[Skip to Content]
[Skip to Content Landing]
Table 1.  Demographic and Occupational Characteristics of Responders
Demographic and Occupational Characteristics of Responders
Table 2.  Severity Categories of Depression, Anxiety, Insomnia, and Distress Measurements in Total Cohort and Subgroups
Severity Categories of Depression, Anxiety, Insomnia, and Distress Measurements in Total Cohort and Subgroups
Table 3.  Scores of Depression, Anxiety, Insomnia, and Distress Measurements in Total Cohort and Subgroups
Scores of Depression, Anxiety, Insomnia, and Distress Measurements in Total Cohort and Subgroups
Table 4.  Association of Hospital Type With Scores of Mental Health Outcomes Among Frontline Workers
Association of Hospital Type With Scores of Mental Health Outcomes Among Frontline Workers
Table 5.  Risk Factors for Mental Health Outcomes Identified by Multivariable Logistic Regression Analysis
Risk Factors for Mental Health Outcomes Identified by Multivariable Logistic Regression Analysis
1.
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
2.
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
3.
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
4.
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)
5.
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
6.
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
7.
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
8.
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
9.
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
10.
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
11.
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
12.
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
13.
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
14.
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
15.
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
16.
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
17.
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
18.
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
19.
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
20.
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
21.
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
22.
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
    EXPAND ALL
    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."
    CONFLICT OF INTEREST: None Reported
    READ MORE
    "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.
    CONFLICT OF INTEREST: None Reported
    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.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Original Investigation
    Psychiatry
    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.

    Abstract

    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.

    Introduction

    Since the end of December 2019, the Chinese city of Wuhan has reported a novel pneumonia caused by coronavirus disease 2019 (COVID-19), which is spreading domestically and internationally.1 The virus has been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this report, we will refer to the disease, COVID-19. According to data released by the National Health Commission of China, the number of confirmed cases in mainland China has increased to 80 151 as of March 2, 2020,2 and confirmed cases have been reported in more than a dozen other countries. Moreover, person-to-person transmission has been recorded outside mainland China.3 On January 30, 2020, the World Health Organization held an emergency meeting and declared the global COVID-19 outbreak a public health emergency of international concern.4

    Facing this critical situation, health care workers on the front line who are directly involved in the diagnosis, treatment, and care of patients with COVID-19 are at risk of developing psychological distress and other mental health symptoms. The ever-increasing number of confirmed and suspected cases, overwhelming workload, depletion of personal protection equipment, widespread media coverage, lack of specific drugs, and feelings of being inadequately supported may all contribute to the mental burden of these health care workers. Previous studies have reported adverse psychological reactions to the 2003 SARS outbreak among health care workers.5-8 Studies showed that those health care workers feared contagion and infection of their family, friends, and colleagues,5 felt uncertainty and stigmatization,5,6 reported reluctance to work or contemplating resignation,6 and reported experiencing high levels of stress, anxiety, and depression symptoms,7 which could have long-term psychological implications.7 Similar concerns about the mental health, psychological adjustment, and recovery of health care workers treating and caring for patients with COVID-19 are now arising.

    Psychological assistance services, including telephone-, internet-, and application-based counseling or intervention, have been widely deployed by local and national mental health institutions in response to the COVID-19 outbreak. On February 2, 2020, the State Council of China announced that it was setting up nationwide psychological assistance hotlines to help during the epidemic situation.9 However, evidence-based evaluations and mental health interventions targeting front-line health care workers are relatively scarce.

    To address this gap, the aim of current study was to evaluate mental health outcomes among health care workers treating patients with COVID-19 by quantifying the magnitude of symptoms of depression, anxiety, insomnia, and distress and by analyzing potential risk factors associated with these symptoms. Participants from Wuhan city (the capital of Hubei province) and other areas inside and outside Hubei province in China were enrolled in this survey to compare interregional differences. This study aimed to provide an assessment of the mental health burden of Chinese health care workers, which can serve as important evidence to direct the promotion of mental well-being among health care workers.

