Background: Since the outbreak of the COVID-19 pandemic, the anesthesiologists are involved in the riskiest interventions e.g. airway management, and resuscitation. So, they are subjected to a higher risk of infection compared to other medical specialties. This study aimed to assess the level of anxiety, depression, and post-traumatic stress disorder during COVID-19 pandemic among anesthesiologists.
Methods: This is a cross-sectional, hospital-based survey conducted after getting IRB approval. The primary outcomes are to evaluate the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) among anesthesiologists working in Saudi Arabia. The secondary outcomes include the association of the socio-demographic and occupational characteristics with mental health in the study sample. The survey sent to the target participants using a web-based software platform (https://www.surveymonkey.com/r/ZJ98BTJ) though the Saudi Society of Anesthesia. The study sample included anesthesiologists and their allied health care providers (nurses and technicians) involved in the management of COVID-19 patients. Data were analyzed using SPSS version 21. Descriptive analyses were conducted, and the ranked data for each level for symptoms of depression, anxiety, and PTSD were presented as numbers and percentages. Multi-variable logistic regression analysis was used to explore potential influence factors on the outcomes. P-values of less than 0.05 were considered statistically significant.
Results: The survey sent to (1024) anesthesiologists and anesthetists, through the Saudi Anesthesia Association (SAS). A total number of 347 participants involved in the survey with a response rate (33.887%), while 296 of them completed the survey and included in the statistical analysis. Males represented (71.3%) of the sample, Saudis (58.8%), two-thirds aged 30-50 years, (83.4%) were married, physician anesthesiologists represent (81.3%). The prevalence of PTSD, anxiety, and depression among the included sample were (25.3%, 29.4%, and 30.7%) respectively. The following factors were associated with a higher prevalence of psychological stress: age categories below 40 years, being unmarried, those having relatives diagnosed with COVID-19, unsatisfied by the safety measures, smoking habits, and among female gender compared to males. Also, the prevalence of stress was higher among resident anesthetists compared to the nurses, technicians, and consultants. The association of psychological outcomes and other factors were inconsistent.
Conclusion: According to the results of the survey, being a frontline health care providers, dealing with the COVID-19 patients, there is a growing risk of experiencing more psychological burden. Special care should be taken to protect the mental health and promote the mental well-being of anesthesiologists exposed to COVID-19.
COVID-19 pandemic, Anesthesiologists and anesthetists, Psychological stress, Anxiety, Depression, Post traumatic stress disorder (PTSD)
COVID-19: Coronavirus Disease; PTSD: Post-Traumatic Stress Disorder; IRB: Institutional Review Board; SAS: Saudi Anesthesia Society; KSMC: King Saud Medical City; SARS: Severe Acute Respiratory Syndrome; STROBE: Strengthening The Reporting of Observational Studies in Epidemiology
Since the outbreak of COVID-19 in China a few months ago, followed by the wide and rapid spread of COVID-19 in other countries, millions of people became infected and several hundred thousand died. COVID-19 is characterized by its unambiguous capacity of person-to-person transmission . Many of the healthcare practitioners became infected and even died as well. As a result, the levels of stress, anxiety, and depression were further increased among health care providers.
Special considerations are taken with those on the front-lines e.g Anesthesiologist, ICU, emergency department, and infectious diseases practitioners are more subjected to the risk more than the others. It is known that the anesthetists are usually involved in the riskiest interventions e.g. airway management, endotracheal intubation, and resuscitation. So, they are subjected to a higher risk of infection compared to many other medical specialties. The new and re-emerging infectious diseases, as evidenced by the novel corona virus disease (COVID-19) pandemic is threatening not only public health but also psychological health, particularly among healthcare workers [1-5].
Up till now, there is no study in the Gulf Region assessed the impact of COVID-19 on the psychological status of the healthcare providers working in the front-line such as the Anesthetists. Also, the survey is conducted for the staff working in the same country where the risks, roles, guidelines, and health care services are at the same level for all the community including the hospitals and the health care providers.
In light of the limited data available for COVID-19-related psychological impact on health care workers. This study may help to understand the nature and determinants of the psychological stress among anesthesiologists and the allied health care providers during a period of high stress such as a pandemic outbreak.
The aim of this observational cross-sectional study is to assess the level of anxiety, depression and posttraumatic stress disorders (PTSD) among the anesthesiologists and their allied health care providers during the time of the COVID-19 pandemic in Saudi Arabia.
