General Psychiatry

BMJ Publishing Group

Pandemic and mental health of the front-line healthcare

workers: a review and implications in the Indian context amidst
COVID-19
Snehil Gupta and Swapnajeet Sahoo
Additional article information

Associated Data
Supplementary Materials

Abstract
Pandemic, being unprecedented, leads to several mental health problems,
especially among the front-line healthcare workers (HCW). Front-line HCWs often
suffer from anxiety, depression, burnout, insomnia and stress-related disorders.
This is mediated to a large extent by the biopsychological vulnerabilities of the
individuals; socioenvironmental factors such as the risk of exposure to infection,
effective risk communication to HCWs, availability of personal protective
equipment, job-related stress, perceived stigma and psychological impact of the
isolation/quarantine and interpersonal distancing also play the major roles. Despite
the huge magnitude of mental health problems among the front-line HCWs, their
psychological health is often overlooked. Some of the potential measures to reduce
the mental health problems of the front-line HCWs are effective communication,
tangible support from the administration/seniors, mental health problem screening
—and interventional—facilities, making quarantine/isolation less restrictive and
ensuring interpersonal communication through the various digital platforms,
proactively curtailing the misinformation/rumour spread by the media and strict
legal measures against violence/ill treatment with the HCWs, and so on. India,
along with other countries who lately got affected by the COVID-19, must learn
from the experiences of the other countries and also from the previous pandemics
as to how to address the mental health needs of their front-line HCWs and ensure
HCWs’ mental well-being, thereby improving their productivity. Current review
attempts to highlight the mental health aspects of the pandemic on the front-line
HCWs, discusses some of the contentious issues and provides future directions
particularly concerning COVID-19 in the Indian context and other low-resource
countries.
Keywords: mental health

Introduction
Currently, the entire humanity worldwide is facing a severe healthcare crisis, that
is, the unprecedented COVID-19 pandemic for the 21st-century population. In
simpler words, a pandemic is defined as ‘an epidemic occurring worldwide, or
over a very wide area, crossing international boundaries and usually affecting a
large number of people’.1 However, it is not the first time that humanity is facing a
pandemic. Over the last century, many pandemics such as Spanish flu, severe acute
respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), Ebola,
swine flu, and so on have emerged and been tackled.2 Existing literature supports
that pandemic, apart from causing mortality and physical morbidities, also leads to
tremendous mental health problems (insomnia, anxiety, depression, stress-related
disorders including post-traumatic stress disorders (PTSD)) in the sufferers as well
as in the non-infected public.3–6
Front-line healthcare workers (HCW) are health workers who play a crucial role in
providing care to infected persons. Working in such an unprecedented situation,
usually beyond their capacities, and with a risk of contracting the infection, poses
HCWs at an increased risk of mental health problems. Literature suggests a high
prevalence of mental health problems among the front-line workers (such as
burnout, insomnia, anxiety, depression, illness anxiety, PTSD, and so on) which is
mediated by various biopsychosocial factors.3 7–9 Despite this, the mental health
issues of the front-line HCWs and other health workers are often overlooked.3 8 10
11 It is often considered that such disasters are often dealt with by this group of
population and hence they would be able to manage themselves well.
The COVID-19 is the latest entrant in the list of pandemics causing infection.
Although mental health issues related to patients, especially those related to
quarantine/isolation or social distancing,11–13 are increasingly recognised and
efforts are being made to mitigate its psychological impact, literature on the
psychological impact of pandemic (including COVID-19) on the front-line HCWs
is still elusive.
India was also not immune to be affected by COVID-19 and to face COVID-19-
related medicosocioeconomic challenges. Considering the low-resource setting on
healthcare aspects in the country, various strategies had been employed such as
lockdown, the curtailment of routine outpatient services, postponing of elective
surgeries, rotational duty shifts in phases, and so on. Lessons learnt from the
experiences of the countries getting affected earlier and the measures they have
undertaken to ameliorate the psychological impact of the COVID-19 on the HCWs
can serve as a guide for India (and other lately affected counties), in terms of the
planning and implementing necessary measures to mitigate the
medicopsychological impact of COVID-19 among the front-line workers.
The current paper is aimed to review the available literature on mental health
aspects of the pandemic on the front-line HCWs, discusses some of the contentious
issues and provides future directions particularly concerning COVID-19 in the
Indian context and can apply to other developing nations with low-resource
healthcare facilities.

