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      The association between witnessing patient death and mental health outcomes in frontline COVID‐19 healthcare workers


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          Healthcare workers (HCW) treating coronavirus disease 2019 (COVID‐19) patients face high levels of psychological stress. We aimed to compare mental health outcomes, risk and protective factors for posttraumatic stress symptoms (PTSS), probable depression, and anxiety between HCW working in COVID‐19 and non‐COVID‐19 wards.


          A self‐report survey, administered in a large tertiary hospital in Israel during the peak of the COVID‐19 outbreak was completed by 828 HCW (42.2% physicians, 57.8% nurses. Patient‐Reported Outcomes Measurement Information System; the Patient Health Questionnaire‐9; the Primary Care‐Post Traumatic Stress Disorder Screen for DSM‐5 (PC‐PTSD‐5) were used for assessing anxiety, depression, and PTSS, respectively. Pandemic‐related stress factors, negative experiences, and potential protective factors were also assessed.


          Median PC‐PTSD scores differed significantly between study teams ( χ 2 [5] = 17.24; p = .004). Prevalence of probable depression and anxiety were similar in both groups. Risk factors for mental health outcomes included mental exhaustion, anxiety about being infected and infecting family. Overall, higher proportion of the COVID‐19 team witnessed patient deaths as compared to the non‐COVID‐19 team (50.2% vs. 24.7%). Witnessing patient death at the COVID‐19 wards was associated with a four‐fold increased likelihood of PTSS (odds ratio [OR] = 3.97; 95% confidence interval [CI], 1.58–9.99; p = .0007), compared with the non‐COVID‐19 wards (OR 0.91; 95% CI, 0.51–1.61; p = .43).


          Witnessing patient death appears to be a risk factor for PTSS unique to HCW directly engaged in treating patients with COVID‐19. Our findings suggest that helping HCW cope with COVID‐19 related deaths might reduce their risk of posttraumatic stress.

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          Most cited references65

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          A brief measure for assessing generalized anxiety disorder: the GAD-7.

          Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.
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            Is Open Access

            Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China

            Background: The 2019 coronavirus disease (COVID-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. Research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. The aim of this study was to survey the general public in China to better understand their levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak. The data will be used for future reference. Methods: From 31 January to 2 February 2020, we conducted an online survey using snowball sampling techniques. The online survey collected information on demographic data, physical symptoms in the past 14 days, contact history with COVID-19, knowledge and concerns about COVID-19, precautionary measures against COVID-19, and additional information required with respect to COVID-19. Psychological impact was assessed by the Impact of Event Scale-Revised (IES-R), and mental health status was assessed by the Depression, Anxiety and Stress Scale (DASS-21). Results: This study included 1210 respondents from 194 cities in China. In total, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. Most respondents spent 20–24 h per day at home (84.7%); were worried about their family members contracting COVID-19 (75.2%); and were satisfied with the amount of health information available (75.1%). Female gender, student status, specific physical symptoms (e.g., myalgia, dizziness, coryza), and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (p < 0.05). Specific up-to-date and accurate health information (e.g., treatment, local outbreak situation) and particular precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05). Conclusions: During the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. Our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the COVID-19 epidemic.
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              Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

              Key Points 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.

                Author and article information

                Depress Anxiety
                Depress Anxiety
                Depression and Anxiety
                John Wiley and Sons Inc. (Hoboken )
                05 February 2021
                : 10.1002/da.23140
                [ 1 ] The Chaim Sheba Medical Center Ramat Gan Israel
                [ 2 ] Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
                [ 3 ] School of Psychological Sciences Tel Aviv University Tel Aviv Israel
                [ 4 ] Bar‐Ilan University Ramat Gan Israel
                Author notes
                [*] [* ] Correspondence Itai M. Pessach, MD, PhD, MPH, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer 52621, Israel.

                Email: Itai.Pessach@ 123456Sheba.gov.il

                Mariela Mosheva and Raz Gross equal contribution as first author.

                Author information
                © 2021 Wiley Periodicals LLC

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                : 11 January 2021
                : 18 October 2020
                : 17 January 2021
                Page count
                Figures: 1, Tables: 4, Pages: 12, Words: 7816
                Funded by: Foundation Dora and the Binational Science Foundation
                Award ID: 2017369
                Research Article
                Research Articles
                Custom metadata
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.0.1 mode:remove_FC converted:01.04.2021

                Clinical Psychology & Psychiatry
                anxiety,covid‐19,depression,mental health,ptsd,stress
                Clinical Psychology & Psychiatry
                anxiety, covid‐19, depression, mental health, ptsd, stress


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