|Year : 2022 | Volume
| Issue : 1 | Page : 12-19
The psychological status of resident doctors during the COVID-19 pandemic and its association with resilience and social support: A cross-sectional study
Kathleen Anne Mathew, Kudrat Jain, Arya Jith
Department of Psychiatry, Amrita School of Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
|Date of Submission||14-Jul-2021|
|Date of Decision||22-Oct-2021|
|Date of Acceptance||03-Dec-2021|
|Date of Web Publication||24-Jan-2022|
Dr. Kathleen Anne Mathew
Department of Psychiatry, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi - 682 041, Kerala
Source of Support: None, Conflict of Interest: None
CONTEXT: The COVID-19 pandemic has affected the psychological status of frontline medical professionals who constantly work under stressful situations. The role of social support and resilience in safeguarding the mental health of resident doctors, is an area, which has not received due attention.
AIMS: To assess the psychological status (depression, anxiety, and fear of COVID-19) and its association with resilience and perceived social support in resident doctors during COVID-19 pandemic.
SETTINGS AND DESIGN: A cross-sectional descriptive study was conducted among the resident doctors in a tertiary hospital in Kochi, Kerala.
MATERIALS AND METHODS: A web-based survey created using Google forms was sent via social media groups to the resident doctors of a teaching hospital in Kochi between August to September 2020. Two hundred completed responses were obtained. Study tools included a sociodemographic proforma, Patient Health Questionnaire-9, Generalized Anxiety Disorder scale-7, Fear of COVID-19 scale, Brief Resilience Scale, and Medical Outcomes Study Social Support Survey.
STATISTICAL ANALYSIS USED: Psychological status (depression, anxiety, fear of COVID-19) was expressed using descriptive statistics; its association with sociodemographic variables using Chi-square test and its correlation with resilience and social support using Pearson correlation.
RESULTS: Depression and anxiety were reported in 69% and 59.5% of the respondents, respectively. The mean fear of COVID-19 score was 24.06 (3.220). Resilience and overall social support index showed a significant negative correlation with depression and anxiety scores (P = 0.000). Emotional social support and affectionate social support showed a significant negative correlation with fear of COVID-19 (P = 0.040; P = 0.045, respectively).
Conclusion: A large proportion of resident doctors were noted to have depression, anxiety, and fear of COVID-19. Individuals with higher levels of resilience and perceived social support had lesser levels of depression, anxiety, and fear of COVID-19.
Keywords: Psychological status, resident doctors, resilience, social support
|How to cite this article:|
Mathew KA, Jain K, Jith A. The psychological status of resident doctors during the COVID-19 pandemic and its association with resilience and social support: A cross-sectional study. Indian J Health Sci Biomed Res 2022;15:12-9
|How to cite this URL:|
Mathew KA, Jain K, Jith A. The psychological status of resident doctors during the COVID-19 pandemic and its association with resilience and social support: A cross-sectional study. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 May 19];15:12-9. Available from: https://www.ijournalhs.org/text.asp?2022/15/1/12/336299
| Introduction|| |
The novel coronavirus infection was declared a global pandemic by the World Health Organisation on March 11, 2020. The COVID-19 pandemic has overwhelmed health-care systems across the nations. Frontline medical professionals have been facing unprecedented levels of psychological problems including depression, anxiety, fear, and stress during the pandemic. These, if left unaddressed, can cause impairment in attention, memory, and clinical judgment, which can lead to performance reduction. Resident doctors comprising the main workforce dealing with the ongoing pandemic are among the most vulnerable frontline health-care professionals. Cancellation of academic programs, being mobilized to work in high-risk setups with constant exposure to patients with COVID-19, and having to constantly face ethical dilemmas add on to their psychological morbidity. Studies from around the world have tried to explore the psychological status of medical professionals in the wake of the pandemic. The first such study from Wuhan in China found that of the 994 medical professionals assessed, 34.4% had mild depressive symptoms, 22.4% had moderate symptoms, and 6.2% had severe disturbances. A web-based study by Chatterjee et al. among doctors in India observed that among the 152 participants, 34.9% had depression, 39.5% had anxiety, and 32.9% reported significant stress.
Fear is the response of an individual to a situation perceived as a threat, which is also a defense mechanism that has the potential to improve the chances of survival. When the level of fear is excessive and maladaptive, it can have a detrimental effect on an individual's mental and physical health. Shehada et al. conducted a study on 300 doctors in Palestine and reported that 45.7% of the respondents reported high levels of fear to COVID-19. Malik et al. conducted an online survey on 421 Pakistani doctors and reported that doctors who reported high levels of fear of COVID-19 were more likely to develop workplace avoidance.