    Methods
    Study Design

    This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. Approval from the clinical research ethics committee of Renmin Hospital of Wuhan University was received before the initiation of this study. Verbal informed consent was provided by all survey participants prior to their enrollment. Participants were allowed to terminate the survey at any time they desired. The survey was anonymous, and confidentiality of information was assured.

    The study is a cross-sectional, hospital-based survey conducted via a region-stratified, 2-stage cluster sampling from January 29, 2020, to February 3, 2020. During this period, the total confirmed cases of COVID-19 exceeded 10 000 in China. To compare the interregional differences of mental health outcomes among health care workers in China, samples were stratified by their geographic location (ie, Wuhan, other regions inside Hubei province, and regions outside Hubei province). Because Wuhan was most severely affected, more hospitals in Wuhan were sampled. Hospitals equipped with fever clinics or wards for COVID-19 were eligible to participate in this survey. A total of 20 hospitals in Wuhan (10 designated by the local government to treat COVID-19 and 10 nondesignated), 7 hospitals in other regions of Hubei province, and 7 hospitals from 7 other provinces with a high incidence of COVID-19 (1 hospital from each province) were included. In total, 34 hospitals were involved. Milestone events during the outbreak of COVID-19 and the duration of this study are presented in the eFigure in the Supplement.

    Participants

    One clinical department was randomly sampled from each selected hospital, and all health care workers in this department were asked to participate in this study. The target sample size of participants was determined using the formula N = Zα2P(1 − P) / d2, in which α = 0.05 and Zα = 1.96, and the estimated acceptable margin of error for proportion d was 0.1. The proportion of health care workers with psychological comorbidities was estimated at 35%, based on a previous study of the SARS outbreak.7 To allow for subgroup analyses, we amplified the sample size by 50% with a goal of at least 1070 completed questionnaires from participants.

    Outcomes and Covariates

    We focused on symptoms of depression, anxiety, insomnia, and distress for all participants, using Chinese versions of validated measurement tools.10-13 Accordingly, the 9-item Patient Health Questionnaire (PHQ-9; range, 0-27),10 the 7-item Generalized Anxiety Disorder (GAD-7) scale (range, 0-21),11 the 7-item Insomnia Severity Index (ISI; range, 0-28),12 and the 22-item Impact of Event Scale–Revised (IES-R; range, 0-88)13 were used to assess the severity of symptoms of depression, anxiety, insomnia, and distress, respectively. The total scores of these measurement tools were interpreted as follows: PHQ-9, normal (0-4), mild (5-9), moderate (10-14), and severe (15-21) depression; GAD-7, normal (0-4), mild (5-9), moderate (10-14), and severe (15-21) anxiety; ISI, normal (0-7), subthreshold (8-14), moderate (15-21), and severe (22-28) insomnia; and IES-R, normal (0-8), mild (9-25), moderate (26-43), and severe (44-88) distress. These categories were based on values established in the literature.10-13

    The cutoff score for detecting symptoms of major depression, anxiety, insomnia, and distress were 10, 7,14 15, and 26, respectively. Participants who had scores greater than the cutoff threshold were characterized as having severe symptoms.

    Demographic data were self-reported by the participants, including occupation (physician or nurse), sex (male or female), age (18-25, 26-30, 31-40, or >40 years), marital status, educational level (≤undergraduate or ≥postgraduate), technical title (junior, intermediate, or senior), geographic location (Wuhan, Hubei province outside Wuhan, or outside Hubei province), place of residence (urban or rural), and type of hospital (secondary or tertiary). The different technical titles of respondents refer to the professional titles certificated by the hospital. Participants were asked whether they were directly engaged in clinical activities of diagnosing, treating, or providing nursing care to patients with elevated temperature or patients with confirmed COVID-19. Those who responded yes were defined as frontline workers, and those who answered no were defined as second-line workers.

