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Shu Jing, Zhenwei Dai, Xiaoyang Liu, Xiaoyou Su, An In-depth Examination of Depressive and Anxiety symptoms among Healthcare workers in the Chinese Mainland during the COVID-19 Pandemic Surge, QJM: An International Journal of Medicine, Volume 117, Issue 8, August 2024, Pages 619–621, https://doi.org/10.1093/qjmed/hcae083
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Dear Editor,
We appreciate the interest shown by Ibrahim et al. in our previously published cross-sectional study, where we investigated the prevalence and influencing factors of depressive and anxiety symptoms among Chinese hospital-based healthcare workers during the surge phase of the coronavirus disease 2019 (COVID-19) pandemic.1 We are delighted to respond to their insightful comments accordingly.
First, this cross-sectional study was conducted from 5 January to 9 February 2023, after all of the COVID-19 lockdown measures in China had been thoroughly lifted. Therefore, the original design of the study did not include investigating the impact of strict lockdown measures on depressive and anxiety symptoms among hospital-based healthcare workers during the surge phase. However, our research team previously conducted a multi-center survey to investigate the mental health status of frontline healthcare workers at the beginning of the COVID-19 outbreak from 23 February to 5 March 2020. This earlier study revealed that the prevalence of depressive and anxiety symptoms among healthcare workers were 13.6% and 13.9%, respectively, both lower than the rates observed in the current study (70.75% and 47.87%).2 These findings suggest that despite the implementation of strict lockdown measures in China during the early stage of the COVID-19 pandemic in 2020, the depression and anxiety symptoms experienced by healthcare workers during the surge phase of the pandemic in 2023 were still more widespread and severe, even though the lockdown measures were no longer in place at the time of the study.2
Regarding the food insecurity crisis mentioned by Ibrahim et al., it is important to note that there was no shortage of food supply in China during our investigation. Logistics and transportation were no longer restricted, which differed from the scenario in Shanghai mentioned by the authors. Additionally, our research team conducted qualitative interviews and a pilot questionnaire survey during the questionnaire design phase. All interviewed healthcare workers reported no food shortage either in their homes and hospitals during that time. Local governments and hospital administrators ensured food supply through various measures, such as centralized procurement and stable supply channels. Therefore, food insecurity issues were not applicable during the period of our study.
Second, we thank Ibrahim et al. for their meaningful comments regarding the potential differences in the prevalence and influencing factors of depressive and anxiety symptoms between doctors and nurses. Indeed, we found the similar results in another study we conducted at the beginning of the outbreak in 2020, indicating that nurses experienced higher levels of mental disorders such as depressive symptoms and PTSD compared to physicians.2 To address this suggestion, the Mann–Whitney U test was utilized to examine the difference in the