This study was approved by the IRB committee, College of Medicine, King Saud University (IRB approval of research project No. E-20-4975). The survey, including the consent was available in an electronic format for all participants and this format was approved by the IRB Committee. The consent form was included on the first page of the survey explaining the purpose of the survey and participants were asked to voluntarily fill the questionnaires after through reading of the consent form. All data are collected anonymously. The survey was conducted from (1-20 June 2020). The targeted participants were anesthesiologists and the allied healthcare workers (e.g., anesthesia nurses and technicians) who were working in hospitals and caring for patients with COVID-19 in Saudi Arabia.
The study is across-sectional, hospital-based survey design by using an anonymous online questionnaire. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) were followed to report the study results .
Anesthesiologists, anesthesia technicians and anesthesia nurses in the hospitals involved with the managements of COVID-19 were invited to participate in the survey, through the Saudi Society of Anesthetists by emails and/or WhatsApp.
Participants within the age group between (18 - 60 years old) were included in this study. Participants outside Saudi Arabia during the time of the COVID-19 pandemic were excluded.
A convenient sampling technique was followed. The online survey was distributed to the Head of the departments from different hospitals through the Saudi Society of Anesthetists (SAS). The following formula used to calculate the size of the required sample n = (z)2 p (1 - p) / d2, z = level of confidence (at level of confidence of 95%, z = 1.96), d “the estimated acceptable margin of error for population proportion” = 0.1, and p = expected proportion of health care workers with psychological comorbidities was considered 57% based on a previous study during the SARS outbreak . The estimated minimal sample size was 196 which was increased to 296 to compensate for incomplete data .
The primary outcome is to assess the prevalence of anxiety, depression, and PTSD among anesthesiologists and the allied healthcare workers (e.g., anesthesia technicians and nurses) in Saudi Arabia during the time of COVID-19 pandemic.
While the secondary outcomes include the association of the socio-demographic and occupational characteristics with anxiety, depression, and PTSD in the study sample, for example, gender, occupations, marital status, age group, working hours, and safety measures.
Participants’ demographic and occupational variables such as gender, age, years of experience, educational degree, position at the hospital, unit of work and hospital type.
Outcome variables: The prevalence of anxiety, depression, and PTSD.
Study data were collected using a secure, web-based software platform; Internet survey monkey . Multiple methods were used to encourage survey responses such as individual personalized email invitations, multiple reminders to increase the response rate.
The survey can be accessed through; https://www.surveymonkey.com/r/ZJ98BTJ
Questionnaires/data Sheets from other authors (Copyrights or permission to use, or open access for academic and research purpose).
The depression and anxiety were assessed by using the ultra-brief screening scale of Patient Health Questionnaire-4 (PHQ-4) . The tool contains four items, two for the evaluation of anxiety derived from the first two items of Generalized Anxiety Disorder scale (GAD-7) and two for the evaluation of depression derived from the first two items Patient Health Questionnaire scale (PHQ-9), the scale is available for free to users. The self-reported questionnaire requires respondents (Over the last 2 weeks) to rate on a four-point scale ranging from 0 (Not at all) to 3(Nearly every day). The total maximum sum score = 0-12 points, six for anxiety and six for depression. PHQ-4 proved to be an instrument with good psychometric properties [11-16]. The Instrument has been used extensively in research and clinical settings, with a range of populations. The tool shows a good reliability and validity among occupational healthcare workers [17-19]. The cut point ≥ three suggests clinically significant anxiety and depression [12,13].
The psychological distress of the outbreak will be assessed using the Impact of Event Scale-Revised Questionnaires (IES-R) [20,21]. The 22-item self-administered instrument designed to measures the subjective distress after exposure to stressful circumstances, within one week of exposure. The response format of IES-R consists of a 5-point Likert rating scale from 0 to 4 (0 - Not at all, 1 - A little bit, 2 - Moderately, 3 - Quite a bit, 4 - Extremely). The total score has a range of (0 to 88). The instrument has demonstrated good psychometric properties [20,22]. The IES-R has been used to assess the psychological impact of the outbreak on general population [1,23] and Health Care Workers [24-26]. The total IES-R score was graded for severity from normal (0-23), mild (24-32), moderate (33-36), and severe psychological impact (> 37), and the cutoff score to diagnose any level of PTSD was ≥ 34 points [1,22,23].
Data were analyzed using SPSS Version 21. Descriptive analyses were conducted to describe demographic characteristics. The ranked data, which were derived from the counts of each level for symptoms of depression, anxiety, and PTSD were presented as numbers and percentages. The original scores of the 3 outcomes were presented as medians and interquartile range (IQR). Multivariable logistic regression analysis was used to explore potential factors associated with the outcomes of mental health, namely PTSD, anxiety, and depression, such as sex, age, marital status, educational level, Job title and type of hospital, etc. P-values of less than 0.05 were considered statistically significant (2-sided tests).