    Statistical Analysis

    Data analysis was performed using SPSS statistical software version 20.0 (IBM Corp). The significance level was set at α = .05, and all tests were 2-tailed. The original scores of the 4 measurement tools were not normally distributed and so are presented as medians with interquartile ranges (IQRs). The ranked data, which were derived from the counts of each level for symptoms of depression, anxiety, insomnia, and distress, are presented as numbers and percentages. The nonparametric Mann-Whitney U test and Kruskal-Wallis test were applied to compare the severity of each symptom between 2 or more groups. To determine potential risk factors for symptoms of depression, anxiety, insomnia, and distress in participants, multivariable logistic regression analysis was performed, and the associations between risk factors and outcomes are presented as odds ratios (ORs) and 95% CIs, after adjustment for confounders, including sex, age, marital status, educational level, technical title, place of residence, working position (first-line or second-line), and type of hospital.

    Results
    Demographic Characteristics

    In the study, among the 1830 health care workers (702 [38.4%] physicians and 1128 [61.6%] nurses) asked to participate, 1257 respondents (68.7%) completed the survey. The occupational and geographic data of nonrespondents were similar to those of respondents (eTable 1 in the Supplement). Of the 1257 responding participants, 493 (39.2%) were physicians, and 764 (60.8%) were nurses. The response rates for physicians and nurses were 70.2% and 67.7%, respectively. Of the participants, 760 (60.5%) worked in Wuhan, 261 (20.8%) worked in Hubei province outside Wuhan, and 236 (18.8%) worked outside Hubei province. Most participants were women (964 [76.7%]), were aged 26 to 40 years (813 [64.7%]), were married, widowed, or divorced (839 [66.7%]), had an educational level of undergraduate or less (953 [75.8%]), had a junior technical title (699 [55.6%]), and worked in tertiary hospitals (933 [74.2%]). A total of 522 participants (41.5%) were frontline health care workers directly engaged in diagnosing, treating, or caring for patients with or suspected to have COVID-19. Nearly all participants (1220 [97.1%]) lived in urban areas (Table 1).

    Severity of Measurements and Associated Factors

    A considerable proportion of participants had symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Nurses, women, frontline workers, and those in Wuhan reported experiencing more severe symptom levels of depression, anxiety, insomnia, and distress (eg, severe depression among physicians vs nurses: 24 [4.9%] vs 54 [7.1%]; P = .01; severe anxiety among men vs women: 10 [3.4%] vs 56 [5.8%]; P = .001; severe insomnia among frontline workers vs second-line workers: 9 [1.7%] vs 3 [0.4%]; P < .001; severe distress among workers in Wuhan vs Hubei outside Wuhan and outside Hubei: 96 [12.6%] vs 19 [7.2%] among those in Hubei outside Wuhan and 17 [7.2%] among those outside Hubei; P < .001) (Table 2). Compared with those working in tertiary hospitals, participants working in secondary hospitals were more likely to report severe symptoms of depression (53 [5.6%] vs 25 [7.7%]; P = .003), anxiety (48 [5.1%] vs 18 [5.5%]; P = .046), and insomnia (10 [1.0%] vs 2 [0.6%]; P = .02) but not distress (Table 2).

    Scores of Measurements and Associated Factors

    The median (IQR) scores on the PHQ-9 for depression, the GAD-7 for anxiety, the ISI for insomnia, and the IES-R for distress for all respondents were 5.0 (2.0-8.0), 4.0 (1.0-7.0), 5.0 (2.0-9.0), and 20.0 (7.0-31.0), respectively. Similar to findings in severity of symptoms, participants who were nurses, women, frontline health care workers, and working in Wuhan had higher scores in all 4 scales compared with those who were physicians, men, second-line health care workers, and working in Hubei province outside Wuhan or outside Hubei province (eg, median [IQR] PHQ-9 scores among physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007; median [IQR] GAD-7 scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] ISI scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001; median [IQR] IES-R 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) (Table 3). Compared with health care workers in tertiary hospitals, those in secondary hospitals reported higher scores on scales measuring symptoms of depression, anxiety, and insomnia (median [IQR] PHQ-9 score, 4.0 [1.0-7.0] vs 5.0 [2.0-9.0]; P < .001; median [IQR] GAD-7 score, 3.0 [0-7.0] vs 4.0 [1.0-7.0]; P = .005; median [IQR] ISI score, 4.0 [2.0-9.0] vs 6.0 [2.0-10.0]; P = .008). There were no differences in hospital status for scores of distress (median [IQR] IES-R score: workers in tertiary hospitals, 19.0 [7.0-32.0]; workers in secondary hospitals, 20.0 [6.0-31.0]; P = .46). However, frontline health care workers from tertiary and secondary hospitals reported equally high scores on all 4 scales (eg, median [IQR] PHQ-9 score, 5.0 [2.0-8.0] vs 6.0 [3.0-9.0]; P = .08) (Table 4). In pairwise comparisons, participants from Hubei province outside Wuhan and participants outside Hubei province reported similar levels of symptoms of depression, anxiety, insomnia, and distress but were all lower than that of health care workers in Wuhan, the origin of the epidemic (eTable 2 in the Supplement). Analyses of scores of 3 factors (avoidance, intrusion, and hyperarousal) derived from the IES-R are presented in eTable 3, eTable 4, and eTable 5 in the Supplement.