prevalence of depressive and anxiety symptoms between doctors and nurses. Additionally, stepwise ordinal logistic regression was performed to conduct subgroup analysis. All statistical analyses were conducted using SAS 9.4 and the results are shown in Tables 1 and 2. We found that compared with doctors, nurses experienced more severe mental health problems, and this difference was statistically significant, consistent with previous studies.3–5 The results of the subgroup analysis did not reveal obvious differences in the influencing factors of depressive and anxiety symptoms between doctors and nurses, which aligns with previous findings.1 During the surge phase of the COVID-19 pandemic, nurses are required to provide direct care for patients infected with COVID-19, leading to longer and closer contact with patients and facing the pressure of negative clinical outcomes.2,6,7 In addition, our published study revealed that increased workloads and COVID-19 infections among nurses during this period also threatened their mental health.1
Mann–Whitney U test for depressive and anxiety symptoms of doctors and nurses
| Variable . | Doctors (%) . | Nurses (%) . | Z . | P . |
|---|---|---|---|---|
| Depressive symptoms | −6.215 | <0.001 | ||
| No depressive symptoms | 31.9 | 25.4 | ||
| Low depressive symptoms | 36.3 | 36.7 | ||
| Moderate depressive symptoms | 17.3 | 19.2 | ||
| Severe depressive symptoms | 14.4 | 18.7 | ||
| Anxiety symptoms | −4.831 | <0.001 | ||
| No anxiety symptoms | 54.1 | 48.5 | ||
| Low anxiety symptoms | 29.1 | 30.5 | ||
| Moderate anxiety symptoms | 11.0 | 12.8 | ||
| Severe anxiety symptoms | 5.8 | 8.2 |
| Variable . | Doctors (%) . | Nurses (%) . | Z . | P . |
|---|---|---|---|---|
| Depressive symptoms | −6.215 | <0.001 | ||
| No depressive symptoms | 31.9 | 25.4 | ||
| Low depressive symptoms | 36.3 | 36.7 | ||
| Moderate depressive symptoms | 17.3 | 19.2 | ||
| Severe depressive symptoms | 14.4 | 18.7 | ||
| Anxiety symptoms | −4.831 | <0.001 | ||
| No anxiety symptoms | 54.1 | 48.5 | ||
| Low anxiety symptoms | 29.1 | 30.5 | ||
| Moderate anxiety symptoms | 11.0 | 12.8 | ||
| Severe anxiety symptoms | 5.8 | 8.2 |
Mann–Whitney U test for depressive and anxiety symptoms of doctors and nurses
| Variable . | Doctors (%) . | Nurses (%) . | Z . | P . |
|---|---|---|---|---|
| Depressive symptoms | −6.215 | <0.001 | ||
| No depressive symptoms | 31.9 | 25.4 | ||
| Low depressive symptoms | 36.3 | 36.7 | ||
| Moderate depressive symptoms | 17.3 | 19.2 | ||
| Severe depressive symptoms | 14.4 | 18.7 | ||
| Anxiety symptoms | −4.831 | <0.001 | ||
| No anxiety symptoms | 54.1 | 48.5 | ||
| Low anxiety symptoms | 29.1 | 30.5 | ||
| Moderate anxiety symptoms | 11.0 | 12.8 | ||
| Severe anxiety symptoms | 5.8 | 8.2 |
| Variable . | Doctors (%) . | Nurses (%) . | Z . | P . |
|---|---|---|---|---|
| Depressive symptoms | −6.215 | <0.001 | ||
| No depressive symptoms | 31.9 | 25.4 | ||
| Low depressive symptoms | 36.3 | 36.7 | ||
| Moderate depressive symptoms | 17.3 | 19.2 | ||
| Severe depressive symptoms | 14.4 | 18.7 | ||
| Anxiety symptoms | −4.831 | <0.001 | ||
| No anxiety symptoms | 54.1 | 48.5 | ||
| Low anxiety symptoms | 29.1 | 30.5 | ||
| Moderate anxiety symptoms | 11.0 | 12.8 | ||
| Severe anxiety symptoms | 5.8 | 8.2 |
Subgroup analysis of influencing factors on depressive and anxiety symptoms between doctors and nurses
