ORIGINAL RESEARCH published: 14 January 2021

doi: 10.3389/fpsyt.2020.619540

Frontiers in Psychiatry | www.frontiersin.org 1 January 2021 | Volume 11 | Article 619540

Edited by:

Christos Theleritis,

National and Kapodistrian University

of Athens, Greece

Reviewed by:

Abdallah Y. Naser,

Isra University, Jordan

Zezhi Li,

Shanghai JiaoTong University, China

*Correspondence:

Khizra Sultana

[email protected]

†These authors have contributed

equally to this work

Specialty section:

This article was submitted to

Public Mental Health,

a section of the journal

Frontiers in Psychiatry

Received: 20 October 2020

Accepted: 09 December 2020

Published: 14 January 2021

Citation:

Al Ammari M, Sultana K, Thomas A, Al

Swaidan L and Al Harthi N (2021)

Mental Health Outcomes Amongst

Health Care Workers During COVID

19 Pandemic in Saudi Arabia.

Front. Psychiatry 11:619540.

doi: 10.3389/fpsyt.2020.619540

Mental Health Outcomes Amongst Health Care Workers During COVID 19 Pandemic in Saudi Arabia Maha Al Ammari1,2,3,4†, Khizra Sultana2,3,4*†, Abin Thomas5,6, Lolowa Al Swaidan1,2,3,4 and

Nouf Al Harthi1,2,3,4

1 Department of Pharmacy Service, King Abdul Aziz Medical City, Riyadh, Saudi Arabia, 2 Ministry of National Guard Health

Affairs (MNGHA), King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia, 3 King Abdullah

International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia, 4 King Saud Bin Abdulaziz University for Health

Sciences (KSAU-HS), Riyadh, Saudi Arabia, 5 College of Biomedical and Life Sciences, Cardiff University, Cardiff,

United Kingdom, 6 Centre for Trials Research, Cardiff University, Cardiff, United Kingdom

Objectives: The study aimed to assess the mental health outcomes and associated

factors among health care workers during COVID 19 in Saudi Arabia.

Design, Setting, and Participants: We conducted a cross-sectional survey of health

care workers from tertiary care and ministry of health Centers across the Central, Eastern,

and Western regions of Saudi Arabia. There were 1,130 participants in the survey, and

we collected demographic and mental health measurements from the participants.

Primary Outcomes and Measures: The magnitude of symptoms of depression,

anxiety, and insomnia was measured using the original version of 9-item patient health

questionnaire (PHQ-9), the 7-item generalized anxiety disorder scale (GAD-7), and 7-item

insomnia severity index (ISI). We use the multiple logistic regression analysis to identify

the associated risk factors of individual outcomes.

Results: The scores on the PHQ-9 showed that the largest proportion of health

care workers (76.93%) experienced only normal to mild depression (50.83 and 26.1%,

respectively). The scores on the GAD-7 showed that the largest proportion of health care

workers (78.88%) experienced minimal to mild anxiety (50.41 and 28.47%, respectively).

The scores on the ISI showed that the largest proportion of health care workers (85.83%)

experienced absence to subthreshold insomnia (57.08 and 28.75%, respectively). The

risk factors for depression in health care workers were Saudi, living with family, working

from an isolated room at home and frontline worker. For anxiety, being female was risk

factor and for insomnia, being frontline worker was risk factor.

Conclusion: It was observed that the symptoms of depression, anxiety, and insomnia

were reported in a lower proportion of health care workers in our study. The participants

who were female, frontline workers, Saudi, living with family, and working from home in

isolated rooms were predisposed to developing psychological disorders.