Social support is individuals' perception or experience in terms of being involved in a social group where people mutually support each other. The “buffer theory of social support” points to the role of social support in protecting the individual from developing a psychiatric disorder in the event of adverse psychosocial events. A review of epidemiological studies by Masuchi and Kishi showed that depressive symptoms are associated with a reduced social network as well as lower emotional and instrumental support. A study done by Lorant et al. in Belgium with 20,792 participants showed that the lockdown during the first wave of COVID-19, which led to a reduction in social activity and social support, was associated with increased psychological distress.
Another important contributor to the promotion of mental health is the individual's capacity to deal with significant adversities and recover quickly, known as resilience. The “protective factor model of resilience” postulates that there is a constant interaction between protective factors and risk factors on exposure to stress. Protective factors such as problem-solving skills, self-efficacy, perseverance, and optimism help an individual to rise above the stress. A descriptive study by Arslan et al. involving 671 doctors reported that a significant negative correlation was noted between resilience scores and the scores of depression and anxiety (P < 0.05). Measures to build the resilience of health professionals including imparting latest information and training to handle the pandemic, improving working conditions and resilience training need to receive due attention.
The sustainability of health-care interventions during a global crisis such as a pandemic cannot be ensured unless the physical and mental health of resident doctors is safeguarded. Previous Indian studies have assessed the levels of anxiety and depression among health-care workers. However, they have not captured their fear of COVID-19 or the protective role of resilience and social support. This study was undertaken to assess the psychological status (depression, anxiety, and fear of COVID-19) and its association with resilience and perceived social support in resident doctors during the COVID-19 pandemic.
| Materials and Methods|| |
This was a cross-sectional, descriptive, web-based study. Ethical clearance was obtained from Institutional Ethical Committee of Amrita Institute of Medical Sciences, Kochi with Ref no IRB-AIMS-2020-251 dated 15.09.2020.
Study setting and participants
The study was conducted among the resident doctors (broad specialty and super specialty) of a tertiary teaching hospital in Kochi, Kerala, from August to September 2020.
A pilot study was conducted on ten samples recruited from among the resident doctors, during the COVID-19 pandemic. Descriptive statistics were used to calculate the proportion of depression in the sample. Based on the results of the pilot study, with depression (30%) among resident doctors and with 20% relative precision and 95% confidence, the minimum sample size came out to be 224.
This included sociodemographic and clinical variables such as gender, age, marital status, clinical postings, medical comorbidities, substance use, and financial difficulty.
Patient health questionnaire 9
To assess the depressive symptoms in the sample, patient health questionnaire-9 (PHQ-9) was used. At nine items, PHQ-9 has sensitivity and specificity comparable to other measures of depression. Possible scores range from 0 to 27, since each of the items can be scored from 0 (not at all) to 3 (nearly every day). Cutoff scores of 5, 10, and 15 were used to categorize depression as mild, moderate and severe according to pre-existing literature.
Generalized anxiety disorder-7
This 7-item scale was employed for the assessment of anxiety symptoms. Generalized anxiety disorder scale-7 (GAD-7) is a self-rated scale used in clinical practice to evaluate the severity of anxiety and has good reliability and validity in the general population. It can score the level of anxiety from minimal to severe. The total score ranges from 0 to 21. Cutoff scores of 5, 10, and 15 can be interpreted as mild, moderate, and severe anxiety. This scale has been demonstrated to have good reliability as well as procedural, criterion, and construct validity.
Fear of COVID-19 scale
It is a seven-item scale, which has been found to be reliable and valid in assessing fear of COVID-19 among the general population. This self-reported scale developed by Ahorsu et al. uses a Likert scale for participant response to each item, with minimum score being 1 (strongly agree) and maximum being 5 (strongly disagree). The possible total score range is 7–35. Higher scores indicate greater fear of COVID-19.
Brief resilience scale
Brief resilience scale is a reliable measure of the ability to bounce back from stress according to Smith et al. There are six items on the scale. Responses are recorded on a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Items 2, 4, and 6 are reverse scored. A total score is calculated by adding all the item scores and dividing the result by 6. Higher scores are indicative of greater levels of resilience. The scale has been shown to have good internal consistency with Cronbach's alpha of 0.80–0.91.
Medical outcomes study social support survey
Perceived social support was assessed using the medical outcomes study social support survey (MOS-SS). It is a 19-item, self-administered social support survey developed for patients in the MOS. It covers four domains (emotional/informational support, tangible/instrumental support, positive social interaction, and affection) and has good reliability. The domain scores can be converted to a transformed score in the range of 1–100. An overall support index can also be calculated. Higher scores reflect greater perceived social support.