| Variable . | Depressive symptoms . | Anxiety symptoms . | ||||||
|---|---|---|---|---|---|---|---|---|
| Doctors (N = 2584) . | Nurses (N = 3112) . | Doctors (N = 2584) . | Nurses (N = 3112) . | |||||
| OR . | P . | OR . | P . | OR . | P . | OR . | P . | |
| Gender | ||||||||
| Male | 1 | – | – | – | – | – | – | |
| Female | 1.294 | <0.001 | – | – | – | – | – | – |
| Education | ||||||||
| Associate degree or below | – | – | – | – | – | – | 1 | |
| Bachelor | – | – | – | – | – | – | 1.263 | 0.021 |
| Master or above | – | – | – | – | – | – | 0.911 | 0.731 |
| Marital status | – | – | – | – | – | – | ||
| Single/unmarried | – | – | – | – | – | – | 1 | |
| Married | – | – | – | – | – | – | 1.502 | <0.001 |
| Divorced/widowed | – | – | – | – | – | – | 1.154 | 0.571 |
| Income (Yuan per month) | – | – | – | – | – | – | ||
| <5000 | 1 | 1 | 1 | 1 | ||||
| 5000–10 000 | 0.819 | 0.023 | 0.764 | <0.001 | 0.759 | 0.004 | 0.770 | 0.001 |
| 10 000–30 000 | 0.695 | 0.004 | 0.577 | <0.001 | 0.676 | 0.006 | 0.691 | 0.024 |
| ≥30 000 | 1.448 | 0.385 | 1.008 | 0.992 | 1.537 | 0.336 | 0.540 | 0.515 |
| Years of working | ||||||||
| <5 | 1 | 1 | 1 | – | – | |||
| 5–10 | 1.438 | 0.003 | 1.822 | <0.001 | 1.342 | 0.030 | – | – |
| 10–20 | 1.581 | <0.001 | 2.147 | <0.001 | 1.480 | <0.001 | – | – |
| ≥20 | 1.257 | 0.041 | 2.024 | <0.001 | 1.151 | 0.263 | – | – |
| Treating COVID-19 patients in your working departments (November 2022 to February 2023) | ||||||||
| No | – | – | 1 | – | – | – | – | |
| Yes | – | – | 1.239 | 0.011 | – | – | – | – |
| Supporting other departments that have treated COVID-19 patients (November 2022 to February 2023) | ||||||||
| No | – | – | – | – | – | – | 1 | |
| Yes | – | – | – | – | – | – | 1.245 | 0.003 |
| Perceiving a higher risk of COVID-19 infection due to work (November 2022 to February 2023) | ||||||||
| No | 1 | 1 | 1 | 1 | ||||
| Yes | 1.932 | <0.001 | 1.850 | <0.001 | 1.632 | 0.008 | 1.656 | 0.002 |
| Perceiving a higher Work Intensity (November 2022 to February 2023) | ||||||||
| No | 1 | 1 | 1 | |||||
| Yes | 1.489 | 0.002 | 1.626 | <0.001 | 1.794 | <0.001 | 1.880 | <0.001 |
| COVID-19 infection status (November 2022 to February 2023) | ||||||||
| Not infected | 1 | 1 | 1 | 1 | ||||
| Infected once (positive PCR test or antigen test result) | 1.489 | <0.001 | 1.842 | <0.001 | 1.313 | 0.083 | 1.419 | 0.011 |
| Infected twice or more (positive PCR test or antigen test result) | 2.302 | 0.005 | 1.559 | 0.267 | 5.044 | <0.001 | 1.239 | 0.617 |
| Infected, with COVID-19 symptoms, but without PCR test or antigen test result | 3.783 | <0.001 | 1.631 | 0.002 | 1.065 | 0.733 | 1.124 | 0.495 |
| Mindfulness | 0.807 | <0.001 | 0.814 | <0.001 | 0.779 | <0.001 | 0.801 | <0.001 |
| Resilience | 0.970 | <0.001 | 0.964 | <0.001 | 0.937 | <0.001 | 0.948 | <0.001 |
| Perceived social support | 0.941 | <0.001 | 0.930 | <0.001 | 0.951 | <0.001 | 0.943 | <0.001 |
| Variable . | Depressive symptoms . | Anxiety symptoms . | ||||||
|---|---|---|---|---|---|---|---|---|
| Doctors (N = 2584) . | Nurses (N = 3112) . | Doctors (N = 2584) . | Nurses (N = 3112) . | |||||
| OR . | P . | OR . | P . | OR . | P . | OR . | P . | |
| Gender | ||||||||
| Male | 1 | – | – | – | – | – | – | |
| Female | 1.294 | <0.001 | – | – | – | – | – | – |
| Education | ||||||||
