1-s2.0-S1876034120306353.pdf

Journal of Infection and Public Health 13 (2020) 1432–1437

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Journal of Infection and Public Health

j o u r n a l h o m e p a g e : h t t p : / / w w w . e l s e v i e r . c o m / l o c a t e / j i p h

Original Article

Mental health among healthcare providers during coronavirus disease(COVID-19) outbreak in Saudi Arabia

Deemah A. AlAteeq a,!, Sumayah Aljhani b, Ibrahim Althiyabi c, Safaa Majzoub da Clinical Sciences Department, College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabiab Department of Psychiatry, College of Medicine, Qassim University, Qassim, Saudi Arabiac Department of Psychiatry, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabiad Ministry of Health — The National Transformation Program, Saudi Arabia

a r t i c l e i n f o

Article history:Received 8 May 2020Received in revised form 16 August 2020Accepted 29 August 2020

Keywords:DepressionAnxietyHealthcare providersCOVID-19Pandemic

a b s t r a c t

Background: The novel coronavirus (COVID-19) was recently declared a pandemic by the World HealthOrganization (WHO). The first confirmed case in Saudi Arabia was announced on March 2, 2020. Sev-eral psychiatric manifestations may appear during pandemics, especially among frontline healthcareproviders.Objectives: This study sought to explore depression and anxiety levels among healthcare providers duringthe COVID-19 outbreak in Saudi Arabia.Methods: This was a cross-sectional study of a convenience sample of 502 healthcare providers in theMinistry of Health. Depression and anxiety were assessed via the Patient Health Questionnaire (PHQ-9)and Generalized Anxiety Disorder 7 (GAD-7) questionnaires, respectively.Results: The respondents represented various healthcare occupations: administrators (28.49%), nurses(26.29%), physicians (22.11%), non-physician specialists (13.94%), technicians (6.77%), and pharmacists(2.30%). The majority of them were male (68.1%). More than half of them had depressive disorder (55.2%),which ranged from mild (24.9%), moderate (14.5%), and moderately severe (10%) to severe (5.8%). Halfof the sample had generalized anxiety disorder (51.4%), which ranged from mild (25.1%) and moderate(11%) to severe (15.3%). Multivariate analysis showed that males were significantly less predicted to haveanxiety (Beta = "0.22, P-value <0.04), 30–39 years age group were significantly more predicted to havedepression and anxiety group (Beta = 0.204, P-value <0.001 and beta = 0.521, P-value <0.003 respectively),and nurses had significantly higher mean score of anxiety (Beta = 0.445, P-value <0.026).Conclusions: This study revealed that depression and anxiety are prevailing conditions among healthcareproviders. Although efforts were accelerated to support their psychological well-being, more attentionshould be paid to the mental health of female, 30–39 age group and nursing staff. Promoting healthcareservice as a humanitarian and national duty may contribute to making it a more meaningful experience inaddition to advocating for solidarity, altruism, and social inclusion. Longitudinal research studies need tobe conducted to follow up on healthcare providers’ mental health symptoms and develop evidence-basedinterventions.

© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University forHealth Sciences. This is an open access article under the CC BY-NC-ND license (http://creativecommons.

org/licenses/by-nc-nd/4.0/).

Introduction

An idiopathic pneumonia began in Wuhan, China in December2019 [1]. The first case with a similar presentation discovered out-side China was in Thailand on January 13, 2020 [2]. The World

! Corresponding author.E-mail addresses: [email protected] (D.A. AlAteeq), [email protected]

(S. Aljhani), [email protected] (I. Althiyabi), [email protected](S. Majzoub).

Health Organization (WHO) gave this new coronavirus disease thename COVID-19 on February 2020 [3]. One month afterward, theWHO declared COVID-19 a global pandemic on March 11, 2020[2]. Coronaviruses are a group of viruses that can infect humansand animals and the cause of severe acute respiratory syndrome(SARS), Middle East respiratory syndrome (MERS), and COVID-19[1]. Saudi Arabia announced its first case of COVID-19 on March2, 2020 [4]. Psychiatric symptoms and illnesses may emerge sec-ondary to an infectious disease outbreak. They may appear duringthe acute phase or at later stages. Several presentations could

https://doi.org/10.1016/j.jiph.2020.08.0131876-0341/© 2020 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CCBY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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D.A. AlAteeq et al. / Journal of Infection and Public Health 13 (2020) 1432–1437 1433

appear, ranging from mild mood and anxiety symptoms to psy-chosis and significant cognitive deficits [5]. The outbreak itself isa stressful event and it is even more stressful to be a healthcareprovider who works in the first line to tackle such serious illness[6]. Several factors play important roles in responses to trauma,including the presence of prior psychiatric history, coping styles,culture, and support systems. In addition to being overwhelmed,it is also stressful to deal with shortages of medical equipmentand concerns over infecting family members [7,8]. In China, whereCOVID-19 started, a cross-sectional study was conducted on 31hospitals to measure factors linked with mental health outcomesamong healthcare providers who encountered COVID-19; thisstudy showed that frontline nurses and healthcare providers hada greater risk of negative mental health outcomes [9]. As far as weknow, no local study has addressed this topic yet. We aim to explorethe depression and anxiety prevalence among healthcare providersduring the COVID-19 outbreak in Saudi Arabia and identify theirseverity.

