Mental Health of Young Physicians in China During the Novel Coronavirus Disease 2019 Outbreak

With more than 3 million cases worldwide, the novel coronavirus disease 2019 (COVID-19) poses a growing global public health challenge.1 Medical personnel disproportionately bear the additional physical and psychological burdens associated with pandemics, yet the mental health implications of COVID-19 for physicians are unknown.2,3 In this cohort study, we assessed anxiety, depression, mood, and other established factors associated with mental health problems in a cohort of young physicians in China before and during the outbreak.


Introduction
With more than 3 million cases worldwide, the novel coronavirus disease 2019 (COVID-19) poses a growing global public health challenge. 1 Medical personnel disproportionately bear the additional physical and psychological burdens associated with pandemics, yet the mental health implications of COVID-19 for physicians are unknown. 2,3 In this cohort study, we assessed anxiety, depression, mood, and other established factors associated with mental health problems in a cohort of young physicians in China before and during the outbreak.

Methods
The ethics committees of Shanghai Jiao Tong University and the University of Michigan approved this study. All participants provided written informed consent and were compensated ¥25 (as of May 7, 2020, ¥1 = $0.14 US). This study follows the American Association for Public Opinion Research (AAPOR) reporting guideline.
Training physicians from 12 Shanghai hospitals who enrolled in the prospective Intern Health Study in August 2019 completed surveys 2 weeks before beginning residency and again at 3 months (before the COVID-19 outbreak) and 6 months (during the COVID-19 outbreak) that assessed anxiety (Generalized Anxiety Disorder-7 scale), depression (Patient Health Questionnaire-9), and workplace violence. 4,5 Mood valence (rated from 1 to 10, with higher scores indicating better mood) was measured daily via a mobile smartphone application. The same protocol was used to collect data in the prior 2018 to 2019 residency cohort.
A series of random effect mixed models were fitted to assess changes in Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and mood scores and experience, observation, and fear of workplace violence between quarter 1 and quarter 2 for both the 2018 to 2019 and 2019 to 2020 cohorts. Preresidency baseline (mood score, Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 total scores, and a personal history of depression) and within-residency (work hours, sleep duration, and experience, observation, and fear of violence before and after the outbreak) factors that have previously been associated with depression and anxiety in training physicians were included in the models. 6 All analyses were performed using SAS statistical software version 9.4 (SAS Institute). Statistical significance was calculated with generalized linear mixed models. A 2-tailed P < .05 was considered statistically significant. Data analyses were performed in March and April 2020.

Discussion
This study found that physicians in China experienced an increase in mental health symptoms and fear of violence and a decline in mood after the COVID-19 outbreak. These findings may reflect training physicians' added clinical workload with the emergence of COVID-19 and are consistent with past evidence that the additional stressors physicians face during infectious disease outbreaks place them at greater risk for both short-term and long-term mental health problems. 2,3  .70 Abbreviations: GAD-7, Generalized Anxiety Disorder-7; OR, odds ratio; PHQ-9, Patient Health Questionnaire-9; Q1, quarter 1; Q2, quarter 2.  Lines and dots depict daily mood score using a moving weekly mean. The mood score difference between quarter 1 (before the COVID-19 outbreak) and quarter 2 (after the COVID-19 outbreak) was statistically significant for the 2019 to 2020 cohort (β = −0.50; 95% CI, −0.80 to −0.20; P = .002). No statistically significant difference was observed for the 2018 to 2019 cohort. The rectangles indicate the time frame for each survey period for the 2019 to 2020 cohort.
The ovals indicate the date range for the Lunar New Year holiday for the 2018 to 2019 cohort (February 4, 2019, to February 19, 2019) and 2019 to 2020 cohort (January 24, 2020, to February 8, 2020).