The survey sent to (1024) anesthesiologists and anesthetists, through the Saudi Anesthesia Association (SAS) by emails and/or WhatsApp. The invited participants represented the healthcare providers working in Riyadh Hospitals and dealing with COVID-19 patients. A total number of (347) were responded to the survey within the allowed duration, with a response rate of (33.887%). Fifty-one (51) participants were excluded from the statistical analysis because of incomplete data, while a total number of 296 participants were included in the study and the statistical analysis. Participants’ characteristics such as age, gender, nationality, marital status, etc. are summarized in Table 1. Males amounted to (71.6%) of the total sample, the proportion of non-Saudis (58.8%) exceeds that of the Saudis, about two-third of respondents aged 31-50 years, and in total (83.4%) were married. Physicians' anesthesiologists (81.4%) outnumbered allied healthcare workers. As much (83.1%) of respondents worked in tertiary hospitals, and more than (85%) had working experience for more than five years. About half of the respondents worked 20-44 hours/ week, and more than one-third worked ≥ 45 hours/ week.
Table 1: Baseline characteristics of the study sample (N = 296). View Table 1
Prevalence of PTSD, anxiety, and depression among the included sample were (25.3%, 29.4%, and 30.7%) respectively (Table 2). In bivariate analysis, the following factors were significantly associated with a higher prevalence of two or more psychological outcomes: age categories below 40 years, being unmarried, working in secondary hospitals, having a relative or a friend diagnosed with COVID-19, dissatisfaction with safety measure, feeling stigmatized, and smoking more or started smoking during the pandemic (Table 2). For example, PTSD, anxiety, and depression were about three times more likely among those feeling stigmatized and about two times more likely if respondents were unsatisfied with the safety measures. Regarding the nationality, the prevalence of PTSD and anxiety were significantly higher in Saudis compared to non-Saudis, while the prevalence of depression was slightly higher in non-Saudis compared to Saudis.
Table 2: Factors associated with mental health using bivariate analysis in a sample of anesthesiologists and allied healthcare workers (N = 296). View Table 2
Moreover, our results showed a significantly higher prevalence of PTSD, anxiety and depression in females (35.7%, 36.9%, and 38.1%) versus (21.2%, 26.4%, and 27.8%) respectively in males.
In the three psychological outcomes, working experience less than 15 years was more likely associated with higher prevalence, yet the result was only significant in anxiety for those whose working experience was less than 11 years. Despite working hours per week for more than 20 hours per week was more likely associated with higher prevalence of the three psychological, yet the result was not statistically significant.
Of note, the prevalence of PTSD, anxiety, and depression was higher among physician anesthesiologists compared to the allied health workers, yet the result was only significant in anxiety. The burden of the three psychological outcomes was less likely among those living without families, but the difference was only significant in depression. The odds of PTSD and anxiety was significantly higher in singles.
The adjusted analysis confirmed that dis-satisfaction and feeling stigmatized increased the risk of the three psychological outcomes by more than 200%. Despite, physician anesthesiologists, respondents working for extended hours and respondents having contact with COVID-19 infected family members or friends were more likely to have PTSD, anxiety, and depression, yet the result was not statistically significant (Table 3). However, the median score of PTSDs, as well that of the intrusion, avoidance and hyperarousal subdomains were higher in physicians compared to nurses and technicians (Figure 1). The same finding was also noted for anxiety and depression (Figure 2). In addition, severe levels of the three psychological outcomes were higher in physicians, with residents were the highest of all. For example, severe levels of PSTD, anxiety and depression were 32.9%, 17.3%, and 10% respectively in residents compared to 12.7%, 7.3%, and 1.8% in nurses and technicians (Figure 3, Figure 4 and Figure 5).
Figure 1: Median and Inter quartile range of post-traumatic stress disorder (PTSD) scores by profession.
PTSD is measured by IES-R, maximum score is 88, maximum scores of intrusion subdomain = 32, avoidance = 32, and hyperarousal = 24. View Figure 1
Figure 2: Median and Inter quartile range of anxiety and depression scores by profession.
Anxiety and depression were measured by Patient Health Questionnaire-4 (PHQ-4). The total maximum score of anxiety and depression is 6. View Figure 2
Figure 3: Prevalence of PTSD according to the level by profession.