Materials and methods

Study design

For this study, data were collected via a cross-sectional surveyduring the COVID-19 outbreak on March 2020. Ethical approval wasprovided from the Institutional Review Board at Princess NourahBint Abdulrahman University (PNU) in Riyadh, Saudi Arabia. Theaims of the study were elucidated and the participants gave theirinformed consent to participate in the study.

Sample population

This study included both male and female participants who werehealthcare providers and Arabic speakers living in Saudi Arabia atthe time of the study.

Recruitment

Convenience sampling technique and Google forms were usedto collect responses. The sample size was calculated using Raosoftsoftware [10]. The required sample size was estimated at the 95-confidence level with an estimated 50% response distribution anda margin of error of ±5%. The recommended minimum sample sizeis 384. An online survey was sent to all healthcare providers fromdifferent specialties and levels who were working in COVID-19centers at the Ministry of Health and living in Saudi Arabia. Theyreceived the online survey through emails and phone messages,which was arranged by collaborators in the internal communica-tion channels at the health clusters of Riyadh, Qassim and Easternregion.

Data collection

The online survey contained three components. First, the surveyrecorded socio-demographic characteristics, including age, gen-der, level of education, and living region. Second, survey includedthe Patient Health Questionnaire (PHQ-9), which is a widely usedand valid tool for detecting depression and has 9 items withLikert-scale answers rated from 0 (not experienced at all) to 3(experienced nearly daily). These items detect depressive symp-toms that occurred during the last two weeks. The final participant’sscore is out of 27, which is categorized by the total mean score asmild (score of 5–9), moderate (score 10–14), moderately severe(score 15–19), or severe (score 20–27) [11]. Internal consistencywas evaluated using Cronbach’s alpha ( ̨ = 0.89). Finally, the survey

also included the Generalized Anxiety Disorder 7 (GAD-7) question-naire, which is also a valid tool for detecting anxiety and has 7 itemswith Likert-scale answers. The final participant’s score is out of 21is categorized by the total mean score as mild (score of 5–9), mod-erate (score 10–14), or severe (score 15–21). Internal consistencywas evaluated using Cronbach’s alpha ( ̨ = 0.95). Arabic versions ofboth scales are valid and reliable for screening for depression andanxiety [12].

Statistical analysis

Statistical analysis was performed using Statistical Package forthe Social Sciences (SPSS) version 23.0 software (SPSS Inc., Chicago,IL, USA), which was used for data entry and statistical analysis. Wecalculated percentages and frequencies for all nominal variables forthe different items of the PHQ-9 and GAD-7. Also, we calculated themean, median, and standard deviation ranges of the total scoresof the items of the PHQ-9 and GAD-7. We used non-parametricMann–Whitney U tests or Kruskal–Wallis tests to compare the totalscores of depression (PHQ-9) and total scores of anxiety (GAD-7)with respect to demographic characteristics. Results are consideredsignificant for P-values below 0.05 (P < 0.05). In order to ascer-tain the findings from the bivariate analysis, the generalized mixedlinear models were used to assess the combined and individualassociations between the sociodemographic characteristics and themean of depression and anxiety scores. The association betweenthese characteristics with the depression and anxiety scores wereexpressed as beta coefficients. The anxiety and depression scoreswere log-transformed to stabilize their variance via taking the nat-ural logarithm of the mean scores after adding a constant ( = 1) toeach participant’s scores of depression and anxiety to get rid of thezero scores when taking the natural logarithm. The statistical signif-icance alpha level was considered at 0.05 level. However, becausethe anxiety is a known sign of depression, we added the GAD scoreas a covariate in the analysis in order to adjust the associationsbetween the factors after partialing out the effect of any underlyinganxiety [13].

Results

Sociodemographic characteristics

A total of 502 healthcare providers responded to the survey. Thesociodemographic characteristics of the surveyed population arepresented in Table 1. The majority of the respondents were male(68.1%) and held a university degree or above (85.5%). More thanhalf of them were 30–39 years old (55.4%). The respondents rep-resented various healthcare occupations: administrators (28.49%),nurses (26.29%), physicians (22.11%), non-physician specialists(13.94%), technicians (6.77%), and pharmacists (2.30%). They wereliving in diverse regions, including the Qassim region (60.96%),Riyadh region (28.29%), Eastern region (9.16%), and other regions(1.59%).