Methodology
The literature was searched in the PubMed, Medline and Google Scholar databases
with the following search terms: ‘epidemics’[MeSH Terms] OR ‘infection’ OR
‘outbreak/epidemic’ OR ‘severe acute respiratory syndrome’[MeSH Terms] OR
‘ebolavirus’[MeSH Terms] OR ‘middle east respiratory syndrome
coronavirus’[MeSH Terms] OR ‘COVID19’ OR ‘h1n1/09’ NOT ‘acquired
immunodeficiency syndrome’[MeSH Terms] NOT ‘hiv’[MeSH Terms])) AND
‘health care providers’ OR ‘health professionals/care’ OR ‘nurse’ OR ‘para
medical workers’ OR ‘frontline health worker*’ AND ‘mental health’[MeSH
Terms]) OR ‘stress, psychological’[MeSH Terms]) OR ‘anxiety’[MeSH Terms])
OR ‘fear’[MeSH Terms]) OR ‘depression’[MeSH Terms]) OR ‘insomnia/anxiety’
(online supplementary file 1).

Supplementary data
gpsych-2020-100284supp001.pdf
The inclusion criteria were: articles dealing with the pandemics as per the World
Health Organization's (WHO’s) list, an article published in any language with full
text available and directly dealing with the mental health aspects of the HCWs.
Exclusion criteria include: dealing with HIV/AIDS or other non-pandemic
conditions, and not directly dealing with the mental health aspects of the HCWs.
Bibliographic search, and grey literature search by visiting the official website of
the WHO, Centers for Disease Control and Prevention (CDC), National Health
Commission, China; CDC USA; Ministry of Health and Family Welfare,
Government of India (GoI) were also conducted. The literature search included all
articles until 7 April 2020.

Results
As the literature on COVID-19 is rapidly booming, a total of 127 articles were
obtained until 7 April 2020. On data extraction, only 37 articles (including 10
articles obtained from the bibliographic search) were found to be eligible for
inclusion in the review (process of study selection shown in figure 1). Most of the
studies were related to SARS (16) followed by COVID-19 (10, including 3 Indian
studies), influenza (4), MERS (3), Ebola (2) and psychological impact of
quarantine and isolation (2). The majority of them were cross-sectional (24), out of
which most were questionnaire survey-based (including online survey) (20) while
some were interview-based (4, including 2 qualitative studies); however, two
longitudinal studies were also available. The rest were viewpoints/commentaries
(n=11). We could not find any review dealing specifically with the mental health
aspects of the pandemic on the front-line HCWs.

Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) figure
depicting the process of study selection. HCW, healthcare worker.

The common mental health conditions assessed in the literature were: knowledge
and attitude about the illness, coping strategy, and perceived health status (n=11),
health distress (including burnout) (5), perceived stress and post-traumatic
disorders (5), anxiety (5), depression (3), insomnia (3) and perceived stigma (4).
The sample size of the study varied based on the design and setting of the study.
For instance, online survey-based studies had a relatively large sample size
(varying from 333 to 1557) while hospital-based surveys were conducted on a
sample size ranging from 148 to 333 (however, one study included 994 subjects).
Comparative cross-sectional studies (30–40 subjects in each arm) and longitudinal
studies were conducted (of 20 in each arm) with a relatively small sample size. As
expected, the qualitative study was conducted with a sample size as low as 10.
The nurses were the most common population of the study followed by doctors.
Interestingly, two studies also involved non-HCWs of the hospitals.

The magnitude of mental health problems in the HCWs

The literature revealed that a significant proportion of the HCWs during pandemic
suffer from mental health problems including diagnosable mental health disorders
(table 1). They are enumerated as follows.