    Risk Factors of Mental Health Outcomes

    Multivariable logistic regression analysis showed that, after controlling for confounders, being a woman and having an intermediate professional title were associated with severe symptoms of depression, anxiety, and distress (eg, severe depression among women: OR, 1.94; 95% CI, 1.26-2.98; P = .003; severe anxiety among those with intermediate professional titles: OR, 1.82; 95% CI, 1.38-2.39; P < .001). Compared with working in a tertiary hospital, working in secondary hospitals was associated with more severe symptoms of depression (OR, 1.65; 95% CI, 1.17-2.34; P = .004) and anxiety (OR, 1.43; 95% CI, 1.08-1.90; P = .01). Working outside Hubei province was associated with a lower risk of feeling distressed than working in Wuhan (OR, 0.62; 95% CI, 0.43-0.88; P = .008). Compared with working in second-line positions, working in the frontline directly treating patients with COVID-19 appeared to be an independent risk factor for all psychiatric symptoms after adjustment (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; distress: OR, 1.60; 95% CI, 1.25-2.04; P < .001) (Table 5).

    Discussion

    This cross-sectional survey enrolled 1257 respondents and revealed a high prevalence of mental health symptoms among health care workers treating patients with COVID-19 in China. Overall, 50.4%, 44.6%, 34.0%, and 71.5% of all participants reported symptoms of depression, anxiety, insomnia, and distress, respectively. Participants were divided in 3 groups (Wuhan, other regions in Hubei province, and regions outside Wuhan province) to compare interregional differences. Most participants were female, were nurses, were aged 26 to 40 years, were married, and worked in tertiary hospitals with a junior technical title. Nurses, women, those working in Wuhan, and frontline workers reported more severe symptoms on all measurements. Our study further indicated that being a woman and having an intermediate technical title were associated with experiencing severe depression, anxiety, and distress. Working in the front line was an independent risk factor for worse mental health outcomes in all dimensions of interest. Together, our findings present concerns about the psychological well-being of physicians and nurses involved in the acute COVID-19 outbreak.

    In this study, a significant proportion of participants experienced anxiety, depression, and insomnia symptoms, and more than 70% reported psychological distress. In a previous study during the acute SARS outbreak, 89% of health care workers who were in high-risk situations reported psychological symptoms.8 The psychological response of health care workers to an epidemic of infectious diseases is complicated. Sources of distress may include feelings of vulnerability or loss of control and concerns about health of self, spread of virus, health of family and others, changes in work, and being isolated.15 The fact that COVID-19 is human-to-human transmissible,1,3 associated with high morbidity, and potentially fatal16 may intensify the perception of personal danger. Additionally, predictable shortages of supplies and an increasing influx of suspected and actual cases of COVID-19 contribute to the pressures and concerns of health care workers.17

    Of note, 76.7% of all participants were women, and 60.8% were nurses (90.8% of whom were female). Our findings further indicate that women reported more severe symptoms of depression, anxiety, and distress. Frontline nurses treating patients with COVID-19 are likely exposed to the highest risk of infection because of their close, frequent contact with patients and working longer hours than usual.18,19 Moreover, 71.5% of all nurses had junior titles, indicating that most had fewer years of work experience. During the SARS outbreak, a study conducted among health care workers in emergency departments also showed that nurses were more likely to develop distress and use behavioral disengagement than physicians.15 Frontline nurses treating patients with SARS were physically and psychologically challenged when committing themselves to providing high-quality nursing care for patients.19-22 Moreover, at the early stage of the SARS epidemic, nurses may have been less likely to be warned about exposure or provided with adequate protections.22 Particular attention is warranted regarding the mental health well-being of women and nurses treating patients with COVID-19.