Depressive symptoms among healthcare providers

Table 2 displays the healthcare providers’ responses to the 9items of the PHQ-9. Through the last 2 weeks preceding the surveythese providers responded affirmatively to the following as occur-ring for several days, more than half the days, or nearly every day:feeling tired or having little energy (67.9%); little interest or plea-sure in doing things (58.5%); trouble falling or staying asleep orsleeping too much (57.9%); poor appetite or overeating (55.5%);feeling down, depressed, or hopeless (52.2%); trouble concentrat-ing on things, such as reading the newspaper or watching television(44.1%); moving or speaking so slowly that other people could

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Table 1Frequencies or means of demographic characteristics, by depressive and anxiety symptom score (N = 502).

Characteristics Total (%) Depressive symptom score ± SD Anxiety symptom score ± SD

GenderMale 342 (68.1%) 6.56 ± 6.53 5.93 ± 6.45Female 160 (31.9%) 8.11 ± 6.17** 7.43 ± 6.10**

Age groups18–29 y 38 (7.6%) 7.24 ± 6.70 6.58 ± 6.5330–39 y 278 (55.4%) 8.27 ± 6.37*** 7.40 ± 6.59**40–49 y 141 (28.1%) 5.40 ± 6.35 4.83 ± 5.6350 y+ 45 (8.9%) 4.62 ± 5.29 5.11 ± 5.99

Educational levelsSecondary or less 73 (14.5%) 5.88 ± 6.50 5.81 ± 6.52University or higher 429 (85.5%) 7.26 ± 6.43* 6.51 ± 6.35

Region of residenceRiyadh region 142 (28.29%) 9.07 ± 7.38*** 8.04 ± 6.88***Qassim region 306 (60.96%) 6.10 ± 5.93 5.54 ± 6.01Eastern region 46 (9.16%) 6.67 ± 5.06 6.54 ± 5.78

OccupationsPhysician 111 (22.11%) 7.45 ± 6.68 6.74 ± 5.79Nurse 132 (26.29%) 8.80 ± 6.82* 7.49 ± 6.27*Administrator 143 (28.49%) 6.82 ± 6.03 6.38 ± 6.78Pharmacist 12 (2.30%) 5.92 ± 5.68 4.50 ± 4.91Non-physician specialist 70 (13.94%) 5.43 ± 5.69 4.66 ± 6.03Technician 34 (6.77%) 5.74 ± 6.39 5.50 ± 7.25

* P < 0.05.** P < 0.001.

*** P < 0.0001.

Table 2Responses to depression symptoms.

Depression symptoms: Not at all Several days More than half the days Nearly every day

1- Little interest or pleasure in doing things. 208 (41.4%) 142 (28.3%) 83 (16.5%) 69 (13.7%)2- Feeling down, depressed, or hopeless. 240 (47.8%) 138 (27.5%) 69 (13.7%) 55 (11.0%)3- Trouble falling or staying asleep, or sleeping too much. 211 (42.0%) 123 (24.5%) 83 (16.5%) 85 (16.9%)4- Feeling tired or having little energy. 161 (32.1%) 180 (35.9%) 82 (16.3%) 79 (15.7%)5- Poor appetite or overeating. 223 (44.4%) 113 (22.5%) 93 (18.5%) 73 (14.5%)6- Feeling bad about yourself, or that you are a failure or have let yourself or your

family down.375 (74.7%) 58 (11.6%) 44 (8.8%) 25 (5.0%)

7- Trouble concentrating on things, such as reading the newspaper or watchingtelevision.

281 (56.0%) 120 (23.9%) 53 (10.6%) 48 (9.6%)

8- Moving or speaking so slowly that other people could have noticed? Or theopposite-being so fidgety or restless that you have been moving around a lot morethan usual?

336 (66.9%) 90 (17.9%) 47 (9.4%) 29 (5.8%)

9- Thoughts that you would be better off dead or of hurting yourself in some way 456 (90.8%) 22 (4.4%) 13 (2.6%) 11(2.2%)

have noticed; so fidgety or restless that you have been movingaround a lot more than usual (33.1%); feeling bad about yourselfor that you are a failure or have let yourself or your family down(25.4%); and thoughts that you would be better off dead or of hurt-ing yourself in some way (9.2%). However, although more thanhalf of the respondents had depressive disorder (55.2%), which wasmild (24.9%), moderate (14.5%), moderately severe (10%), or severe(5.8%).