Table 1
Prevalence of mental health problems among the front-line healthcare workers
during various pandemics

Emotional distress and burnout

A study from Canada reported that 36% of the HCWs facing the SARS epidemic
experienced a high level of distress (measured by the Impact of Event Scale) with
nurses having a higher rate than doctors.3 Another study conducted during the
Ebola pandemic found that about two-thirds of HCWs suffered from the emotional
exhaustion (Maslach Burnout Inventory).9 The latest studies conducted amidst
COVID-19 reported that 62%–71% of the HCWs experienced some sort of distress
(Physical Health Questionnaire-9, PHQ-9).8 Similarly, another study from Hubei
(China) found the prevalence of depression among the front-line HCWs to be
50.4% (PHQ-9) with significantly higher rates in nurses, females and those
working in the tertiary care setting.14

Anxiety disorders
The studies from China amidst COVID-19 have reported the prevalence of anxiety
(both studies used Generalized Anxiety Disorder-7) among HCWs ranging from
44.6%14 to 62% (roughly 30% had a moderate or severe level of anxiety).8 A non-
COVID study conducted in India during the swine flu has found that as high as
98.5% of the health professionals experienced the anxiety of mild type (Beck’s
Anxiety Inventory)15 and another comparative study has reported significantly
higher anxiety scores (Spielberger State-Trait Anxiety Inventory (STAI)) among
the HCWs working in SARS unit than their non-SARS unit counterparts.16

Depression/depressive symptoms
Studies conducted during the SARS have reported a prevalence of the depression
among the front-line HCWs to be 38.5% (vs 3.1% in non-front-line HCWs (Beck’s
Depression Inventory))16 and 29%, respectively (General Health Questionnaire-
12),5 with the latter study having found a higher prevalence among the nurses
(45%) than the doctors. Studies that have evaluated stress and depression in HCWs
after 1 year of the SARS epidemic had also revealed higher depression, anxiety and
post-traumatic symptoms (ie, overall high degree of psychological
distress).17 COVID-related studies had found high rates of depressive symptoms
(as high as 50%) in HCWs.14 18

Insomnia
A comparative study from Taiwan reported that 37% of the HCWs working in the
SARS unit suffered (vs 9.7% working in non-SARS unit) from insomnia
(Pittsburgh Sleep Quality Index).16 The latest studies have reported the prevalence
of insomnia (by Insomnia Severity Index) among the front-line HCWs to be
around 35%–38%.8 14 18

Acute stress reactions and PTSD

Acute stress reactions and PTSD (early as well as late-onset) are common among
the front-line HCWs. For instance, a study from China has found that the
prevalence of the symptomatic PTSD (Davidson Trauma Scale) among nurses
working in the SARS intensive care unit (ICU) and regular SARS unit was 33%
and 29.5%, respectively (non-SARS unit nurses, 18.7%).16 A 1 year longitudinal
study reported that HCWs who worked in the high-risk units (respiratory ward)
experienced significantly higher PTSD symptoms (Impact of Event Scale-Revised,
IES-R) than their colleagues working in the low-risk unit (general ward). It has
been observed that the front-line HCWs’ stress score (Perceived Stress Scale-10
(PSS-10) score) correlated with their depression and anxiety score (Depression
Anxiety Stress Scale).19 Similar reports of post-traumatic stress had been reported
following the SARS pandemic among the Canadian HCWs 1 year after the
SARS.17 The latest study from China reported that about one-third of the front-
line workers experienced the least moderate grade of PTSD (IES-R) with the
prevalence being significantly higher among the nurses (74.55) than the physicians
(66.9).14

Other psychological problems

HCWs frequently suffer from other psychological issues such as health-related
concerns (one-third of HCWs reported this),5 poorly perceived self-
health,8 depersonalisation,9 low personal achievement9 and lack of control over
their lives during the period of quarantine.10
Table 1 illustrates the mental health problems faced by the HCWs during previous
pandemics and the available data related to the ongoing impact of COVID-19 on
the mental health of HCWs.

Factors contributing to the mental health problems in the HCWs

Many biological, psychological and social/environmental factors and their
interplay predispose an individual to an increased risk of mental health problems
(table 1). They are enumerated as follows.

Biological factors
History of mood disorder and earlier age (vs later age) have been identified to
predispose the HCWs for an increased risk of mental health problems during the
period of pandemic.16 This is also mediated by socioenvironmental factors such as
having a child3 5 or a sick elderly in the family, whom they have to additionally
care for while delivering duties as HCWs during the pandemic.