| Associate degree or below | – | – | – | – | – | – | 1 | |
| Bachelor | – | – | – | – | – | – | 1.263 | 0.021 |
| Master or above | – | – | – | – | – | – | 0.911 | 0.731 |
| Marital status | – | – | – | – | – | – | ||
| Single/unmarried | – | – | – | – | – | – | 1 | |
| Married | – | – | – | – | – | – | 1.502 | <0.001 |
| Divorced/widowed | – | – | – | – | – | – | 1.154 | 0.571 |
| Income (Yuan per month) | – | – | – | – | – | – | ||
| <5000 | 1 | 1 | 1 | 1 | ||||
| 5000–10 000 | 0.819 | 0.023 | 0.764 | <0.001 | 0.759 | 0.004 | 0.770 | 0.001 |
| 10 000–30 000 | 0.695 | 0.004 | 0.577 | <0.001 | 0.676 | 0.006 | 0.691 | 0.024 |
| ≥30 000 | 1.448 | 0.385 | 1.008 | 0.992 | 1.537 | 0.336 | 0.540 | 0.515 |
| Years of working | ||||||||
| <5 | 1 | 1 | 1 | – | – | |||
| 5–10 | 1.438 | 0.003 | 1.822 | <0.001 | 1.342 | 0.030 | – | – |
| 10–20 | 1.581 | <0.001 | 2.147 | <0.001 | 1.480 | <0.001 | – | – |
| ≥20 | 1.257 | 0.041 | 2.024 | <0.001 | 1.151 | 0.263 | – | – |
| Treating COVID-19 patients in your working departments (November 2022 to February 2023) | ||||||||
| No | – | – | 1 | – | – | – | – | |
| Yes | – | – | 1.239 | 0.011 | – | – | – | – |
| Supporting other departments that have treated COVID-19 patients (November 2022 to February 2023) | ||||||||
| No | – | – | – | – | – | – | 1 | |
| Yes | – | – | – | – | – | – | 1.245 | 0.003 |
| Perceiving a higher risk of COVID-19 infection due to work (November 2022 to February 2023) | ||||||||
| No | 1 | 1 | 1 | 1 | ||||
| Yes | 1.932 | <0.001 | 1.850 | <0.001 | 1.632 | 0.008 | 1.656 | 0.002 |
| Perceiving a higher Work Intensity (November 2022 to February 2023) | ||||||||
| No | 1 | 1 | 1 | |||||
| Yes | 1.489 | 0.002 | 1.626 | <0.001 | 1.794 | <0.001 | 1.880 | <0.001 |
| COVID-19 infection status (November 2022 to February 2023) | ||||||||
| Not infected | 1 | 1 | 1 | 1 | ||||
| Infected once (positive PCR test or antigen test result) | 1.489 | <0.001 | 1.842 | <0.001 | 1.313 | 0.083 | 1.419 | 0.011 |
| Infected twice or more (positive PCR test or antigen test result) | 2.302 | 0.005 | 1.559 | 0.267 | 5.044 | <0.001 | 1.239 | 0.617 |
| Infected, with COVID-19 symptoms, but without PCR test or antigen test result | 3.783 | <0.001 | 1.631 | 0.002 | 1.065 | 0.733 | 1.124 | 0.495 |
| Mindfulness | 0.807 | <0.001 | 0.814 | <0.001 | 0.779 | <0.001 | 0.801 | <0.001 |
| Resilience | 0.970 | <0.001 | 0.964 | <0.001 | 0.937 | <0.001 | 0.948 | <0.001 |
| Perceived social support | 0.941 | <0.001 | 0.930 | <0.001 | 0.951 | <0.001 | 0.943 | <0.001 |
Subgroup analysis of influencing factors on depressive and anxiety symptoms between doctors and nurses
| Variable . | Depressive symptoms . | Anxiety symptoms . | ||||||
|---|---|---|---|---|---|---|---|---|
| Doctors (N = 2584) . | Nurses (N = 3112) . | Doctors (N = 2584) . | Nurses (N = 3112) . | |||||
| OR . | P . | OR . | P . | OR . | P . | OR . | P . | |
| Gender | ||||||||
| Male | 1 | – | – | – | – | – | – | |
| Female | 1.294 | <0.001 | – | – | – | – | – | – |
| Education | ||||||||
| Associate degree or below | – | – | – | – | – | – | 1 | |
| Bachelor | – | – | – | – | – | – | 1.263 | 0.021 |
| Master or above | – | – | – | – | – | – | 0.911 | 0.731 |
| Marital status | – | – | – | – | – | – | ||
| Single/unmarried | – | – | – | – | – | – | 1 | |
| Married | – | – | – | – | – | – | 1.502 | <0.001 |
| Divorced/widowed | – | – | – | – | – | – | 1.154 | 0.571 |