Anxiety symptoms among healthcare providers

Table 3 displays the participants’ responses to the 7 items ofthe GAD-7. Through the last 2 weeks preceding the survey for sev-eral days, these providers responded affirmatively to the followingas occurring more than half the days or nearly every day: feelingnervous, anxious or on edge (62.6%); worrying too much aboutdifferent things (61.7%); trouble relaxing (55.9%); becoming eas-ily annoyed or irritable (55%); not being able to stop or controlworrying (49.4%); feeling afraid as if something awful might hap-pen (46.4%); and being so restless that it is hard to sit still (42.1%).Although half of the respondents had generalized anxiety disorder(51.4%), their cases ranged from mild (25.1%) or moderate (11%) tosevere (15.3%).

Differences in mental health based on sociodemographiccharacteristics

A number of sociodemographic variables were significantlyassociated with depression and anxiety, as shown in Table 1.Females had higher scores of depression and anxiety, comparedto males (Mean ± SD: 8.11 ± 6.17 and 7.43 ± 6.10, respectively)(P-value <0.001). About third of the female respondents had mod-erate to severe levels of depression and anxiety (33.6% and 30.7%,respectively). The 30–39 age group had higher scores of depres-sion and anxiety than other age groups (Mean ± SD: 8.27 ± 6.37and 7.40 ± 6.59, respectively) (P-value <0.0001 and <0.001, respec-tively). Third or more of the 30–39 age group respondents hadmoderate to severe levels of depression and anxiety (38.4% and33.1%, respectively). Nurses had higher scores of depression andanxiety than other healthcare providers, such as physicians, phar-macists, specialists, technicians, and administrators (Mean ± SD:8.80 ± 6.82 and 7.49 ± 6.27, respectively) (P-value <0.05). Third ormore of the nurses had moderate to severe levels of depression andanxiety (37.9% and 32.9%, respectively). Healthcare providers livingin the Riyadh region had higher scores of depression and anxietythan respondents living in other regions (Mean ± SD: 9.07 ± 7.38and 8.04 ± 6.88, respectively) (P-value <0.0001). Finally, healthcareproviders with university degrees or above had higher score of

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Table 3Responses to anxiety symptoms.

Anxiety symptoms Not at all Several days More than half the days Nearly every day

1- Feeling nervous, anxious or on edge 188 (37.5%) 177 (35.3%) 62 (12.4%) 75 (14.9%)2- Not being able to stop or control worrying 254 (50.6%) 120 (23.9%) 69 (13.7%) 59 (11.8%)3- Worrying too much about different things 192 (38.2%) 151 (30.1%) 84 (16.7%) 75 (14.9%)4- Trouble relaxing 221 (44.0%) 139 (27.7%) 77 (15.3%) 65 (12.9%)5- Being so restless that it is hard to sit still 291 (58.0%) 117 (23.3%) 61 (12.2%) 33 (6.6%)6- Becoming easily annoyed or irritable 226 (45.0%) 150 (29.9%) 65 (12.9%) 61 (12.2%)7- Feeling afraid as if something awful might happen 269 (53.6%) 112 (22.3%) 53 (10.6%) 68 (13.5%)

Table 4Generalized linear mixed model explaining the association of sociodemographiccharacteristics with depression and anxiety scores (N = 502).

Characteristics Beta coefficient(95%CI) fordepression

Beta coefficient(95%CI) for anxiety

GenderMale "0.04 ("0.10 to 0.02) "0.22 ("0.43 to "0.02)*Female (reference) 0 0

Age groups18–29 y 0.13 ("0.01 to 0.26) 0.24 ("0.029 to 0.922)30–39 y 0.20 (0.10–0.31)*** 0.52 (0.15–0.87)**40–49 y 0.11 (0.001–0.216)* 0.15 ("0.21 to 0.50)50 y+ (reference) 0 0

Educational levelsSecondary or less "0.01 ("0.10 to 0.08) 0.05 ("0.24 to 0.34)University or higher 0 0

Region of residenceRiyadh region 0.03 ("0.07 to 0.13) 0.16 ("0.19 to 0.50)Qassim region 0.02 ("0.08 to 0.11) "0.18 ("0.50 to 0.14)Eastern region 0 0

OccupationsPhysician 0.15 ("0.10 to 0.39) 0.81 ("0.09 to 1.70)Nurse 0.10 ("0.02 to 0.21) 0.45 (0.05–0.84)*Administrator 0.05 ("0.07 to 0.17) 0.31 ("0.08 to 0.69)Pharmacist 0.01 ("0.19 to 0.21) 0.07 ("0.61 to 0.75)Non-Physician specialist 0.06 ("0.07 to 0.18) 0.03 ("0.40 to 0.46)Technician 0 0

GAD-7 score 0.38 (0.34–0.41)***

* P < 0.05.** P < 0.01.