Keywords: mental health, Saudi Arabia (KSA), COVID-19, outcomes—health care, health care workers

Al Ammari et al. Mental Health Outcomes During COVID 19

INTRODUCTION

The severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), also known as COVID-19, started in Wuhan’s Chinese city at the end of December 2019 and was declared a global public health concern by WHO at the end of January 2020 (1). As of 14 May 2020, the Coronavirus positive cases were at 44,830 in the Kingdom of Saudi Arabia (KSA), which was the highest in the Gulf Cooperation Council states (2). In the context of the COVID-19 pandemic, it is essential to evaluate the mental health of the Health Care Workers (HCWs) as they are constantly exposing themselves to the risk of infection and separating themselves from their families for weeks to avoid transmitting the virus to them. HCWs are also most susceptible to emotional distress in the current pandemic due to their risk of exposure to the virus, fear about infecting and caring for their loved ones, scarcity of personal protective equipment (PPE), and long work hours (3, 4). During the 2003 SARS outbreak, a study reported that HCWs feared infecting their families or friends and felt stigmatized because they were known to contact with sick patients (5–8) This led to them experiencing significant long- term psychological stress even after 1 year from the outbreak (8). It has been observed that in Italy and the US, where this pandemic took a toll on the health care system, in addition to a shortage of infectious disease consultants, other doctors were trained to care for an influx of patients within 7 days (9). Many of them would have post-traumatic stress disorder or other mental health problems down the line as they have no experience watching a patient being intubated or die in front of them (9).

Health care workers already deal with disproportionately high rates of depression—about three times higher than the general public (10). However, the strain of treating coronavirus patients, and the impossible decisions many doctors and nurses are being forced to make, will likely worsen their mental health (11). Several studies were done in KSA during the MERS- CoV outbreak (12–16). One of the studies reported that half of the respondents for MERS-CoV reported decreased work performance, and 75% reported having psychological problems. In this study, 61.2% of HCW reported anxiety about contracting MERS-CoV from patients (12). None of the surveys done during this period used validated instruments to assess the mental well- being of the HCWs.

The workplace is a vital setting for activities to improve well-being for adults. By addressing mental health issues in the workplace, employers can reduce healthcare costs for their businesses and employees. Evaluation and intervention for psychosocial concerns must be undertaken in these settings. Poor mental health and stress negatively a!ect the employees by decreasing job performance, engagement in work, communication with coworkers, and physical capabilities (17). Protecting and maintaining the mental well-being of health care workers in KSA was a priority during the COVID19 pandemic. It is crucial not only to assess the mental health of HCWs but also associated factors or risk factors as these factors predict the probability of developing the condition, which is not recognized by the patient (18). A risk factor is any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease (19).

Several studies have explored the psychological impact of COVID 19 in HCWs and the general public using di!erent scales in KSA. Alateeq et al. conducted a study using the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) in the ministry of health care hospitals, mostly located in the Qassim region. The authors used the Arabic version of these questionnaires and in only Arabic speaking population (20). Al Mater et al. conducted their study on the psychological health of ophthalmologists from di!erent regions in KSA. They used the English version of PHQ-9, GAD-7, Insomnia Severity Index (ISI), and Perceived Stress Scale (PSS) (21). Alzaid et al. administered a survey in the Eastern Province of KSA in the English language to study anxiety in HCWs. The authors developed the survey with 34 questions, divided into four sections, and the last section included the GAD-7 scale to measure anxiety (22). Zaki et al. surveyed the Northen armed forces hospital in Arabic and English to report the stress and psychological consequences in HCWs. The authors designed the instrument with four sections and the last section included the Impact of Events Scale-Revised(IES-R) (23). Alenazi et al. (24) surveyed the HCWs’ in the Arabic language to study the prevalence and predictors of anxiety in 13 regions of KSA. Alsulais et al. explored the psychological impact of COVID 19 in physicians. The authors adapted a questionnaire in the English language from a previous Canadian study done on SARS (25). Temsah et al. surveyed HCWs in King Khalid University Hospital Riyadh. The authors designed the survey and included the GAD-7 to assess anxiety (26). Al Hanawi et al. (27) conducted their study using the Peritraumatic Distress Index (CPDI) administered in Arabic in HCWs and the general public.

In this study, we assessed the mental health and associated risk factors among HCWs during the COVID 19 pandemic using the English version of validated assessment scales—Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), and Insomnia Severity Index (ISI) scale to measure the depression, anxiety, and insomnia.