| Income (Yuan per month) | – | – | – | – | – | – | ||
| <5000 | 1 | 1 | 1 | 1 | ||||
| 5000–10 000 | 0.819 | 0.023 | 0.764 | <0.001 | 0.759 | 0.004 | 0.770 | 0.001 |
| 10 000–30 000 | 0.695 | 0.004 | 0.577 | <0.001 | 0.676 | 0.006 | 0.691 | 0.024 |
| ≥30 000 | 1.448 | 0.385 | 1.008 | 0.992 | 1.537 | 0.336 | 0.540 | 0.515 |
| Years of working | ||||||||
| <5 | 1 | 1 | 1 | – | – | |||
| 5–10 | 1.438 | 0.003 | 1.822 | <0.001 | 1.342 | 0.030 | – | – |
| 10–20 | 1.581 | <0.001 | 2.147 | <0.001 | 1.480 | <0.001 | – | – |
| ≥20 | 1.257 | 0.041 | 2.024 | <0.001 | 1.151 | 0.263 | – | – |
| Treating COVID-19 patients in your working departments (November 2022 to February 2023) | ||||||||
| No | – | – | 1 | – | – | – | – | |
| Yes | – | – | 1.239 | 0.011 | – | – | – | – |
| Supporting other departments that have treated COVID-19 patients (November 2022 to February 2023) | ||||||||
| No | – | – | – | – | – | – | 1 | |
| Yes | – | – | – | – | – | – | 1.245 | 0.003 |
| Perceiving a higher risk of COVID-19 infection due to work (November 2022 to February 2023) | ||||||||
| No | 1 | 1 | 1 | 1 | ||||
| Yes | 1.932 | <0.001 | 1.850 | <0.001 | 1.632 | 0.008 | 1.656 | 0.002 |
| Perceiving a higher Work Intensity (November 2022 to February 2023) | ||||||||
| No | 1 | 1 | 1 | |||||
| Yes | 1.489 | 0.002 | 1.626 | <0.001 | 1.794 | <0.001 | 1.880 | <0.001 |
| COVID-19 infection status (November 2022 to February 2023) | ||||||||
| Not infected | 1 | 1 | 1 | 1 | ||||
| Infected once (positive PCR test or antigen test result) | 1.489 | <0.001 | 1.842 | <0.001 | 1.313 | 0.083 | 1.419 | 0.011 |
| Infected twice or more (positive PCR test or antigen test result) | 2.302 | 0.005 | 1.559 | 0.267 | 5.044 | <0.001 | 1.239 | 0.617 |
| Infected, with COVID-19 symptoms, but without PCR test or antigen test result | 3.783 | <0.001 | 1.631 | 0.002 | 1.065 | 0.733 | 1.124 | 0.495 |
| Mindfulness | 0.807 | <0.001 | 0.814 | <0.001 | 0.779 | <0.001 | 0.801 | <0.001 |
| Resilience | 0.970 | <0.001 | 0.964 | <0.001 | 0.937 | <0.001 | 0.948 | <0.001 |
| Perceived social support | 0.941 | <0.001 | 0.930 | <0.001 | 0.951 | <0.001 | 0.943 | <0.001 |
| Variable . | Depressive symptoms . | Anxiety symptoms . | ||||||
|---|---|---|---|---|---|---|---|---|
| Doctors (N = 2584) . | Nurses (N = 3112) . | Doctors (N = 2584) . | Nurses (N = 3112) . | |||||
| OR . | P . | OR . | P . | OR . | P . | OR . | P . | |
| Gender | ||||||||
| Male | 1 | – | – | – | – | – | – | |
| Female | 1.294 | <0.001 | – | – | – | – | – | – |
| Education | ||||||||
| Associate degree or below | – | – | – | – | – | – | 1 | |
| Bachelor | – | – | – | – | – | – | 1.263 | 0.021 |
| Master or above | – | – | – | – | – | – | 0.911 | 0.731 |
| Marital status | – | – | – | – | – | – | ||
| Single/unmarried | – | – | – | – | – | – | 1 | |
| Married | – | – | – | – | – | – | 1.502 | <0.001 |
| Divorced/widowed | – | – | – | – | – | – | 1.154 | 0.571 |
| Income (Yuan per month) | – | – | – | – | – | – | ||
| <5000 | 1 | 1 | 1 | 1 | ||||
| 5000–10 000 | 0.819 | 0.023 | 0.764 | <0.001 | 0.759 | 0.004 | 0.770 | 0.001 |
| 10 000–30 000 | 0.695 | 0.004 | 0.577 | <0.001 | 0.676 | 0.006 | 0.691 | 0.024 |
| ≥30 000 | 1.448 | 0.385 | 1.008 | 0.992 | 1.537 | 0.336 | 0.540 | 0.515 |
| Years of working | ||||||||
| <5 | 1 | 1 | 1 | – | – | |||
| 5–10 | 1.438 | 0.003 | 1.822 | <0.001 | 1.342 | 0.030 | – | – |
