Psychological impact of disease outbreaks on healthcare workers: A narrative review

Shweta Sunil; Manoj Kumar Sharma

doi:10.4103/IJCFM.IJCFM_112_20

REVIEW ARTICLE

Year : 2022 | Volume : 8 | Issue : 1 | Page : 5-8

Psychological impact of disease outbreaks on healthcare workers: A narrative review

Shweta Sunil¹, Manoj Kumar Sharma²
¹ Department of Psychology, CMR University, CMR Groups of Institution, Bengaluru, Karnataka, India
² Department of Clinical Psychology, Service for Healthy Use of Technology Clinic, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India

Date of Submission	26-Sep-2020
Date of Acceptance	09-Mar-2022
Date of Web Publication	30-Jun-2022

Correspondence Address:
Manoj Kumar Sharma
Department of Clinical Psychology, Service for Healthy Use of Technology Clinic, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCFM.IJCFM_112_20

Abstract

Disease outbreaks can have an impact on one's mental health. A comprehensive knowledge about the psychological state of healthcare workers (HCWs) during disease outbreak is limited. This review aims to present HCWs' psychological issues due to multiple outbreaks in the past and present, including SARS, MERS, Ebola, and COVID-19. The results indicated the presence of affective symptoms, paranoia, and decreased trust among HCWs. The review reveals the need of research to understand strategies and interventions that can enhance the well-being of HCWs.

Keywords: Disease outbreak, healthcare workers, psychological issues

How to cite this article:
Sunil S, Sharma MK. Psychological impact of disease outbreaks on healthcare workers: A narrative review. Indian J Community Fam Med 2022;8:5-8

How to cite this URL:
Sunil S, Sharma MK. Psychological impact of disease outbreaks on healthcare workers: A narrative review. Indian J Community Fam Med [serial online] 2022 [cited 2022 Nov 27];8:5-8. Available from: https://www.ijcfm.org/text.asp?2022/8/1/5/349377

Introduction

The psychological impact of epidemics or pandemics on the public has been largely explored. Epidemics such as severe acute respiratory syndrome (SARS), Ebola, H1N1, and Middle East respiratory syndrome (MERS) have had a significant impact on the public,^[1] with people showing symptoms of panic, anxiety, depression, stress, hypochondriasis, and cyberchondriasis amid a pandemic. Considering the present COVID-19 pandemic, studies have substantiated that the public has shown increased anxiety,^[2] depression,^[3] phobias and obsessive–compulsive disorder (OCD),^[4] acute stress and posttraumatic stress disorder (PTSD),^[5] health anxiety, and cyberchondriasis.^[1] However, another emerging concept in this pandemic is the understanding of psychological distress among healthcare workers (HCWs). Healthcare professionals have also been seeking to psychological therapy, taking breaks using hobbies and music, looking for greater communication within the team, and looking for peer support to cope with anxiety and depression due to COVID.^[6] There is no available review which has addressed the effects across epidemics and pandemics. The present narrative review strengthens the understanding of the psychological impact of the epidemics and pandemics on HCWs and its implications for improving their resilience.

Material and Methods

This narrative review was used to understand the effects of disease outbreaks such as SARS, Ebola, MERS, and COVID-19 on HCWs. Research papers explored using various search engines such as PubMed, NCBI, ResearchGate, Google Scholar, and RefSeek.

Inclusion criteria

The review included all the studies published between 2004 and 2020. The keywords such as psychological impact, disease outbreaks, healthcare workers, hospital employees, Ebola, SARS, and COVID-19 were used.

Exclusion criteria

Dissertations, pilot/protocol/prototype studies, and studies published in a language other than English were excluded.

Study selection and data extraction

To assist in the database screening for inclusion criteria, Rayyan software was used.^[7] All the articles were reviewed, and those articles that did not meet the inclusion criteria were excluded. Cross-referencing of the excluded and selected studies was done by agreement of the co-authors.

A total of 34 papers were found as a result of the search. Identified studies were independently reviewed for eligibility in a two-step process: a first screening was performed based on the title and abstract, and then, full-texts were retrieved for a second screening. At both stages, data were extracted based on the inclusion criteria.

Results

The common effects of disease outbreaks were of stress and Post Traumatic Stress Disorder (PTSD), anxiety and depression, and health anxiety. Other additional findings were the prevalence of Obsessive Compulsive Disorder (OCD), fatigue, loss of sleep, and paranoid ideation.

