Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019 | Global Health | JAMA Network Open | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Audio Editors' Summary (14:42)
Li  Q, Guan  X, Wu  P,  et al.  Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia  [published online January 29, 2020].  N Engl J Med. 2020. doi:10.1056/NEJMoa2001316PubMedGoogle Scholar
The National Health Commission of China. Updates on the novel coronavirus outbreak up to March 2, 2020. Accessed March 3,2020. http://www.nhc.gov.cn/xcs/yqtb/202003/c588ee20113b4136b27f2a07faa7075b.shtml
Rothe  C, Schunk  M, Sothmann  P,  et al.  Transmission of 2019-nCoV infection from an asymptomatic contact in Germany  [published online January 30, 2020].  N Engl J Med. 2020. doi:10.1056/NEJMc2001468PubMedGoogle Scholar
World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). Published January 30, 2020. Accessed February 2, 2020. https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)
Maunder  R, Hunter  J, Vincent  L,  et al.  The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital.  CMAJ. 2003;168(10):1245-1251.PubMedGoogle Scholar
Bai  Y, Lin  CC, Lin  CY, Chen  JY, Chue  CM, Chou  P.  Survey of stress reactions among health care workers involved with the SARS outbreak.  Psychiatr Serv. 2004;55(9):1055-1057. doi:10.1176/appi.ps.55.9.1055PubMedGoogle ScholarCrossref
Lee  AM, Wong  JG, McAlonan  GM,  et al.  Stress and psychological distress among SARS survivors 1 year after the outbreak.  Can J Psychiatry. 2007;52(4):233-240. doi:10.1177/070674370705200405PubMedGoogle ScholarCrossref
Chua  SE, Cheung  V, Cheung  C,  et al.  Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers.  Can J Psychiatry. 2004;49(6):391-393. doi:10.1177/070674370404900609PubMedGoogle ScholarCrossref
The State Council of China. A notification to set up nationwide psychological assistance hotlines against the 2019-nCoV outbreak. Published February 2, 2020. Accessed March 3, 2020. http://www.gov.cn/xinwen/2020-02/02/content_5473937.htm
Zhang  YL, Liang  W, Chen  ZM,  et al.  Validity and reliability of Patient Health Questionnaire-9 and Patient Health Questionnaire-2 to screen for depression among college students in China.  Asia Pac Psychiatry. 2013;5(4):268-275. doi:10.1111/appy.12103PubMedGoogle ScholarCrossref
He  XY, Li  CB, Qian  J, Cui  HS, Wu  WY.  Reliability and validity of a generalized anxiety scale in general hospital outpatients.  Shanghai Arch Psychiatry. 22(4):200-203. doi:10.3969/j.issn.1002-0829.2010.04.002Google Scholar
Yu  DS.  Insomnia Severity Index: psychometric properties with Chinese community-dwelling older people.  J Adv Nurs. 2010;66(10):2350-2359. doi:10.1111/j.1365-2648.2010.05394.xPubMedGoogle ScholarCrossref
Wu  KK, Chan  KS.  The development of the Chinese version of Impact of Event Scale–Revised (CIES-R).  Soc Psychiatry Psychiatr Epidemiol. 2003;38(2):94-98. doi:10.1007/s00127-003-0611-xPubMedGoogle ScholarCrossref
Tong  X, An  D, McGonigal  A, Park  SP, Zhou  D.  Validation of the Generalized Anxiety Disorder-7 (GAD-7) among Chinese people with epilepsy.  Epilepsy Res. 2016;120:31-36. doi:10.1016/j.eplepsyres.2015.11.019PubMedGoogle ScholarCrossref
Wong  TW, Yau  JK, Chan  CL,  et al.  The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope.  Eur J Emerg Med. 2005;12(1):13-18. doi:10.1097/00063110-200502000-00005PubMedGoogle ScholarCrossref
Wang  W, Tang  J, Wei  F.  Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China.  J Med Virol. 2020;92(4):441-447. doi:10.1002/jmv.25689PubMedGoogle ScholarCrossref
Chan-Yeung  M.  Severe acute respiratory syndrome (SARS) and healthcare workers.  Int J Occup Environ Health. 2004;10(4):421-427. doi:10.1179/oeh.2004.10.4.421PubMedGoogle ScholarCrossref
Li  L, Cheng  S, Gu  J.  SARS infection among health care workers in Beijing, China.  JAMA. 2003;290(20):2662-2663. doi:10.1001/jama.290.20.2662PubMedGoogle ScholarCrossref
Shih  FJ, Gau  ML, Kao  CC,  et al.  Dying and caring on the edge: Taiwan’s surviving nurses’ reflections on taking care of patients with severe acute respiratory syndrome.  Appl Nurs Res. 2007;20(4):171-180. doi:10.1016/j.apnr.2006.08.007PubMedGoogle ScholarCrossref
Chan  S.  Nurses fighting against severe acute respiratory syndrome (SARS) in Hong Kong.  J Nurs Scholarsh. 2003;35(3):209. doi:10.1111/j.1547-5069.2003.00209.xPubMedGoogle ScholarCrossref
Tzeng  HM.  Fighting the SARS epidemic in Taiwan: a nursing perspective.  J Nurs Adm. 2003;33(11):565-567. doi:10.1097/00005110-200311000-00005PubMedGoogle ScholarCrossref
Mok  E, Chung  BP, Chung  JW, Wong  TK.  An exploratory study of nurses suffering from severe acute respiratory syndrome (SARS).  Int J Nurs Pract. 2005;11(4):150-160. doi:10.1111/j.1440-172X.2005.00520.xPubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    3 Comments for this article
    Gender differences?
    Ron M, MS1 | Medical Student
    In the methodology, we are told that "Nurses, women, those working in Wuhan, and frontline workers reported more severe symptoms on all measurements." However, what of the psychosocial aspects of self-reporting depression? The question of bias in data collection, particularly the fact that women are more likely to be open about feelings of depression than men (be it down to machoism or what not), has not been sufficiently addressed.