METHODS

This study is a cross-sectional web-based survey administered using LIME software for HCWs from 27 April to 4 May 2020. We used the purposive sampling method for this study. The weblink to the questionnaire was sent to prospective participants through WhatsApp, Twitter, and o"cial emails. The number of HCWs who participated in the survey was 1,130, out of which 720 completed the survey. All participants were given information about the purpose of the study and were assured confidentiality. Participating in the survey indicated their consent to the study. The participants included health care providers (physicians, nurses, pharmacists, respiratory therapists, physical therapists, nutritionist, and paramedics) working in di!erent departments in Ministry of National Guard Health A!airs (MNGHA) hospitals across the Central, Eastern, and Western regions and some Ministry of Health (MOH) Centers across Central Region.

Frontiers in Psychiatry | www.frontiersin.org 2 January 2021 | Volume 11 | Article 619540

Al Ammari et al. Mental Health Outcomes During COVID 19

Outcomes and Covariates We assessed the level of depression, anxiety, and insomnia using the validated scales original version. The 9-item Patient Health Questionnaire(PHQ-9; range, 0–27) the 7-item Generalized Anxiety Disorder (GAD-7; range, 0–21) scale, and the 7-item Insomnia Severity Index (ISI; range, 0–28) (28–30).

The PHQ-9 helps in screening, diagnosing, monitoring, and measuring the severity of depression. It has a one factorial structure with nine questions. These questions are scored 0– 3 (“Not at all,” “Several days,” “More than half the days,” and “Nearly every day”), providing a 0 to 27 severity score. There is an additional question in the end: a follow-up non-scored question that screens and assigns weight to the degree to which depressive problems have a!ected the patient’s level of function. The total PHQ-9 score is classified into 0–4 = “Minimal depression,” 5– 9 = “Mild depression,” 10–14 = “Moderate depression,” 15– 19 = “Moderately severe depression,” and 20–27 = “Severe depression” (29).

The GAD-7 helps in screening, diagnosing, and measuring the severity of anxiety. It consists of one factorial structure with seven questions. These questions are scored 0–3 (“not at all,” “several days,” “more than half the days,” and “nearly every day”) providing 0–21 severity score. There is an additional question in the end, which is a follow-up non-scored question that assigns weight to the degree to which anxiety problems have a!ected the patient’s functional level. The GAD-7 score is classified into 0–4 = “Minimal anxiety,” 5–9 = “Mild anxiety,” 10–14 = “Moderate anxiety,” and 15–21 = “Severe anxiety” (31).

The Insomnia Severity Index (ISI) is a brief instrument that assesses the severity of both nighttime and daytime insomnia components. It comprises of one factorial structure with seven questions. A 5 point Likert scale is used to rate each item from 0 to 4 with di!erent answer options according to the questions providing 0 to 28 severity scores. The ISI score is classified into 0–7 = “No clinically significant insomnia,” 8–14 = “Subthreshold insomnia,” 15–21 = “Clinical insomnia (moderate severity),” and 22–28 = “Clinical insomnia (severe)” (28).

Demographic data was self-reported by the participants which included “age,” “gender,” “nationality,” “region,” “marital status,” “educational level,” “have children,” and “living with family during the outbreak.” Job-related questions include “department,” “profession,” “clinical experience,” “working position (front line or second line),” “duration of employment in MNGHA.”

Analysis The data was extracted in MS Excel, and incomplete or missing responses were removed; hence the analysis data was complete without any missing values. Data analysis was performed using SAS 9.4 [Copyright (c) 2016 by SAS Institute Inc., Cary, NC, USA]. The PHQ-9, GAD-7, and ISI questions were scored as described in the guidelines (28–30). Due to fewer frequencies, some multicategory variables were merged into lesser categories such as Central and Other regions; Marital status: Single and Married; Departments: Critical care, Pharmacy, Medicine, and Others; Professional title: Physician, Nurse, Pharmacist, and Others.

The tools’ scores were presented as medians, and interquartile ranges (IQRs) and frequency and percentages were used to summarize the demographics, work environment, and the living condition related questions. The analysis estimated the relative frequencies of demographic, work-related, and living condition related variables across the PHQ-9, GAD-7, and ISI categories. A Chi-square test is used to calculate the p-value for all cross- tabulation. A two tailed test with p < 0.05 is considered as evidence for an association.