Stress and posttraumatic stress disorder

During disease outbreaks, HCWs have been found to be stressed and have PTSD as evident in multiple studies. During the SARS outbreak, the stress and PTSD levels among high-risk HCWs were much higher than those among low-risk HCWs, and other findings indicated that doctors were 1.6 times more likely to manifest PTSD symptoms than other HCWs.^{[8],[9],[10],[11],[12]} Other research found that approximately 11% of HCWs in a nursing community hospital had signs of stress reaction syndrome (anxiety, depression, somatization, and hostility),^[13] PTSD symptoms, and increased alcohol consumption.^[14] During the SARS epidemic, HCWs also had intrusive symptoms, avoidance symptoms, and elevated hyperarousal symptoms.^[15]

Researchers corroborate that findings by the reporting during the MERS outbreak, HCWs had significant degrees of avoidance, intrusion, numbness, and hyperarousal symptoms.^[16] The HCWs who were isolated at home experienced a lot of numbness and insomnia. During the MERS outbreak, they also felt a great deal of anxiety and distress.^[17] The COVID-19 pandemic had a psychological impact on HCWs in the form of stress and emotional distress. Stress symptoms were seen in 34.3%–57% of HCWs, whereas PTSD symptoms such as extreme emotional weariness and depersonalization, as well as clinical manifestations, were seen in 7.7%–36.7%.^{[18],[19],[20]}

Anxiety and depression

During the SARS epidemic, HCWs reported depression (77.2%), anxiety (as high as 77.4%) in certain studies, and exhaustion with reduced sleep (52.3%).^{[10],[21],[22]} It is also possible that their elevated levels of concern and panic are related to the disease spreading to their loved ones.^[12] HCWs who had interaction with patients were also found to have a high rate of OCD, depression, and paranoid ideation.^[23] During the Ebola outbreak, HCWs lost faith in one another due to fear of getting the disease, and they also felt disconnected from their coworkers. Increased isolation and stigmatization frequently result in sadness, fear, and a lack of respect.^[22] During the MERS outbreak and COVID-19, a similar pattern was seen. It not only made HCWs anxious and depressed,^[17] but it also made them feel uncomfortable, anxious, frightened, and threatened.^{[5],[24],[25],[26]} During COVID-19, studies in China, Singapore, and the United States found high levels of psychological distress, anxiety, depression, lack of appetite, poor sleep quality, fatigue, and stress among HCWs.^{[27],[28],[29],[30],[31]}

Health anxiety

HCWs experienced increased somatization as one of the acute symptoms of stress during the SARS outbreak. The fear of contracting COVID-19 was found to be amplified among healthcare professionals by media and news reports.

Discussion

The narrative review revealed the presence of anxiety, depression, health anxiety, stress, and PTSD among HCWs during disease outbreaks [Figure 1]. Other common psychologically distressing symptoms also revolved around like OCD, paranoid ideation, loss of sleep, reduced trust, and fatigue.

Figure 1: Common issues faced by healthcare workers during a disease outbreak: A concept map

Click here to view

Hypochondriasis and cyberchondriasis become highly common during disease outbreaks, according to several research.^[32],[33] However, because the focus of symptom manifestations such as health anxiety in HCWs could be particularly important due to their proximity to patients, more research is needed. Similarly, OCD and paranoid symptoms in HCWs need to be better understood, particularly in light of the ongoing COVID-19 pandemic.

The strength of this study is that it helps understand the psychological state of HCWs from a more holistic perspective, taking into account several recent and past public health epidemics. This will allow HCWs to learn from past outbreaks, understand the current situation, and develop plans for the COVID-19 pandemic. There are several drawbacks to this study as well. Some online studies on the COVID-19 pandemic could have had methodological issues due to bias. There are also no studies that are thematically based. Despite the fact that there are very few articles highlighting HCWs' coping strategies during the pandemic, there is not enough formal research on the topic. It is important to focus on the measures that HCWs can use to improve their well-being.

Conclusion

With most sources of support being channelized toward patients and the general public, it is essential that HCWs also be made aware of the varied number of coping strategies one can employ, such as physical activity and exercise, resilience-building,^[19] positive thinking,^[34] and clear communication.^[35] Future research can be directed toward understanding what kind of interventions can be employed (both at the individual and organizational level) to help HCWs cope with the stress associated with the current pandemic. It is also important to help HCWs by conducting well-being interventions that can encourage positive thinking and resilience building, as the same can encourage better mental health in the current scenario.^[20],[34]