Data collection procedure
The survey created using Google forms was sent via social media groups to all postgraduate (MD/MS) and superspeciality (DM/MCh) resident doctors in the hospital. Institutional Ethics Committee approval was obtained before the commencement of the study. Informed consent was obtained from all the participants.
Data obtained was analyzed using IBM SPSS version 20 software (SPSS, Chicago, IL, USA). Levels of depression and anxiety were represented as number and percentages. Mean and standard deviation of fear of COVID-19, resilience and levels of social support among the resident doctors were expressed with 95% confidence. Chi-square test was used to assess the statistical significance of the comparison of sociodemographic variables with depression and anxiety. Pearson correlation was employed to test the statistical significance of the correlation of resilience and levels of social support with depression, anxiety, and fear of COVID-19. The level of significance was P < 0.05.
| Results|| |
We received 200 completed responses to the study questionnaire which was sent to all the resident doctors in the hospital. The mean age of the sample was 28.32 (3.458), and majority were females (52%). Thirty-nine (19.5%) had medical risk factors such as diabetes mellitus, hypertension, pregnancy, and immunocompromised state, which put them at a high risk for severe COVID-19 illness. 81 (40.5%) participants reported using substances such as alcohol, tobacco, or cannabis, with once a month use (27%) being the most common pattern, followed by once weekly use (11.5%). The majority of the respondents (58%) reported having encountered some financial difficulty during the pandemic [Table 1].
According to PHQ-9 scores, 138 (69%) respondents were noted to have depression, with the highest proportion reporting features of mild depression (42.5%). Anxiety scores on GAD-7 revealed that 119 (59.5%) participants had anxiety, with the majority observed to have mild anxiety (42%). The mean score on Fear of COVID-19 scale was noted to be 24.06 (3.220), which is on the higher end of the score range (7–35) [Table 2].
|Table 2: Levels of anxiety, depression, fear of corona virus disease-2019, resilience and social support|
Click here to view
Association between sociodemographic and work-related variables with the levels of depression and anxiety was analyzed. Postings in COVID isolation ward were found to be significantly associated with the levels of depression (P = 0.042) and levels of anxiety (P = 0.013). Tobacco use and cannabis use were found to be significantly associated with higher levels of depression (P = 0.001, P = 0.010, respectively) and anxiety (P = 0.010, P = 0.014). Participants who experienced more financial difficulty during the pandemic were likely to experience significantly greater severity of depression (P = 0.000) and anxiety (P = 0.003) [Table 3] and [Table 4].
|Table 3: Association of sociodemographic and work- related variables with levels of depression|
Click here to view
|Table 4: Association of sociodemographic and work. related variables with levels of anxiety|
Click here to view
Resilience scores were found to show a significant negative correlation with depression scores (-0.451, P = 0.000) and anxiety scores (r = − 0.451, P = 0.000) which means that individuals who had higher resilience had lower levels of depression and anxiety. Each of the four subscales of MOS Social Support Survey showed a significant negative correlation with depression scores as well as anxiety scores. The overall social support index was observed to have a moderate negative correlation with depression scores (r = −.425, P = 0.000) and mild negative correlation with anxiety scores (r = −0.300, P = 0.000), the associations of which were significant. This means that in participants who had greater social support, depression and anxiety levels tended to be lower. Emotional social support scores and affectionate social support scores showed significant low negative correlation with scores on Fear of COVID-19 scale (r = −0.146, P = 0.040; r = −0.142, P = 0.045, respectively) [Table 5].
|Table 5: Correlation of resilience scores and social support scores with depression, anxiety and fear of corona virus disease-2019 scores|
Click here to view
| Discussion|| |
To our knowledge, this is the first study from India exploring the association of both resilience and perceived social support of resident doctors with their psychological status described through measures of depression, anxiety, and fear of COVID-19 during this pandemic. Sixty-nine percent of the study participants had depression, and 59.5% reported anxiety. The majority of the respondents had mild depression (42.5%) and mild anxiety (42%). The respondents' fear of COVID-19 was noted to be high. Individuals who had high resilience were found to have significantly lower depression and anxiety levels. Those who reported high social support were significantly less anxious and depressed. Greater emotional and affectionate social support was significantly associated with lesser fear of COVID-19.