PST is measured by IES-R, the total IES-R score was graded for severity from normal (0-23), mild (24-32), moderate (33-36), and severe psychological impact (> 37). View Figure 3
Figure 4: Prevalence of anxiety according to the level by profession.
Anxiety is measured by Patient Health Questionnaire-4 (PHQ-4). The total score was graded for severity from normal (0), for several days (1-2), more than half days (3-4), and nearly every day (> 4). View Figure 4
Figure 5: Prevalence of depression according to the level by profession.
Depression is measured by Patient Health Questionnaire-4 (PHQ-4). The total score was graded for severity from normal (0), for several days (1-2), more than half days (3-4), and nearly every day (> 4). View Figure 5
Table 3: Logistic regression analysis of factors associated with mental health in a sample of anesthesiologists and allied healthcare workers (n = 296). View Table 3
This study looked at the psychological responses of the anesthesia physicians, technicians, and anesthesia nurses who are working in hospitals and involved with the management of COVID-19 patients. The survey was conducted on anesthetists working within one country; where the roles, regulations, facilities as well as the resources are more or less similar within the different regions of the same country. So that all the healthcare providers are working within the same levels of safety profiles and environments.
This cross-sectional survey enrolled 296 respondents. Overall, PTSD, anxiety, and depression were identified in 25.3%, 29.4%, and 30.7% respectively of respondents. The results indicated that the prevalence of mental health symptoms was higher in higher in those who are dis-satisfaction with preventive and safety measures and feeling stigmatized. In addition to those respondents working for extended hours and those who are in contact with COVID-19 infected family member or friend. Whilst the prevalence was lower in consultants, and anesthesia nurses and technicians.
A similar study conducted in China and included (1,257) healthcare providers on the frontline medical workers dealing with the COVID-19 coronavirus in (34) Chinese hospitals and were experiencing psychological burden reported by most of the respondents. According to the study, a large portion reported suffering from the various psychological burden. This includes the prevalence of distress in 71.5%, anxiety 44.6%, depression 50.4%, and finally, insomnia 34% . When comparing these results versus the results of our survey, it appears that the psychological stress among healthcare providers working in China was significantly higher than that in Saudi Arabia. This may reflect the severity of the pandemic in China especially among those who worked in Wuhan City and represented a significant percentage of the included participants (60.5%). Additionally, a Chinese survey was conducted before recent declines in positive tests for the virus.
Another survey conducted in the USA demonstrated that a vast majority of physician respondents were concerned about the virus affecting them or their patients directly. The survey also showed that about (96%) of the physician were reported high levels of stress as a response of the COVID-19 pandemic in the USA. Despite this high level of stress, the U.S. survey was performed before the pandemic had fully taken hold of the country. This is partly explained by the higher levels of dis-satisfactions of the US physicians by the steps and safety measures in the country as a whole and US hospitals specifically . On the other hand, the lower levels of stress among anesthesiologists in our survey compared to both China and USA surveys may be explained partly by the strong safety measures and management protocols in Saudi Arabia.
Our findings showed that the anesthesia assistance (anesthesia nurses) have lower prevalence of psychological stress. This was consistent with a recent study conducted in Singapore  and compared the three components of the psychological outcomes in both health care providers working in the frontline versus non-medical health care providers. Interestingly, this study showed that nurses working in the front line demonstrating lower scores than non-front line nurses. Reasons for that may be attributed to less accessibility to formal psychological support, less-first hand medical information on the outbreak, and less intensive training on infection control measures. In addition. Anesthesia nurses were not involved directly in the high-risk procedure such as intubation, and their role mainly preparation.
In contrast to earlier finding [24,28] our results showed that being a physician had higher level anxiety, depression, PTSD comparing with nurses and other health workers. Our results have been found to be consistent with previous studies conducted during the SARS epidemic in Singapore  Taiwan  which reported that the physicians developed mental symptoms, had more somatic symptoms and suffer from a psychiatric disorder more than nurses and other health workers.
In a large academic hospital in New York City with available personal protective equipment, 15% of the surveyed physicians reported COVID-19-like symptoms that they attributed to a work-related exposure, and COVID-19 antibodies were found in 12% of tested participants. Depending on these results and similar studies, it appears that protecting first-line healthcare providers against work-related COVID-19 infection at the onset of the pandemic has been a crucial challenge. Anesthesiologists in particular are considered at risk, since aerosol-generating procedures, such as airway managements and resuscitation, have been shown to significantly increase the odds for respiratory infections during severe acute respiratory syndrome outbreaks .
