychological distress and trauma of doctors working in the UK and Ireland during the first wave of the COVID-19 pandemic.   

Doctors working in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) were asked to complete online surveys at the acceleration, peak and deceleration of the COVID-19 first wave, providing an insight into their psychological well-being at different phases of the pandemic. Exposure to previous infectious disease outbreaks has shown that elevated psychological distress is associated with the development of chronic stress, depression, anxiety, physical health problems, increased sickness rates, emotional exhaustion and impaired performance at work. Given that the COVID-19 pandemic will undoubtedly have a significant impact on the mental health of healthcare workers in the UK and Ireland, this study is important to understand the extent of the pandemic’s impact in these settings. The study also looked at personal and professional factors associated with increased distress in an attempt to identify those who are most at-risk and may benefit from early intervention.  

Methods

The study was carried out using a prospective online three-part longitudinal survey administered at the acceleration, peak and deceleration of the COVID-19 first wave.  Primary outcome measures were psychological distress and trauma, measured using the General Health Questionnaire for distress and the Impact of Event Scale -Revised for trauma.  These tools have been extensively utilised across different settings and cultures.

The survey was distributed to doctors in Emergency Medicine (EM), Anaesthetics and Intensive Care Medicine (ICM) in the UK and Ireland through existing trainee research networks, faculties and Royal Colleges.  

After participation in the first survey, the subsequent surveys were emailed directly to participants.  Survey distribution dates were decided based on public health data on confirmed cases and deaths in the UK and Ireland.   The following dates were used:

• Acceleration phase UK: 18/03/2020 – 26/03/2020, Ireland: 25/03/2020 – 02/04/2020
• Peak phase UK: 21/04/2020 – 05/05/2020, Ireland: 28/04/2020 – 12/05/2020
• Deceleration phase UK: 03/06/2020 – 17/06/2020, Ireland: 10/06/2020 – 24/06/2020

Personal and professional characteristics relating to participants’ current roles and their preparedness and experiences during the pandemic were also collected. 

Results 

Of the estimated 34,188 eligible doctors, the response rate for the initial acceleration survey was 15.9% (n=5440).  Peak and deceleration response rates were 71·6% (n=3896) and 56·6% (n=3079) respectively. (Ed. note– You could argue that the peak and deceleration responses were 11% and 9% of all eligible doctors).

Prevalence of psychological distress was highest during the acceleration phase at 44·7%, then declined through peak and deceleration phases of the first wave to a level comparable to pre-pandemic levels, reflecting a degree of natural recovery. The prevalence of trauma was highest at the peak of the pandemic at 23·7%. The figures for both psychological distress and trauma were substantially higher than for the general population.  The most significant personal and professional predictors associated with distress and trauma related to familial safety, personal safety, and established mental health conditions.  Whilst ethnicity was not strongly associated with distress, it was a stronger predictor of trauma (R2 = 0·03).   

Strengths

This is a large-scale longitudinal study that prospectively examined the psychological well-being of frontline doctors. It used GHQ-12 and IES-R, validated self-report measures for assessing distress and trauma, respectively. These outcome measures have been used in previous infectious disease outbreaks. A pre-specified analysis plan was published and is available online. 

This study included responses from 5,440 frontline doctors throughout the UK and Ireland, an impressive response rate given that it was undertaken during a pandemic and achieved thanks to the collaboration of multiple Emergency Medicine and Intensive Care research networks. (TERN, PERUKI, RAFT, ITERN, TRIC)  

Due to the extent of the data collected, this study’s findings offer essential insight into the mental health of frontline doctors during an infectious disease outbreak. These findings can inform policymakers about developing interventions for the current pandemic and future outbreaks. The three-phase approach means interventions can be targeted in a timely manner.    

The study identifies ethnicity as a novel, key predictor of trauma.  By including the impact of ethnicity in the study, the researchers have recognised the important role that ethnicity has played in this pandemic, given the higher rates of reported mortality in ethnic minority groups.  

Limitations

The surveys were distributed within a specific time frame based on the number of cases in both countries without accounting for regional variation. 

As such, the researchers recognise that the variation in regional peaks may have influenced the accurate capturing of psychological distress and trauma rates. In addition, pre-pandemic levels of distress and trauma in the cohort included in the study remain unknown. 

There was a considerable drop-out rate in responses throughout the study, with a 56.6% response in the final deceleration phase.  The researchers noted no significant difference in the GHQ-12 or IES-R scores between those who dropped out and those who remained in the study.  However, the reason for the participants’ lack of response is unknown, and these participants may have been experiencing increased distress. Alternatively, some without any concerns may have felt it no longer necessary to complete the survey, therefore exaggerating the finding of significant trauma in those who responded.