The prevalence of depression and anxiety noted in the current study is higher than that reported by previous studies conducted worldwide. A systematic review by Muller et al. which included 29 studies noted that the median prevalence of depression and anxiety was 21% and 24%, respectively. A study by Wilson et al. conducted among Indian medical professionals observed that moderate to severe level of depression and anxiety was noted in 11.4% and 17.7% of the respondents, respectively. In our study, 26.5% and 17.5% of participants reported such severity of depression and anxiety, which warrants clinical intervention. Since many of the previous studies were conducted early on during the pandemic, the psychological status of the medical work force would have been less affected. It is also noteworthy that the peak of first wave of COVID-19 in India was in September 2020, the same period when this study was conducted. Several months into the pandemic with the worsening crisis situation, the mental health of resident doctors seems to have been more afflicted. The findings of a recent study by Alnazly et al. in which higher rates of severe depression and anxiety (40% and 60%, respectively) were reported supports this notion. The mean score on fear of COVID-19 scale was found to be 24.06 (3.220), which was higher than the mid-point of the possible score range. Similar findings were noted in a study conducted among health professionals in Jordan where the mean score was 23.64 (6.85). This finding points towards high levels of fear of the illness among the health-care professionals.
Age, gender, or marital status did not show an association with the levels of depression or anxiety of the participants. Although some studies have shown younger age group, female health-care workers and single individuals to have a greater risk for depression and anxiety, the majority of the studies have reported that there was no significant association. Medical professionals who were posted in fever clinics did not have a higher risk of depression or anxiety, but those who had duties in COVID-19 isolation wards were significantly more likely to have depression and anxiety. As resident doctors posted in fever clinic only perform screening of possible COVID cases, while those in isolation wards have to be in close proximity of confirmed COVID-positive patients for the entire duration of their shift and have to attend to COVID-related complications, this is likely to be an added stressor. Research has consistently shown that health-care professionals working in high-risk departments such as infectious disease wards during a pandemic are more likely to develop depressive and anxiety symptoms. Tobacco and cannabis turned out to be significant indicators of the levels of depression and anxiety. A study by Czeisler et al. reported that 13% of the participants started using a substance or increased the quantity and frequency of use as a method to cope with stress during the pandemic. Individuals who reported financial strain during the pandemic were likely to have greater levels of depression and anxiety. As the revenue of most hospitals and medical colleges in the country was affected during the pandemic, doctors and other staff had to face pay cuts. This finding is in agreement with previous studies which have indicated subjective financial difficulties to be associated with depressive and anxiety symptoms.
Another important finding in this study is the significant negative correlation of resilience with both depression and anxiety. This is similar to the findings of a study conducted by Barzilay et al. on a large population of health workers during the COVID-19 outbreak, in which resilience was observed to have a significant inverse correlation with anxiety and depression (P < 0.001). Research has shown resilience to be a strong protective factor against negative emotional states in the face of adversity. A systematic review of studies involving health professionals during the COVID-19 pandemic reported that psychological resilience had a buffering effect in protecting health care workers from adverse psychological effects such as anxiety, depression, stress, and insomnia.
In this study, medical professionals with higher perceived social support were noted to have significantly lower levels of anxiety and depression. Fear of COVID-19 was found to be lower in those who had greater scores on emotional and affectionate domains of social support. These findings are in agreement with previous studies which have highlighted that social support promotes adaptive coping during stressful situations. An online survey by Özmete and Pak, which included 630 participants, observed that perceived social support had a significant negative correlation with both state and trait anxiety.(P < 0.01) A large online survey involving 2014 frontline health workers in China reported a moderate negative correlation of social support with Fear of COVID-19, depression, and anxiety. The role of social support in promoting self-efficacy and reducing negative mental health outcomes, especially during a global catastrophe like the COVID-19 pandemic cannot be emphasized enough.
This study had certain limitations. Since the study was conducted in an online format, self-selection bias may have occurred. Furthermore, since the study design was cross-sectional, the effects of exhaustion in resident doctors due to allostatic load during the ongoing pandemic would not have been captured.
| Conclusion|| |
Resident doctors who play a crucial role in combating the COVID-19 pandemic are at an increased risk of experiencing adverse psychological outcomes. It is important to identify and address mental health problems at an early stage in order to enable the frontline medical workforce to function at their best. Imparting resilience training and building support networks can go a long way in fostering mental well-being among resident doctors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ruitenburg MM, Frings-Dresen MH, Sluiter JK. The prevalence of common mental disorders among hospital physicians and their association with self-reported work ability: A cross-sectional study. BMC Health Serv Res 2012;12:292-8.
Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, et al.
Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun 2020;87:11-7.
Chatterjee SS, Bhattacharyya R, Bhattacharyya S, Gupta S, Das S, Banerjee BB. Attitude, practice, behavior, and mental health impact of COVID-19 on doctors. Indian J Psychiatry. 2020;62:257-65.
