Background: In response to the coronavirus 2019 (COVID-19) pandemic, Singapore raised
its Disease Outbreak Response System Condition alert to “orange,” the second highest
level. Between 19 February and 13 March 2020, confirmed cases rose from 84 to 200
(34.2 per 1 000 000 population), with an increase in patients in critical condition
from 4 to 11 (5.5%) and no reported deaths in Singapore (1). Understanding the psychological
impact of the COVID-19 outbreak among health care workers is crucial in guiding policies
and interventions to maintain their psychological well-being.
Objective: We examined the psychological distress, depression, anxiety, and stress
experienced by health care workers in Singapore in the midst of the outbreak, and
compared these between medically and non–medically trained hospital personnel.
Methods and Findings: From 19 February to 13 March 2020, health care workers from
2 major tertiary institutions in Singapore who were caring for patients with COVID-19
were invited to participate with a self-administered questionnaire. In addition to
information on demographic characteristics and medical history (Table 1), the questionnaire
included the validated Depression, Anxiety, and Stress Scales (DASS-21) and the Impact
of Events Scale–Revised (IES-R) instrument (2, 3). Health care workers included “medical”
(physicians, nurses) and “nonmedical” personnel (allied health professionals, pharmacists,
technicians, administrators, clerical staff, and maintenance workers). The primary
outcome was the prevalence of depression, stress, anxiety, and posttraumatic stress
disorder (PTSD) among all health care workers (Table
2). Secondary outcomes were comparison of the prevalence of depression, anxiety, stress,
and PTSD, and mean DASS-21 and IES-R scores between medical and nonmedical health
care workers. The Pearson χ2 test and Student t test were used to compare categorical
and continuous outcomes, respectively, between the 2 groups. Multivariable regression
was used to adjust for the a priori defined confounders of age, sex, ethnicity, marital
status, presence of comorbid conditions, and survey completion date.
Table 1. Participant Characteristics at Baseline
Table 2. Prevalence of Depression, Anxiety, Stress, and PTSD and Mean DASS-21 and
IES-R Scores in Medical and Nonmedical Health Care Personnel (N = 470)
Of 500 invited health care workers, 470 (94%) participated in the study; baseline
characteristics are shown in Table 1. Sixty-eight (14.5%) participants screened positive
for anxiety, 42 (8.9%) for depression, 31 (6.6%) for stress, and 36 (7.7%) for clinical
concern of PTSD. The prevalence of anxiety was higher among nonmedical health care
workers than medical personnel (20.7% versus 10.8%; adjusted prevalence ratio, 1.85
[95% CI, 1.15 to 2.99]; P = 0.011), after adjustment for age, sex, ethnicity, marital
status, survey completion date, and presence of comorbid conditions. Similarly, higher
mean DASS-21 anxiety and stress subscale scores and higher IES-R total and subscale
scores were observed in nonmedical health care workers (Table 2).
Discussion: Overall mean DASS-21 and IES-R scores among health care workers were lower
than those in the published literature from previous disease outbreaks, such as the
severe acute respiratory syndrome (SARS). A previous study in Singapore found higher
IES scores among physicians and nurses during the SARS outbreak, and an almost 3 times
higher prevalence of PTSD, than those in our study (4). This could be attributed to
increased mental preparedness and stringent infection control measures after Singapore's
SARS experience.
Of note, nonmedical health care workers had higher prevalence of anxiety even after
adjustment for possible confounders. Our findings are consistent with those of a recent
COVID-19 study demonstrating that frontline nurses had significantly lower vicarious
traumatization scores than non–frontline nurses and the general public (5). Reasons
for this may include reduced accessibility to formal psychological support, less first-hand
medical information on the outbreak, less intensive training on personal protective
equipment and infection control measures.
As the pandemic continues, important clinical and policy strategies are needed to
support health care workers. Our study identified a vulnerable group susceptible to
psychological distress. Educational interventions should target nonmedical health
care workers to ensure understanding and use of infectious control measures. Psychological
support could include counseling services and development of support systems among
colleagues.
Our study has limitations. First, data obtained from self-reported questionnaires
were not verified with medical records. Second, the study did not assess socioeconomic
status, which may be helpful in evaluating associations of outcomes and tailoring
specific interventions. Finally, the study was performed early in the outbreak and
only in Singapore, which may limit the generalizability of the findings. Follow-up
studies could help assess for progression or even a potential rebound effect of psychological
manifestations once the imminent threat of COVID-19 subsides.
In conclusion, our study highlights that nonmedical health care personnel are at highest
risk for psychological distress during the COVID-19 outbreak. Early psychological
interventions targeting this vulnerable group may be beneficial.