    Another finding in our study was that, compared with those in Hubei province outside Wuhan and those outside Hubei province, health care workers in Wuhan reported more severe symptoms of depression, anxiety, insomnia, and distress. Multivariable logistic regression analysis showed that working outside Hubei province was associated with lower risk of experiencing distress. These findings indicated more stress among health care workers in Wuhan, the origin and epicenter of the epidemic in China. In addition, working as a frontline health care worker with direct engagement of patients with COVID-19 was an independent risk factor for all symptoms. As frontline health care workers in Wuhan were at especially high risk for symptoms of depression, anxiety, insomnia, and distress, their mental health may require special attention.

    Limitations

    This study has several limitations. First, it was limited in scope. Most participants (81.2%) were from Hubei province, limiting the generalization of our findings to less affected regions. Second, the study was carried out during 6 days and lacks longitudinal follow-up. Because of the increasingly arduous situation, the mental health symptoms of health care workers could become more severe. Thus, long-term psychological implications of this population are worth further investigation. Third, this study was unable to distinguish the association of symptoms with being a clinician in this region vs simply living in this region (because there was no comparator group) and was also unable to distinguish preexisting mental health symptoms vs new symptoms. Fourth, although the response rate of this study was 68.7%, response bias may still exist if the nonrespondents were either too stressed to respond or not at all stressed and therefore not interested in this survey.

    Conclusions

    In this survey study of physicians and nurses in hospitals with fever clinics or wards for patients with COVID-19 in China, health care workers responding to the spread of COVID-19 reported high rates of symptoms of depression, anxiety, insomnia, and distress. Protecting health care workers is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented, with women, nurses, and frontline workers requiring particular attention.

    Back to top
    Article Information

    Accepted for Publication: March 2, 2020.

    Published: March 23, 2020. doi:10.1001/jamanetworkopen.2020.3976

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Lai J et al. JAMA Network Open.

    Corresponding Authors: Zhongchun Liu, MD, Department of Psychiatry, Renmin Hospital of Wuhan University, 238 Jiefang Rd, Wuhan 430060, China (zcliu6@whu.edu.cn); Shaohua Hu, MD, Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, Hangzhou 310003, China (dorhushaohua@zju.edu.cn).

    Author Contributions: Drs Liu and S. Hu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Lai, Ma, and Y. Wang contributed equally and share first authorship. Drs Liu and S. Hu contributed equally as senior authors.

    Concept and design: Liu, S. Hu.

    Acquisition, analysis, or interpretation of data: Lai, Ma, Y. Wang, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang.

    Drafting of the manuscript: Lai, Ma, Y. Wang, Liu, S. Hu.

    Critical revision of the manuscript for important intellectual content: Lai, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang, Liu, S. Hu.

    Statistical analysis: Ma, Y. Wang, Liu, S. Hu.

    Obtained funding: Liu, S. Hu.

    Administrative, technical, or material support: Lai, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang.

    Supervision: G. Wang, Liu, S. Hu.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by grants 2018YFC1314600 and 2016YFC1307100 from the National Key Research and Development Program of China.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank all the participants who contributed to our work.

    References
    1.
    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
    2.
    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
    3.
    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
    4.
    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)
    5.
    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
    6.
    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
    7.
    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
    8.
    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
    9.
    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
    10.
    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
    11.
    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
    12.
    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
    13.
    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
    14.
    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
    15.
    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
    16.
    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
    17.
    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
    18.
    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
    19.
    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
    20.
    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
    21.
    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
    22.
    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
    ×