Multiple logistic regression models are used to determine the factors associated with symptoms of “Moderate or Severe depression,” “Moderate or Severe anxiety,” and “Subthreshold, Moderate or Severe insomnia.” All variables with a p-value of <0.05 in the bivariate analysis are selected for the logistic regression models. For modeling the “Moderate or Severe depression,” the gender, age, nationality, experience, belong to ministry or not, marital status, living with family, have children, and work position variables are selected as independent variables. For modeling the “Moderate or Severe anxiety,” the gender, age, nationality, profession, experience, living with family, and work position variables are independent variables. For modeling the “Subthreshold, Moderate or Severe insomnia,” gender, age, experience, and work position are used as independent variables. The multivariate results are reported as adjusted odds ratios and corresponding 95% confidence limits.

Ethics

The study was planned and conducted as per the declaration of Helsinki 1964 and is approved by King Abdullah International Medical Research Center (KAIMRC) ethics review board with protocol no RC20/169/R.

RESULTS

Demographics In this study, 1,130 HCWs participated, with 720 complete responses. Of the respondents, 194 (26.94%) Physicians, 262 (36.39%) Nurses, and 171 (23.75%) pharmacists completed the survey. The participants’ female respondents (64.17%) were almost double the males (35.83%), with nearly 75% above 30 years of age. Saudis (57.22%) were slightly higher compared to expatriates, with the majority of the participants working in the central region (84.2%) in tertiary care hospitals (71.77%). Most of the participants were postgraduates (91.81%), with nearly 60% with >10 years of professional experience. A little over 60% were single, and 61% were working from home. Nearly 60% of the participants had children, and 62% had no previous experience with the pandemic, and only 32.5% have received some training to work during such a crisis. Only about one-third of the participants were frontline HCWs directly engaged in diagnosing, treating, or caring for the patients with suspected COVID-19 (Table 1).

Scores of Measurement and Associated Factors Table 2 reports the participants’ overall responses, the median, interquartile range, and the Chi-square analysis. The median

Frontiers in Psychiatry | www.frontiersin.org 3 January 2021 | Volume 11 | Article 619540

Al Ammari et al. Mental Health Outcomes During COVID 19

TABLE 1 | Demographics.

Overall N (%) 720 (100)

Gender Number of years of professional

Male 258 (35.83) 1 to 3 96 (13.33)

Female 462 (64.17) 4 to 6 112 (15.56)

Age 7 to 9 92 (12.78)

18–25 31 (4.31) >10 420 (58.33)

26–30 150 (20.83) Do you belong to the MNGHA

31–40 278 (38.61) No 171 (23.75)

>40 261 (36.25) Yes 549 (76.25)

Nationality Type of hospital

Saudi 412 (57.22) Secondary 125 (17.39)

Non-Saudi 308 (42.78) Tertiary 516 (71.77)

Region Other 78 (10.85)

Central 606 (84.2) Missing 1

Western 67 (9.31) Marital Status

Eastern 30 (4.17) Single 450 (62.5)

Other 17 (2.36) Married 253 (35.14)

Department Other 17 (2.36)

Critical care 156 (21.67) Are you living with your family

Emergency medicine 19 (2.64) Yes, working from home 256 (35.56)

Surgical wards 22 (3.06) No 280 (38.89)

Laboratory 15 (2.08) Yes, isolated in separate room 184 (25.56)

Pharmacy 163 (22.64) Do you have children

Medicine 91 (12.64) Yes 420 (58.33)

Other 254 (35.28) No 300 (41.67)

Professional title Previous experience with pandemic

Physician 194 (26.94) No 446 (61.94)

Nurse 262 (36.39) Other 274 (38.06)

Respiratory therapist 11 (1.53) Any kind of training for pandemic

Pharmacist 171 (23.75) No 486 (67.5)

Lab Technician 8 (1.11) Other 234 (32.5)

Other 74 (10.2) What is your working position

Front line 200 (27.78)

Educational level Second line 520 (72.22)

Under graduate 59 (8.19)