Steimer T. The biology of fear- and anxiety-related behaviors. Dialogues Clin Neurosci 2002;4:231-49.
Shehada AK, Albelbeisi AH, Albelbeisi A, El Bilbeisi AH, El Afifi A. The fear of COVID-19 outbreak among health care professionals in Gaza Strip, Palestine. SAGE Open Med 2021;9:20503121211022987.
Malik S, Ullah I, Irfan M, Ahorsu DK, Lin CY, Pakpour AH, et al.
Fear of COVID-19 and workplace phobia among Pakistani doctors: A survey study. BMC Public Health 2021;21:833.
Hajli MN, Shanmugam M, Hajli A, Khani AH, Wang Y. Health care development: Integrating transaction cost theory with social support theory. Inform Health Soc Care 2015;40:334-44.
Alloway R, Bebbington P. The buffer theory of social support a review of the literature. Psychol Med 1987;17:91-108.
Masuchi A, Kishi R. A review of epidemiological studies on the relationship of social networks and support to depressive symptoms in the elderly. Nihon Koshu Eisei Zasshi 2001;48:435-48.
Lorant V, Smith P, Van den Broeck K, Nicaise P. Psychological distress associated with the COVID-19 pandemic and suppression measures during the first wave in Belgium. BMC Psychiatry 2021;21:112.
O'Leary VE. Strength in the face of adversity: Individual and social thriving. J Soc Issues 2010;54:425-46.
Arslan HN, Karabekiroglu A, Terzi O, Dundar C. The effects of the COVID-19 outbreak on physicians' psychological resilience levels. Postgrad Med 2021;133:223-30.
Remuzzi A, Remuzzi G. COVID-19 and Italy: What next? Lancet 2020;395:1225-8.
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.
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.
Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The fear of COVID-19 scale: Development and initial validation. Int J Ment Health Addict 2020 Mar 27;1-9.
Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J. The brief resilience scale: Assessing the ability to bounce back. Int J Behav Med 2008;15:194-200.
Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991;32:705-14.
Muller AE, Hafstad EV, Himmels JPW, Smedslund G, Flottorp S, Stensland SØ, et al.
The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: A rapid systematic review. Psychiatry Res 2020;293:113441.
Wilson W, Raj JP, Rao S, Ghiya M, Nedungalaparambil NM, Mundra H, et al.
Prevalence and predictors of stress, anxiety, and depression among healthcare workers managing COVID-19 pandemic in India: A nationwide observational study. Indian J Psychol Med 2020;42:353-8.
Alnazly E, Khraisat OM, Al-Bashaireh AM, Bryant CL. Anxiety, depression, stress, fear and social support during COVID-19 pandemic among Jordanian healthcare workers. PLoS One 2021;16:e0247679.
Sirois FM, Owens J. Factors associated with psychological distress in health-care workers during an infectious disease outbreak: A rapid systematic review of the evidence. Front Psychiatry 2021;11:589545.
Naushad VA, Bierens JJ, Nishan KP, Firjeeth CP, Mohammad OH, Maliyakkal AM, et al.
A systematic review of the impact of disaster on the mental health of medical responders. Prehosp Disaster Med 2019;34:632-43.
Czeisler MÉ, Wiley JF, Facer-Childs ER, Robbins R, Weaver MD, Barger LK, et al.
Mental health, substance use, and suicidal ideation during a prolonged COVID-19-related lockdown in a region with low SARS-CoV-2 prevalence. J Psychiatr Res 2021;140:533-44.
Hertz-Palmor N, Moore TM, Gothelf D, DiDomenico GE, Dekel I, Greenberg DM, et al.
Association among income loss, financial strain and depressive symptoms during COVID-19: evidence from two longitudinal studies. medRxiv 2020;2020:20195339.
Barzilay R, Moore TM, Greenberg DM, DiDomenico GE, Brown LA, White LK, et al.
Resilience, COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers. Transl Psychiatry 2020;10:291.
Labrague LJ. Psychological resilience, coping behaviours and social support among health care workers during the COVID-19 pandemic: A systematic review of quantitative studies. J Nurs Manag 2021;29:1893-905.
Özmete E, Pak M. The relationship between anxiety levels and perceived social support during the pandemic of COVID-19 in Turkey. Soc Work Public Health 2020;35:603-16.
Hu D, Kong Y, Li W, Han Q, Zhang X, Zhu LX, et al.
Frontline nurses' burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A large-scale cross-sectional study. EClinicalMedicine 2020;24:100424.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]