    On that basis alone, I find the conclusion problematic: "Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented, with women ...
    requiring particular attention."
    "On the Nature of Things"
    Paolo Mazzarello, MD and Emanuela Ciuchi, MD |
    “For their sense of duty and listening to the weak as well as plaintive voice of the patients, [Care Workers] dropped with fatigue and ran the risk of getting infected themselves.”
    Lucretius (1st century BC), “On the Nature of Things”: The Plague of Athens, VI, 1248-50.

    The commented survey is precise and concerns several case histories. However, we agree with Ron M.
    Immediate vs longer term follow up
    Hussain Maqbool Ahmed Khuwaja, BSc Nursing | Aga Khan University School of Nursing and Midwifery
    This is an amazing piece of evidence for other countries to assess status of mental health for their front-line health care workers as well as general population.

    The sample size calculated for this study has used the estimates of stress one year after SARS epidemic. On the contrary, the current study is assessing the stress level of participant immediately after the surge of COVID19 pandemic. I suggest that the sample must have been assessed for all outcomes that have been assessed not merely stress.

    In methods section, the outcome variable of depression is assessed using PHQ-9
    and the scores are mentioned as normal (0-4), mild (5-9), moderate (10-14), and severe (15-21) depression. At the start of this paragraph, the range of possible PHQ-9 scores is mentioned as 0-27. I think the ranges mentioned in categories needs some correction because the range of 22 to 27 is not falling in any category. Moreover, the study that has been cited at 10 in references says that the cut-off for PHQ-9 is suggested to be 11 in Chinese population instead of 10. However, international studies do suggest to use the cut-off value of 10 or more for depression.
    Original Investigation
    March 23, 2020

    Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

    Author Affiliations
    • 1Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
    • 2Department of Psychiatry, Renmin Hospital of Wuhan University, Wuhan, China
    • 3Department of Psychiatry, Wuhan Youfu Hospital, Wuhan, China
    • 4Department of Psychiatry, Jingmen No. 2 People’s Hospital, Jingmen, China
    • 5Department of Psychiatry, Wuhan Wudong Hospital, Wuhan, China
    • 6Department of Nursing, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
    JAMA Netw Open. 2020;3(3):e203976. doi:10.1001/jamanetworkopen.2020.3976
    Key Points español 中文 (chinese)

    Question  What factors are associated with mental health outcomes among health care workers in China who are treating patients with coronavirus disease 2019 (COVID-19)?

    Findings  In this cross-sectional study of 1257 health care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in multiple regions of China, a considerable proportion of health care workers reported experiencing symptoms of depression, anxiety, insomnia, and distress, especially women, nurses, those in Wuhan, and front-line health care workers directly engaged in diagnosing, treating, or providing nursing care to patients with suspected or confirmed COVID-19.

    Meaning  These findings suggest that, among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and front-line health care workers have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.


    Importance  Health care workers exposed to coronavirus disease 2019 (COVID-19) could be psychologically stressed.

    Objective  To assess the magnitude of mental health outcomes and associated factors among health care workers treating patients exposed to COVID-19 in China.

    Design, Settings, and Participants  This cross-sectional, survey-based, region-stratified study collected demographic data and mental health measurements from 1257 health care workers in 34 hospitals from January 29, 2020, to February 3, 2020, in China. Health care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 were eligible.

    Main Outcomes and Measures  The degree of symptoms of depression, anxiety, insomnia, and distress was assessed by the Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale–Revised, respectively. Multivariable logistic regression analysis was performed to identify factors associated with mental health outcomes.

    Results  A total of 1257 of 1830 contacted individuals completed the survey, with a participation rate of 68.7%. A total of 813 (64.7%) were aged 26 to 40 years, and 964 (76.7%) were women. Of all participants, 764 (60.8%) were nurses, and 493 (39.2%) were physicians; 760 (60.5%) worked in hospitals in Wuhan, and 522 (41.5%) were frontline health care workers. A considerable proportion of participants reported symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Nurses, women, frontline health care workers, and those working in Wuhan, China, reported more severe degrees of all measurements of mental health symptoms than other health care workers (eg, median [IQR] Patient Health Questionnaire scores among physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007; median [interquartile range {IQR}] Generalized Anxiety Disorder scale scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] Insomnia Severity Index scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001; median [IQR] Impact of Event Scale–Revised scores among those in Wuhan vs those in Hubei outside Wuhan and those outside Hubei: 21.0 [8.5-34.5] vs 18.0 [6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside Hubei; P < .001). Multivariable logistic regression analysis showed participants from outside Hubei province were associated with lower risk of experiencing symptoms of distress compared with those in Wuhan (odds ratio [OR], 0.62; 95% CI, 0.43-0.88; P = .008). Frontline health care workers engaged in direct diagnosis, treatment, and care of patients with COVID-19 were associated with a higher risk of symptoms of depression (OR, 1.52; 95% CI, 1.11-2.09; P = .01), anxiety (OR, 1.57; 95% CI, 1.22-2.02; P < .001), insomnia (OR, 2.97; 95% CI, 1.92-4.60; P < .001), and distress (OR, 1.60; 95% CI, 1.25-2.04; P < .001).

    Conclusions and Relevance  In this survey of heath care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 in Wuhan and other regions in China, participants reported experiencing psychological burden, especially nurses, women, those in Wuhan, and frontline health care workers directly engaged in the diagnosis, treatment, and care for patients with COVID-19.