The review also implies that HCWs are at risk of developing physical and mental health problems as a result of their interaction with COVID-19 patients. Protecting the health and safety of HCWs through adequate measures is a critical modality in the public health response to outbreaks. If prompt action is not taken, the disease outbreak will eventually subside, but a new group of people suffering from psychological morbidity will arise.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Jungmann SM, Witthöft M. Health anxiety, cyberchondria, and coping in the current COVID-19 pandemic: Which factors are related to coronavirus anxiety? J Anxiety Disord 2020;73:102239.
2.	Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res 2020;287:112934.
3.	Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729.
4.	Biju V. Common presentations of psychological disturbances post COVID-19 in Mental Health in the times of COVID-19 pandemic-Guidance for General Medical and Specialised Mental Health Settings, Department of Psychiatry. NIMHANS 2020:12-7.
5.	Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatr 2020;33:e100213.
6.	CDC. Employees: How to Cope with Job Stress and Build Resilience During the COVID-19 Pandemic. 2019. United States: Centers for Disease Control and Prevention; 2020. p. 2019-20. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/mental-health-healthcare.html. [Last accessed on 2020 Sep 04].
7.	Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan – A web and mobile app for systematic reviews. Syst Rev 2016;5:210.
8.	McAlonan GM, Lee AM, Cheung V, Cheung C, Tsang KW, Sham PC, et al. Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers. Can J Psychiatry 2007;52:241-7.
9.	Chan AO, Huak CY. Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore. Occup Med (Lond) 2004;54:190-6.
10.	Chong MY, Wang WC, Hsieh WC, Lee CY, Chiu NM, Yeh WC, et al. Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. Br J Psychiatry 2004;185:127-33.
11.	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;55:1055-7.
12.	Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168:1245-51.
13.	Chen CS, Wu HY, Yang P, Yen CF. Psychological distress of nurses in Taiwan who worked during the outbreak of SARS. Psychiatr Serv 2005;56:76-9.
14.	Wu P, Bird HR, Liu X, Duarte CS, Fuller C, Fan B, et al. Trauma, posttraumatic stress symptoms, and alcohol-use initiation in children. J Stud Alcohol Drugs 2010;71:326-34.
15.	Verma S, Mythily S, Chan YH, Deslypere JP, Teo EK, Chong SA. Post-SARS psychological morbidity and stigma among general practitioners and traditional Chinese medicine practitioners in Singapore. Ann Acad Med Singap 2004;33:743-8.
16.	Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 2018;87:123-7.
17.	Bukhari EE, Temsah MH, Aleyadhy AA, Alrabiaa AA, Alhboob AA, Jamal AA, et al. Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak perceptions of risk and stress evaluation in nurses. J Infect Dev Ctries 2016;10:845-50.
18.	Giusti EM, Pedroli E, D'Aniello GE, Stramba Badiale C, Pietrabissa G, Manna C, et al. The psychological impact of the COVID-19 outbreak on health professionals: A cross-sectional study. Front Psychol 2020;11:1684.
19.	Tan BY, Chew NW, Lee GK, Jing M, Goh Y, Yeo LL, et al. Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med 2020;173:317-20.
20.	Shechter A, Diaz F, Moise N, Anstey DE, Ye S, Agarwal S, et al. Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. Gen Hosp Psychiatry 2020;66:1-8.
21.	Liu X, Kakade M, Fuller CJ, Fan B, Fang Y, Kong J, et al. Depression after exposure to stressful events: Lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry 2012;53:15-23.
22.	McMahon SA, Ho LS, Brown H, Miller L, Ansumana R, Kennedy CE. Healthcare providers on the frontlines: A qualitative investigation of the social and emotional impact of delivering health services during Sierra Leone's Ebola epidemic. Health Policy Plan 2016;31:1232-9.
23.	Ji D, Ji YJ, Duan XZ, Li WG, Sun ZQ, Song XA, et al. Prevalence of psychological symptoms among Ebola survivors and healthcare workers during the 2014-2015 Ebola outbreak in Sierra Leone: A cross-sectional study. Oncotarget 2017;8:12784-91.
24.	Abolfotouh MA, AlQarni AA, Al-Ghamdi SM, Salam M, Al-Assiri MH, Balkhy HH. An assessment of the level of concern among hospital-based health-care workers regarding MERS outbreaks in Saudi Arabia. BMC Infect Dis 2017;17:4.
25.	Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry 2020;7:e14.
26.	Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of coronavirus disease 2019 (COVID-19) beyond paranoia and panic. Ann Acad Med Singap 2020;49:155-60.
27.	Teng Z, Wei Z, Qiu Y, Tan Y, Chen J, Tang H, et al. Psychological status and fatigue of frontline staff two months after the COVID-19 pandemic outbreak in China: A cross-sectional study. J Affect Disord 2020;275:247-52.
28.	Salman M, Mustafa ZU, Raza MH, Khan TM, Asif N, Tahir H, et al. Psychological effects of COVID-19 among healthcare workers and how they are coping: A web-based, cross-sectional study during the first wave of COVID-19 in Pakistan. Disaster Med Public Health Prep 2022:1-13. Online ahead of print.
29.	Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
30.	Dai Y, Hu G, Xiong H, Qiu H, Yuan X. Psychological impact of the coronavirus disease 2019 (COVID-19) outbreak on healthcare workers in China. medRxiv 2020. Preprint. Available from: https://doi.org/10.1101/2020.03.03.20030874. [Last accessed on 2020 Sep 04].
31.	Ma Y, Rosenheck R, He H. Psychological stress among health care professionals during the 2019 novel coronavirus disease outbreak: Cases from online consulting customers. Intensive Crit Care Nurs 2020;61:102905.
32.	Blakey SM, Abramowitz JS. Psychological predictors of health anxiety in response to the Zika virus. J Clin Psychol Med Settings 2017;24:270-8.
33.	Rettie H, Daniels J. Coping and tolerance of uncertainty: Predictors and mediators of mental health during the COVID-19 pandemic. Am Psychol 2021;76:427-37.
34.	Babore A, Lombardi L, Viceconti ML, Pignataro S, Marino V, Crudele M, et al. Psychological effects of the COVID-2019 pandemic: Perceived stress and coping strategies among healthcare professionals. Psychiatry Res 2020;293:113366.
35.	Petzold MB, Plag J, Ströhle A. Dealing with psychological distress by healthcare professionals during the COVID-19 pandemic. Nervenarzt 2020;91:417-21.