*** P < 0.001.

depression than respondents with secondary school degrees or less(Mean ± SD: 7.26 ± 6.43) (P-value <0.05).

The analysis plan considered a step further via using the mul-tivariate analysis method. Table 4 displays the findings from theanalysis model. It shows that male respondents were found to besignificantly less predicted to have generalized anxiety on averagethan female (Beta = "0.22, P-value <0.04). The analysis model sug-gested that 30–39 years age group were predicted to have beensignificantly more depressed and anxious compared to #50 agegroup (Beta = 0.204, P-value <0.001 and beta = 0.521, P-value <0.003

respectively). Also, healthcare providers aged between 40–49 yearswere found to be significantly more depressed than those aged#50 years (Beta = 0.108, P-value <0.05). Fig. 1 shows the associationbetween healthcare providers’ age groups and their correspond-ing mean anxiety and depression scores, indicating that healthcareproviders’ age correlated significantly and negatively with theirdepression score. In addition, nurses had significantly higher meanlog-transformed anxiety score than technicians (Beta = 0.445, P-value <0.026). However, the analysis model found that participants’anxiety score (log transformed GAD-7 score) converged statisti-cally significantly and positively on their mean log transformeddepression score (Beta = 0.375, P-value <0.001) indicating that par-ticipants’ anxiety predicted significantly higher depression. On theother hand, the healthcare providers’ educational level, residen-tial location and occupation did not converge significantly on theirmean log-transformed depression and anxiety score in the multi-variate analysis. And the gender did not converge significantly ontheir mean log-transformed depression score.

Exploring healthcare providers’ emotions and needs

Various emotions and needs were reported in response to anexploratory question. Negative emotions were reported by 62.15%of the respondents. These emotions included fears about being thecause of spreading the virus to family or other people outside thehospital, anxiety toward the uncertainty and toward people whoare uncommitted to social distancing instructions, exhaustion andstress from the workload, and depression with hopelessness. On theother hand, positivity was also reported by 37.85% of the respon-dents. Many healthcare providers were proud of themselves andfeeling happy to serve the country. Many of them were also hope-ful, optimistic, or having faith in God’s will. However, their needswere workplace-centered; many of them reported needing morephysical, psychological, and financial support in the workplace.

Discussion

It is important to investigate mental health conditions amonghealthcare providers due to the possible impacts of such con-

Fig. 1. The association between healthcare providers’ age groups and their corresponding mean raw anxiety and depression scores.

1436 D.A. AlAteeq et al. / Journal of Infection and Public Health 13 (2020) 1432–1437

ditions on their health and on the quality of patient care [14].This study is the first to investigate the prevalence of depres-sion and anxiety during the COVID-19 outbreak in Saudi Arabiaamong healthcare providers from 3 prominent regions in Saudi Ara-bia and representing various specialties at Ministry of Health. Wefound that depression and anxiety were prevalent among health-care providers (55.2% and 51.4%, respectively). We also found thatfemale respondents and nurses had significantly higher mean scoreof anxiety. And healthcare providers aged from 30 to 39 years hadsignificantly higher mean scores of depression and anxiety. Dur-ing the COVID-19 outbreak, a Chinese study similarly reporteda high prevalence of psychiatric symptoms among 1257 health-care providers, mainly depression, anxiety and distress (50.4%,44.6% and 71.5% respectively). Also, similarly, more severe symp-toms were reported by nurses and female respondents [9]. Inaddition, similar recent results of depression and anxiety preva-lence were found among ophthalmologists in Saudi Arabia duringCOVID-19 pandemic (50.5% and 46.7%, respectively). Also, similarly,anxiety was significantly higher among female ophthalmologists[15]. Moreover, the psychological impact of the pandemic on theSaudi general population have been assessed recently and showedlower prevalence of depression and anxiety symptoms comparedto our study (40.9% and 29.9%, respectively) [16]. Similarly, theresults among Saudi general population indicated that health careproviders and females had higher levels of depression, anxiety andstress [16]. Another similar findings were shown in recent Jor-danian study, which identified females and pulmonologists as ahigher risk of depression group among healthcare providers duringCOVID-19 pandemic [17]. However, the prevalence of depressionand anxiety symptoms among healthcare providers in our studywas much lower compared to Jordan (78.1% and 70.8%, respec-tively) [17]. In another Chinese study, nurses expressed irritability,excitability, and signs of psychological distress. Medical staff werefearful about transmitting the virus to their families. They prior-itized the need for rest and protective supplies and psychologicalskills training for dealing with the patients’ emotional distress [18].In our study, it was expected that females would have significantlyhigher levels of anxiety as this disorder is generally more frequentamong women [19].