Post graduate 661 (91.81)

total score with IQR reported for depression was 4 (2.00–9.00). The scores on the PHQ-9 showed that the largest proportion of HCWs (76.93%) experienced normal to mild depression (50.83% and 26.1%, respectively). The rest (22.99%) reported moderate, moderately severe, and severe depression (13%, 7.91%, and 2.08%, respectively). The median total score with IQR reported for generalized anxiety was 4 (1.00–8.00). The scores on the GAD-7 showed that the largest proportion of HCWs (78.88%) experienced minimal to mild anxiety (50.41% and 28.47%, respectively). The rest (21.1%) reported moderate to severe anxiety (12.77% and 8.33%, respectively). The median total score with IQR reported for insomnia was 6 (2.00–12.00). The scores on the ISI showed that the largest proportion of HCWs (85.83%) experienced absence to subthreshold insomnia (57.08% and 28.75%, respectively). The rest (14.16%)

reported moderately severe to severe insomnia (10.41% and 3.75%, respectively).

The Chi-square test for the scores of these instruments with demographic variables showed that depression, anxiety, and insomnia were correlated significantly according to the age groups with P < 0.0001 for all the three tools, years of professional experience was associated with p <0.001, P = 0.005, and p = 0.011 respectively; and the working position was associated with P = 0.048, p = 0.004, and p = 0.0002, respectively. Depression and anxiety were significantly related to being Saudi vs. non-Saudi with p < 0.0001 and p < 0.0005, respectively. Working from home in isolation or not working from home was associated with depression and anxiety with p = 0.03 and p = 0.008, respectively, whereas insomnia was not significantly related to these variables. Depression was significantly related to

Frontiers in Psychiatry | www.frontiersin.org 4 January 2021 | Volume 11 | Article 619540

A lA

m m a rie

t a l.

M e n ta lH

e a lth

O u tc o m e s D u rin

g C O V ID

1 9

TABLE 2 | Severity categories of depression, anxiety, and insomnia in total cohort and subgroups.

PHQ-9 depression symptoms GAD-7 anxiety ISI-insomnia symptoms

Total score, median

(IQR)

4.00 (2.00–9.00) 4.00 (1.00–8.00) 6.00 (2.00–12.00)

Normal Mild Moderate Moderate

Severe

Severe Normal Mild Moderate Severe Absence Sub

threshold

Moderate

Severity

Severe

Total N (%) 366 (50.83) 188 (26.1) 94 (13) 57 (7.91) 15 (2.08) 363 (50.41) 205 (28.47) 92 (12.77) 60 (8.33) 411 (57.08) 207 (28.75) 75 (10.41) 27 (3.75)

Age N (%) 18–25 17 (54.84) 4 (12.9) 6 (19.35) 3 (9.68) 1 (3.23) 15 (48.39) 8 (25.81) 5 (16.13) 3 (9.68) 18 (58.06) 10 (32.26) 2 (6.45) 1 (3.23)

26–30 50 (33.33) 52 (34.67) 32 (21.33) 14 (9.33) 2 (1.33) 63 (42) 44 (29.33) 25 (16.67) 18 (12) 67 (44.67) 57 (38) 20 (13.33) 6 (4)

31–40 134 (48.2) 74 (26.62) 39 (14.03) 23 (8.27) 8 (2.88) 115 (41.37) 97 (34.89) 44 (15.83) 22 (7.91) 152 (54.68) 79 (28.42) 32 (11.51) 15 (5.4)

>40 165 (63.22) 58 (22.22) 17 (6.51) 17 (6.51) 4 (1.53) 170 (65.13) 56 (21.46) 18 (6.9) 17 (6.51) 174 (66.67) 61 (23.37) 21 (8.05) 5 (1.92)

<0.0001 <0.0001 <0.0001

Nationality No. (%) Saudi 178 (43.2) 123 (29.85) 60 (14.56) 39 (9.47) 12 (2.91) 181 (43.93) 127 (30.83) 62 (15.05) 42 (10.19) 221 (53.64) 128 (31.07) 45 (10.92) 18 (4.37)