Our study showed that 47.6% of participants felt stigmatization and rejection from their neighborhood and friends. Interestingly it has found stigma to be related to distress, depression, and anxiety. Previous experience with epidemics has shown that the stigma caused by SARS and MERS-CoV are associated with psychological distress among healthcare providers [31,32].
Health workers who had family or friends who were infected with COVID-19, had substantially more anxiety and depression and distress symptoms than those without these experiences. Our results are consistent with the results of previous studies in SARS-affected, H1N1 influenza-affected and COVID-19 infected hospitals [33-35].
Our research has found that working for extended hours during pandemic is positively related to PTSD, anxiety, and depression. In the organizational behavior literature, the workload has been conceptualized to have negative impact on physical and psychological status of employee. Subsequently, the levels of psychological abnormalities expected to be exacerbated with greater levels of perceived COVID-19 threat [36,37].
In particular, in this group of workers, the level of PTSD, anxiety and depression were higher among residents compared with consultants. This is consistent with previous studies which reported those who have fewer years of work experience are at increased risk for psychological distress such as, post-traumatic stress disorder (PTSD), depression, and/or anxiety as a result of their perceived risk of infection [38,39]. This findings can be explained that the young medical staff, have less experience in the field and more in direct involvement with the treatment of a suspected and confirmed cases. Therefore, when they suddenly encounter such sudden public health events, they tend to suffer mental problems.
Factors associated with mental health in our survey showed significantly higher prevalence among age categories below 40, being unmarried, working in secondary hospitals, having a relative or friend diagnosed with COVID-19, dissatisfaction with safety measure, feeling stigmatized, and smoking habit. Also, gender difference showed a significantly higher prevalence of the three psychological outcomes in females compared to males. Being a woman with an intermediate professional title was associated with severe symptoms of depression, anxiety, and distress.
The Chinese study also showed that working on the frontline of the pandemic was an independent risk factor across all cohorts. While the respondents from the same study showed a significant association of psychological stress and some socio-demographic factors. This was more or less comparable to the results of our survey, such as the prevalence of the psychological stress was found in (64.7%) among the age groups between (26 and 40 years old), (76.7%) among women, (60.8%) among nurses, and (39.2%) among physicians .
The contrary, one of the important difference from our study showed that the prevalence of the psychological stress among nurses were significantly lower than physicians in our survey compared to the Chinese survey . This reflects the major roles and the hard work that placed on the nurses in China, especially those working in Wuhan City during the COVID-19 pandemic compared to the roles of the nurses in our region. Due to the overwhelming pandemic, the nurses in Wuhan hospitals taken major roles, and responsibilities as well as working for a prolonged and continuous shift.
One of the limitations of this survey that it was conducted once and earlier during the peak of the pandemic and it will be better if repeated after a few weeks and few months following the decline of the pandemic. Another limitation of this survey that the results may not reflect the actual situation, where the non-respondents may be too stressed or not able to complete this survey. Moreover, the measures of psychological symptoms used in this study may be vulnerable to inherent bias because of their self-reported nature.
The outbreak of COVID-19 threatens not only public health but also psychological health, particularly among healthcare workers and those working on the frontline. Being a frontline healthcare provider, dealing with the COVID-19 coronavirus, anesthesiologists reported significant psychological burden. At the same time, this is the first survey in the Gulf Region that assessed the level of stress among the anesthesiologists. Therefore, it enables healthcare leaders and organizations to provide the appropriate supportive measures and may benefit the planning for future outbreaks. In addition, special care should be taken to protect the mental health in health care workers exposed to COVID-19 need to be immediately implemented. As the pandemic evolves, special care should be taken to the most vulnerable group such as women, nurses, and junior anesthesiologists working in the high-risk infected areas.
Salah N El-Tallawy: This author contributes to the conception, study design, tools development, data collection, as well as data analysis and interpretation of results in addition to development of the manuscript.
Maher A Titi: This author contributes to the conception, study design, tools development, and interpretation of results, in addition to development of the manuscript.
Abdelaziz A Ejaz: This author helped in the study design, contributes to data collection, in addition to review of the manuscript.
Ahmed Abdulmomen: This author helped in the study design, contributes to data collection, in addition to review of the manuscript.
Hala Elmorshedy: This author helped in data analysis, interpretation of data for the work, and interpretation of the results
Jumana Baaj: This author helped in the study design, contributes to data collection, in addition to review of the manuscript.
Mohamed Alharbi: This author helped in contribution to data collection, in addition to review of the manuscript.
Ahmad Alqatari: This author helped in contribution to data collection, in addition to review of the manuscript.
None for all authors.
None for all authors.