A similar total anxiety prevalence (52%) was found in 2017among emergency healthcare workers in Saudi Arabia at one of thelargest emergency units in the area and level I trauma center. How-ever, the prevalence of severe anxiety in our study was twice theprevalence in this previous study (15.3% versus 7.6%) [20]. Theseresults indicate higher levels of anxiety, compared to any anxietydisorder, among the Saudi population (16%) [21]. Anxiety duringemergency situations may be explained by work-related stressand high job demands [22]. Other studies that were conductedamong healthcare providers during the SARS outbreak suggestedsome sources of distress: social stigmatization; family members’ostracism; social isolation; loss of control; health of self, family andothers; changes in work; and spread of the virus [23,24]. A lack ofrecognition of anxiety symptoms may lead to serious psychologicalconsequences [21].

It is not surprising that nurses reported significantly highermean score of anxiety than other healthcare providers. The litera-ture has shown that, compared to other professionals, healthcareproviders, especially nurses, have a higher risk of developingemotional distress like depression, anxiety, and burnout dueto work-related stress [25]. Moderate stress was also evidentamong frontline nurses in Saudi Arabia who were highly perceivedinfectability to COVID-19 and germ aversion [26]. There are factorsthat appeared to increase the risk of developing anxiety symp-toms among Chinese nurses, like poor nurse-patient relationships,over-commitment, and lower job rank [27]. Another study that wasconducted among nursing staff from various nationalities in Saudi

Arabia found that having a Middle Eastern nationality, divorce orwidowed marital status, a lack of physical activities, and smokingare risk factors for anxiety and depression [28]. In addition, phys-ical and mental conditions, like depression and anxiety, may beaffected by the nurse’s shift timing [29]. Emergency nurses alsoreported job difficulties like higher work demands, less decision-making authority, and lower financial or social recognition [22].Previous studies that were conducted among healthcare providersduring pandemics illustrated that clinical staff (doctors and nurses)and staff who were working with SARS patients reported sig-nificantly higher levels of anxiety [23]. The SARS outbreak hadcaused increased levels of distress among emergency staff, espe-cially nurses, followed by doctors. Nurses coped mainly throughbehavioral disengagement and doctors coped mainly through plan-ning, whereas healthcare assistants coped through self-distractions[24]. Frontline nurses may also have higher risk of infection due totheir frequent, close contact with the patients and long workinghours [30,31].

On the other hand, the significantly higher mean scores ofdepression and anxiety among the 30–39 age group is similar tothe Jordanian study conducted during COVID-19 pandemic, whichdemonstrated that the #50 years age group of healthcare providershad a significant lower risk to develop depression [17]. This is alsoconsistent with previous studies that found increased prevalenceof psychiatric disorders among younger adults [32–34]. This find-ing may be explained by the less adaptive way reacting to stressors[35] and the age-related biopsychosocial changes [36]. It may alsobe attributed to the higher response rate as they represent 55.4% ofour sample.

Limitations

Although this study is the first Saudi survey to explore men-tal health among healthcare providers, it has multiple limitations.First, the majority of the respondents was from the Qassim region(60.96%), which limits the generalization of our findings to more-affected regions. Second, this study did not assess respondents’previous histories of mental health conditions, which may haveexisted before the COVID-19 outbreak. Third, response bias isalso possible in convenience sampling. Fourth, this cross-sectionalstudy design is unable to make causal conclusions. Finally, manyimportant variables were not considered in the study for time pur-pose, as we aimed to make the shortest possible version of thesurvey in order to increase the response rate during the busy timeof the healthcare providers during COVID-19 outbreak. Examples ofthese important variables that might have association with depres-sion or anxiety include got infected with COVID-19, had a colleagueor family member infected with COVID-19, years of experience andhad a negative experience with previous outbreaks.

Conclusions

In conclusion, depression and anxiety symptoms occurred in afrequency of 55.2% and 51.4% among healthcare providers in SaudiArabia with varied severity, as half of those had mild conditions andthe rest ranged from moderated to severe. However, more atten-tion should be paid to the mental health of nursing, female staff, andthe 30–39 age group. Routine checkups for the mental status shouldbe implemented especially during pandemics. It is also importantto ensure that the physical needs of healthcare providers, includ-ing sufficient sleep and protected times and places to rest, are met.Promoting healthcare service as a humanitarian and national dutymay contribute toward making it a more meaningful experience, inaddition to advocating for solidarity, altruism, and social inclusion.Psychiatric and psychotherapeutic interventions may enhance psy-

D.A. AlAteeq et al. / Journal of Infection and Public Health 13 (2020) 1432–1437 1437

chological resilience and well-being during the COVID-19 epidemic[37]. Finally, longitudinal research studies need to be conducted tofollow up regarding the participants’ mental health symptoms andfor evidence-based interventions.