| 10–20 | 1.581 | <0.001 | 2.147 | <0.001 | 1.480 | <0.001 | – | – |
| ≥20 | 1.257 | 0.041 | 2.024 | <0.001 | 1.151 | 0.263 | – | – |
| Treating COVID-19 patients in your working departments (November 2022 to February 2023) | ||||||||
| No | – | – | 1 | – | – | – | – | |
| Yes | – | – | 1.239 | 0.011 | – | – | – | – |
| Supporting other departments that have treated COVID-19 patients (November 2022 to February 2023) | ||||||||
| No | – | – | – | – | – | – | 1 | |
| Yes | – | – | – | – | – | – | 1.245 | 0.003 |
| Perceiving a higher risk of COVID-19 infection due to work (November 2022 to February 2023) | ||||||||
| No | 1 | 1 | 1 | 1 | ||||
| Yes | 1.932 | <0.001 | 1.850 | <0.001 | 1.632 | 0.008 | 1.656 | 0.002 |
| Perceiving a higher Work Intensity (November 2022 to February 2023) | ||||||||
| No | 1 | 1 | 1 | |||||
| Yes | 1.489 | 0.002 | 1.626 | <0.001 | 1.794 | <0.001 | 1.880 | <0.001 |
| COVID-19 infection status (November 2022 to February 2023) | ||||||||
| Not infected | 1 | 1 | 1 | 1 | ||||
| Infected once (positive PCR test or antigen test result) | 1.489 | <0.001 | 1.842 | <0.001 | 1.313 | 0.083 | 1.419 | 0.011 |
| Infected twice or more (positive PCR test or antigen test result) | 2.302 | 0.005 | 1.559 | 0.267 | 5.044 | <0.001 | 1.239 | 0.617 |
| Infected, with COVID-19 symptoms, but without PCR test or antigen test result | 3.783 | <0.001 | 1.631 | 0.002 | 1.065 | 0.733 | 1.124 | 0.495 |
| Mindfulness | 0.807 | <0.001 | 0.814 | <0.001 | 0.779 | <0.001 | 0.801 | <0.001 |
| Resilience | 0.970 | <0.001 | 0.964 | <0.001 | 0.937 | <0.001 | 0.948 | <0.001 |
| Perceived social support | 0.941 | <0.001 | 0.930 | <0.001 | 0.951 | <0.001 | 0.943 | <0.001 |
Third, our study did not investigate the impact of screen time on the mental health of healthcare workers, which should be addressed in future research. We acknowledge that during the surge phase of the COVID-19 pandemic, both positive and negative reports about the pandemic were present on social media platforms in China, making it complex to ascertain the actual impact of screen time on the mental health of healthcare workers. In addition, previous studies have found that at the beginning of the COVID-19 epidemic, screen time was not associated with mental health problems among healthcare workers, since they may have received supportive and encouraging messages from social media, their families and hospitals.8 It is also possible that they might have reduced screen time due to the heavy workload during the pandemic. A systematic review before the pandemic also found similar results in the youth population.9 However, in surveys of the general adult population, screen time was associated with decreased mental health.10 These inconsistent research findings suggest that more attention should be paid to the impact of screen time and the ‘infodemic’ on the mental health of different populations during future outbreaks of infectious diseases.
It is highly agreeable that the mental health of healthcare workers will remain a crucial issue during future infectious disease outbreaks. We once again extend our gratitude to the authors for their insightful comments regarding our article.
Funding
This Letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
None declared.
References
Author notes
Shu Jing and Zhenwei Dai are joint first authors.
