This cross-sectional study included a total of 3,461 HCW of which 352 were ICU HCW during the first wave of the COVID-19 crisis. Among ICU HCW, 41% had low well-being, 46% had anxiety symptoms, 46% had symptoms of depression and 22% had peritraumatic distress. Scores for risk of depression, anxiety and low well-being were statistically more pathological in the ICU than in other hospital units. A change in lifestyle factors was also highlighted with an increase in alcohol consumption and a modification of eating and sleeping habits among ICU HCW. In the entire studied population (ICU and non-ICU HCW), several factors were found to be associated with symptoms of anxiety, depression, peritraumatic distress and low well-being: being female, the fear of catching and transmitting COVID-19, anxiety of working in contact with COVID-19 patients, being overloaded with work, eating less, increased alcohol consumption and sleeping disorders.
With regard to anxiety and depression among ICU HCW, the present study confirms the findings of several studies conducted during the pandemic reporting a prevalence of anxiety ranging from 48 to 50.4% and depression ranging from 16 to 30.4% among ICU HCW [6, 8]. Comparison with these studies’ results should be made with caution as different scores were used. Many factors may explain the high prevalence of depression and anxiety symptoms described in ICU HCW during this crisis. Firstly, the high rate of anxiety could be explained by the fact that COVID-19 appeared unpredictable and potentially lethal. HCW were exposed to this uncertainty which not only concerned their patients, but themselves as well, making them feel powerless. Secondly, the media coverage of the events with the announcement in February 2020 of more than 3000 caregivers infected with COVID-19 in China could have been a source of stress for HCW [20]. Thirdly, during this first wave of COVID-19, the HUG mainly treated COVID-19 patients while patients with other pathologies were hospitalized in the surrounding hospitals. This distribution could have been a source of anxiety and depression for HCW who were continuously exposed to this extreme situation. No differences in the symptoms of anxiety and depression by occupational category were highlighted in our study. This might be explained by the fact that in our hospital, the staff that had been widely recruited has made it possible to maintain good working conditions with an average of one nurse for every two patients in the ICU. Studies [6, 11] describing a more important role of anxiety and depression in nurses did not mention this type of information thus making this interpretation harder to ascertain.
We assessed peritraumatic distress in ICU HCW because we suspected that the COVID-19 pandemic would potentially expose them to traumatic events [21], such as numerous and unpredictable deaths [22]. Our study showed that 22% of ICU HCW displayed peritraumatic distress. Peritraumatic distress, which is defined as the emotional and physiological distress experienced during and immediately after a traumatic event, is a known risk factor of developing PTSD one month after a traumatic event [14]. Indeed, a French study observed that 27% of ICU HCW experienced PTSD in the context of the pandemic [6]. These results highlight the important risk of PTSD for ICU HCW and the need to implement preventative measures to support them. Protective factors for PTSD include good coping strategies in stressful situations, primary prevention, training before a traumatic event and positive social support following a traumatic event [23, 24].
Another objective of our study was to assess whether ICU HCW had suffered more from the pandemic compared to non-ICU HCW. Indeed, we showed that ICU HCW had more symptoms of anxiety, depression and lower well-being. The ICU is known to be a difficult work environment due to heavy workloads, exposure to critically ill patients, daily confrontation with death and irregular working hours [10]. Even outside major crises, ICU HCW have been shown to be more prone to anxiety and depression compared to staff from other units [10, 25]. During catastrophic situations, ICU HCW tend to leave their needs aside to meet the needs of patients [6]. In an already stressful work environment, poorer mental health outcomes can be expected to be exacerbated by the stress caused by the pandemic with many unknowns, the fear of catching and transmitting the virus, the high influx of patients, the fear of not having enough resources and changes in work habits. However, unlike what might have been expected, no significant difference was found in peritraumatic distress between ICU HCW and non-ICU HCW. As the exposition to traumatic events of unexpected and numerous deaths occurred in all hospital units and not only in the ICU, this could explain the lack of difference in peritraumatic distress between the two groups. A feature of our study was to include a significant rate of “other workers” (41% of our total sample), such as administrative workers, while other studies disregarded this population. Interestingly, a sensitivity analysis showed that this group of workers [over-represented in non-ICU (44%) vs. ICU (15%)] did not influence the differences observed in mental health and well-being outcomes between ICU and non-ICU HCW.
The present study showed important changes in lifestyle behavior in HCW and ICU HCW appeared to have increased their alcohol consumption more than non-ICU HCW. Studies have shown that exposure to traumatic events, such as terrorist attacks, natural events or in this case the COVID-19 outbreak, is associated with increased alcohol consumption [26]. This has also been shown in the general population where an increase in stress-related alcohol consumption during the COVID-19 pandemic has been highlighted [27]. To the best of our knowledge, we are the first to raise this point in HCW in the context of the pandemic and to show its association with more anxiety, depression, peritraumatic distress and low well-being in this setting. The potential for alcohol abuse by exposed HCW must be recognize as it may have implications for their physical health and should be followed up.
Another objective was to identify risk factors for worse mental health outcomes in all the HCW (ICU and non-ICU). Our study significantly showed that ICU HCW suffered more psychologically than non-ICU HCW. Interestingly, after adjustment for socio-demographic variables and lifestyle behaviors, working in the ICU was no longer an independent predictor of poor mental health outcomes. However, we were able to identify several independent risk factors for poor mental health outcomes in all the HCW (ICU and non-ICU). These factors were classified into 5 categories. (1) socio-demographic factors: female have been found to have more anxiety, depression and peritraumatic distress in our study, which is an already known risk factor even outside the coronavirus outbreak [5, 7, 11]. (2) Working environmental factors: as previously described in a French study, being overworked was associated with poorer mental health outcome [28]. A strategy that allows for break times and balanced work schedule could help control this factor. (3) Somatic symptoms: sleep disorders and changes in eating habits among HCW were associated with poor mental health outcomes in the context of the COVID-19 crisis. Indeed, several studies have identified sleeping disorders in frontline HCW during the pandemic [11, 29]. (4) Consumptions: our results show that increased alcohol consumption has been found to be independently associated with poor mental health outcome. (5) Fear towards COVID-19: we were able to identify specific risk factors in the context of this pandemic and found that being afraid of catching, transmitting or working with COVID-19 patients was associated with higher anxiety, depression and peritraumatic distress. As raised in the Azoulay et al. study, fear leads to general discomfort, fatigue and difficulty in decision-making [8]. Since the feeling of fear among HCW was frequently reported in several studies, providing regular, accurate and detailed information on the virus, its mode of transmission and associated protective measures, seems crucial [6, 8, 20]. This study reinforces the knowledge on factors associated with poor mental health outcomes during the COVID-19 crisis. In light of these considerations, hospital managers should be able to pay particular attention to HCW at risk [8, 11, 12, 29].
Some limitations in our study need to be acknowledged. The cross-sectional design of our study does not allow us to infer causality between the factors studied and the psychic symptoms, but only to find an association. Only 25% of the total HCW responded to the study questionnaire and a selection bias is therefore possible; however, the response rate was high among ICU HCW (69%). Another limitation was our inability to assess psychiatric history or previous trauma. The study was monocentric; however, the HUG is a large hospital consortium comprising eight different sites. Finally, we did not further assess ICU HCW to differentiate between back-up ICU HCW and usual ICU HCW.