Funding

No funding sources.

Competing interests

None declared.

Ethical approval

Not required.

Acknowledgements

This research was funded by the Deanship of Scientific Researchat Princess Nourah Bint Abdulrahman University through the Fast-track Research Funding Program.

References

[1] Coronavirus disease (COVID-19) pandemic. World Health Organization; 2020https://www.who.int/emergencies/diseases/novel-coronavirus-2019.

[2] WHO timeline — COVID-19. World Health Organization; 2020.[3] Rolling updates on coronavirus disease (COVID-19). World Health Organi-

zation; 2020 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen.

[4] Saudi Arabia announces first case of coronavirus. REUTERS; 2020 https://www.reuters.com/article/us-health-coronavirus-saudi/saudi-arabia-announces-first-case-of-coronavirus-idUSKBN20P2FK.

[5] Huremović D. Psychiatry of pandemics: a mental health response to infectionoutbreak. Cham: Springer; 2019, http://dx.doi.org/10.1007/978-3-030-15346-5.

[6] Stress and Coping. Centers for disease control and prevention; 2020 https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html.

[7] Send in the therapists? Lancet Psychiatry 2019;7:291, http://dx.doi.org/10.1016/S2215-0366(20)30102-4.

[8] Ayanian JZ. Mental health needs of health care workers providing front-line COVID -19 Care. JAMA Health Forum 2020, http://dx.doi.org/10.1001/jamahealthforum.2020.0397. Published online April 1, 2020.

[9] Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mentalhealth outcomes among health care workers exposed to coronavirus disease2019. JAMA Netw 2020;3:1–12, http://dx.doi.org/10.1001/jamanetworkopen.2020.3976.

[10] Sample size calculator by Raosoft, Inc. n.d. http://www.raosoft.com/samplesize.html. [Accessed 16 August 2020].

[11] Löwe B, Gräfe K, Zipfel S, Witte S, Loerch B, Herzog W. Diagnosing ICD-10depressive episodes: superior criterion validity of the patient health ques-tionnaire. Psychother Psychosom 2004;73:386–90, http://dx.doi.org/10.1159/000080393.

[12] Alhadi AN, Alateeq DA, Al-Sharif E, Bawazeer HM, Alanazi H, Alshomrani AT,et al. An Arabic translation, reliability, and validation of Patient Health Ques-tionnaire in a Saudi sample. Ann Gen Psychiatry 2017:1–9, http://dx.doi.org/10.1186/s12991-017-0155-1.

[13] Kroenke K, Wu J, Yu Z, Bair MJ, Kean J, Stump T, et al. Patient healthquestionnaire anxiety and depression scale: initial validation in three clin-ical trials. Psychosom Med 2016;78:716–27, http://dx.doi.org/10.1097/PSY.0000000000000322.

[14] Haynes C. Stress in health professionals. Psychologist 2000;13:128–9.[15] Almater A, Tobaigy M, Younis A, Alaqeel M, Abouammoh M. Effect of 2019

coronavirus pandemic on ophthalmologists practicing in Saudi Arabia: a psy-chological health assessment. Middle East Afr J Ophthalmol 2020;27:79–85,http://dx.doi.org/10.4103/meajo.MEAJO 220 20.

[16] Alkhamees AA, Alrashed SA, Alzunaydi AA, Almohimeed AS, Aljohani MS. Thepsychological impact of COVID-19 pandemic on the general population ofSaudi Arabia. Compr Psychiatry 2020;102:152192, http://dx.doi.org/10.1016/j.comppsych.2020.152192.

[17] Naser AY, Dahmash EZ, Al-Rousan R, Alwafi H, Alrawashdeh HM, Ghoul I,et al. Mental health status of the general population, healthcare professionals,and university students during 2019 coronavirus disease outbreak in Jordan:a cross-sectional study. Brain Behav 2020;n/a:e01730, http://dx.doi.org/10.1002/brb3.1730.

[18] Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medicalstaff in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e15–6,http://dx.doi.org/10.1016/S2215-0366(20)30078-X.

[19] Gender and women’s mental health. World Health Organization; 2018 https://www.who.int/mental health/prevention/genderwomen/en/.

[20] Alharthy N, Alrajeh OA, Almutairi M, Alhajri A. Assessment of anxiety levelof emergency health-care workers by generalized anxiety disorder-7 tool.Int J Appl Basic Med Res 2017;7:150–4, http://dx.doi.org/10.4103/2229-516X.212963.