Non-Saudi 188 (61.04) 65 (21.1) 34 (11.04) 18 (5.84) 3 (0.97) 182 (59.09) 78 (25.32) 30 (9.74) 18 (5.84) 190 (61.69) 79 (25.65) 30 (9.74) 9 (2.92)

<0.0001 <0.0005 0.171

Professional title

N (%)

Physician 92 (47.42) 51 (26.29) 25 (12.89) 21 (10.82) 5 (2.58) 100 (51.55) 43 (22.16) 26 (13.4) 25 (12.89) 115 (59.28) 45 (23.2) 28 (14.43) 6 (3.09)

Nurse 156 (59.54) 54 (20.61) 32 (12.21) 18 (6.87) 2 (0.76) 151 (57.63) 72 (27.48) 26 (9.92) 13 (4.96) 152 (58.02) 74 (28.24) 25 (9.54) 11 (4.2)

Pharmacist 74 (43.27) 56 (32.75) 23 (13.45) 13 (7.6) 5 (2.92) 73 (42.69) 60 (35.09) 23 (13.45) 15 (8.77) 93 (54.39) 60 (35.09) 13 (7.6) 5 (2.92)

Other 44 (47.31) 27 (29.03) 14 (15.05) 5 (5.38) 3 (3.23) 39 (41.94) 30 (32.26) 17 (18.28) 7 (7.53) 51 (54.84) 28 (30.11) 9 (9.68) 5 (5.38)

0.068 0.004 0.281

Belong to the

Ministry

N (%)

Yes 290 (44.44) 128 (23.32) 75 (13.66) 45 (8.2) 11 (2) 291 (53.01) 149 (27.14) 65 (11.8) 44 (8.01) 312 (56.83) 157 (28.6) 58 (10.56) 22 (4.01)

No 76 (44.44) 60 (35.06) 19 (11.11) 12 (7.02) 4 (2.34) 72 (42.11) 56 (32.75) 27 (15.8) 16 (9.36) 99 (57.89) 50 (29.24) 17 (9.94) 5 (2.92)

0.046 0.094 0.919

Living with family

N (%)

Yes, working from

home

137 (53.52) 68 (26.56) 26 (10.16) 19 (7.42) 6 (2.34) 132 (51.56) 73 (28.52) 31 (12.11) 20 (7.81) 155 (60.55) 64 (25) 29 (11.33) 8 (3.13)

Yes working from

home isolated

room

76 (41.3) 49 (26.63) 37 (20.11) 16 (8.7) 6 (3.26) 75 (40.76) 56 (30.43) 27 (14.67) 26 (14.13) 89 (48.37) 64 (34.78) 22 (11.96) 9 (4.89)

No 153 (54.64) 71 (25.36) 31 (11.07) 22 (7.86) 3 (1.07) 156 (55.71) 76 (27.14) 34 (12.14) 14 (5) 167 (59.64) 79 (28.21) 24 (8.57) 10 (3.57)

0.030 0.008 0.153

Marital Status

N (%)

Single 246 (54.67) 109 (24.22) 55 (12.22) 30 (6.67) 10 (2.22) 231 (51.33) 129 (28.67) 51 (11.3) 39 (8.67) 268 (59.56) 124 (27.56) 43 (9.56) 15 (3.33)

Married 110 (43.48) 75 (29.64) 38 (15.02) 26 (10.28) 4 (1.58) 121 (47.83) 73 (28.85) 41 (16.2) 18 (7.11) 133 (52.57) 80 (31.62) 29 (11.46) 11 (4.35)

0.045 0.282 0.343

Do you have children

N (%)

Yes 235 (55.95) 98 (23.33) 49 (11.67) 29 (6.9) 9 (2.14) 221 (52.62) 120 (28.57) 43 (10.24) 36 (8.57) 252 (60) 107 (25.48) 46 (10.95) 15 (3.57)

No 131 (43.67) 90 (30) 45 (15) 28 (9.33) 6 (2) 142 (47.33) 85 (28.33) 49 (16.33) 24 (8) 159 (53) 100 (33.33) 29 (9.67) 12 (4)

0.027 0.106 0.131

(Continued)

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Al Ammari et al. Mental Health Outcomes During COVID 19

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