[21] Tanios CY, Abou-Saleh MT, Karam AN, Salamoun MM, Mneimneh ZN, Karam EG.The epidemiology of anxiety disorders in the Arab world: a review. J AnxietyDisord 2009;23:409–19, http://dx.doi.org/10.1016/j.janxdis.2008.10.009.

[22] Adriaenssens J, De Gucht V, Van Der Doef M, Maes S. Exploring the bur-den of emergency care: predictors of stress-health outcomes in emergencynurses. J Adv Nurs 2011;67:1317–28, http://dx.doi.org/10.1111/j.1365-2648.2010.05599.x.

[23] Koh D, Lim MK, Chia SE, Ko SM, Qian F, Ng V, et al. Risk perception and impact ofsevere acute respiratory syndrome (SARS) on work and personal lives of health-care workers in Singapore what can we learn? Med Care 2005;43:676–82.

[24] Wong TW, Yau JKY, Chan CLW, Kwong RSY, Ho SMY, Lau CC, et al. The psycho-logical impact of severe acute respiratory syndrome outbreak on healthcareworkers in emergency departments and how they cope. Eur J Emerg Med2005;12.

[25] Fiabane E, Giorgi I, Sguazzin C, Argentero P. Work engagement and occupationalstress in nurses and other healthcare workers: the role of organisational andpersonal factors. J Clin Nurs 2013;22:2614–24, http://dx.doi.org/10.1111/jocn.12084.

[26] Pasay-an E. Exploring the vulnerability of frontline nurses to COVID-19 and itsimpact on perceived stress. J Taibah Univ Med Sci 2020, http://dx.doi.org/10.1016/j.jtumed.2020.07.003.

[27] Gao Y-Q, Pan B-C, Sun W, Wu H, Wang J-N, Wang J-N. Anxiety symptomsamong Chinese nurses and the associated factors: a cross sectional study. BMCPsychiatry 2012;12:141, http://dx.doi.org/10.1186/1471-244X-12-141.

[28] Abbas MAF, Zaid LZA, Hussaein M, Bakheet KH, AlHamdan NA. Anxiety anddepression among nursing staff at King Fahad Medical City, Kingdom of SaudiArabia. J Am Sci 2012;8:788–94.

[29] Portela L, Rotenberg L, Waissmann W. Self-reported health and sleep com-plaints among nursing personnel working under 12 h night and day shifts.Chronobiol Int 2004;21:859–70, http://dx.doi.org/10.1081/CBI-200038513.

[30] Li L, Cheng S, Gu J. SARS infection among health care workers in Beijing, China.JAMA 2003;290:2662–3, http://dx.doi.org/10.1001/jama.290.20.2662.

[31] Shih F-J, Gau M-L, Kao C-C, Yang C-Y, Lin Y-S, Liao Y-C, et al. Dying and caring onthe edge: Taiwan’s surviving nurses’ reflections on taking care of patients withsevere acute respiratory syndrome. Appl Nurs Res 2007;20:171–80, http://dx.doi.org/10.1016/j.apnr.2006.08.007.

[32] Flint AJ, Peasley-Miklus C, Papademetriou E, Meyers BS, Mulsant BH, RothschildAJ, et al. Effect of age on the frequency of anxiety disorders in major depressionwith psychotic features. Am J Geriatr Psychiatry 2010;18:404–12, http://dx.doi.org/10.1097/JGP.0b013e3181c294ac.

[33] Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetimeprevalence and age-of-Onset distributions of DSM-IV disorders in the nationalcomorbidity survey replication. Arch Gen Psychiatry 2005;62:593–602, http://dx.doi.org/10.1001/archpsyc.62.6.593.

[34] Wells JE, Oakley Browne MA, Scott KM, McGee MA, Baxter J, Kokaua J. Preva-lence, interference with life and severity of 12 month DSM-IV disorders in TeRau Hinengaro: the New Zealand Mental Health Survey. Aust N Z J Psychiatry2006;40:845–54, http://dx.doi.org/10.1080/j.1440-1614.2006.01903.x.

[35] Schilling OK, Diehl M. Psychological vulnerability to daily stressors in oldage. Z Gerontol Geriatr 2015;48:517–23, http://dx.doi.org/10.1007/s00391-015-0935-7.

[36] Epidemiology and comorbidity of anxiety disorders in the elderly. Am J Psychi-atry 1994;151:640–9, http://dx.doi.org/10.1176/ajp.151.5.640.

[37] Christodoulou N, Christodoulou NG, Christodoulou GN. Financial crises:impact on mental health and suggested responses. Psychother Psychosom2013;82:279–84, http://dx.doi.org/10.1159/000351268.