Psychological factors
Literature suggests that the personality traits of the HCWs are one of the important
determinants for the development of mental health issues during the pandemic
situation. For instance, a study conducted during SARS pandemic on HCWs found
that the individuals having anxious avoidant personality traits, fear of scrutiny and
avoidant coping mechanism3 were at higher risk of mental health stress, supported
by several other studies.3 20–22 Further, HCWs indulged in the emotion-focused
coping strategies suffer from higher emotional exhaustion, stress, anxiety,
depression and PTSDs.23 24
Similarly, HCWs suffering from role conflict (between the professional and
familial role)24 25 and getting caught into potential moral injury exposure (defined
as profound psychological distress which results from actions, or the lack of them,
which violate one’s moral or ethical code26) have a higher rate of mental stress
and mental disorders.27 More so, having a sense of unworthiness or being non-
essential (among non-front-line HCWs)10 25 and resorting to denial (defence
mechanism) towards the current psychological impact of an outbreak result in
heightened risk of persistent stress and PTSD symptoms.19
On the contrary, personality traits such as hardiness (commitment, belief of having
things under control, accepting a challenge, and considering it a chance to self-
develop) directly mediate the positive mental health amidst an outbreak and also
indirectly benefit the HCWs by decreasing their level of stress.28 Similarly, vigour
(defined as high levels of energy, mental resilience, stamina and persistence when
problems arise)29 is associated with a lower score on emotional exhaustion among
the nurses during the SARS pandemic and also associated with a positive attitude
towards the work and better organisational functioning.22 Further, altruistic
acceptance of the work-related risk of contracting infection among the HCWs
during the SARS pandemic was found to be negatively correlated with the long-
term PTSD symptoms.
Literature also suggests that those involved in reflective practices (Aguilera model:
self-awareness, problem sensing, and structuring, generating an answer, and
evaluating it30) experience lesser mental distress,3 31 32 and develop problem-
focused coping. Similarly, problem-focused coping strategy among the HCWs
during the pandemic has been reported to decrease their mental stress16 and
alleviated their fear,33 thereby decreasing the mental health problems.

Socioenvironmental factors

Inadequate communication and lack of information

Lack of proper communication from the higher authorities to the front-line HCWs
and rapidly changing guidelines regarding infection control measures could lead to
uncertainty, apprehension, lack of knowledge and a sense of uncontrollability over
the situation. These act as important mediators for the development of mental
health problems among the HCWs. Misinformation/rumour (often labelled as
‘misinfodemic’) prevalent during the pandemic, if not adequately clarified by the
administration, adds to mental health stress among the HCWs.4 22 25 34
Risk of exposure to infection
The HCWs working in the high-risk area (screening out patient department(OPD),
inpatient and ICUs) are at a higher risk of exposure to infection.5 12 28 35 A study
from Wuhan (China) reports that as high as 87.5% of HCWs got infected from
COVID-19.7 Such a high risk of exposure to infection gives rise to fear,
apprehension and stress among the HCWs, which often get compounded by the
fear of being a contagion for their family members and loved ones, resulting in
significant mental health problems. Further, exposure to end-stage resuscitative
procedures to save the lives of the patients including their colleagues could lead to
PTSD.3 16 19

Social distancing
Avoiding interpersonal contact/communication (social distancing) is considered as
an important measure to tackle the infective outbreak, greatly practised in the
ongoing COVID-19.3 5 16 36 As a result, HCWs are mandated to maintain
distance from their colleagues, both at the workplace and outside, which deprives
them of otherwise much-needed social support. Further, maintaining social
distancing from their family members (including sharing beds with one’s partner)
results in lack of emotional support from the significant others and adds to
emotional stress and mental health problems.3 10 22

Job stress/occupational stress

The HCWs contracting infections results in gross understaffing at the healthcare
institutes.3 32 33 Such a situation poses the HCWs to work with limited resources,
long working hours and frequently changing duties, and to work in an unfamiliar
environment that, also with the new teammates, results in huge mental stress. This
gets compounded by the unprecedented needs of quarantine/isolation and strict
maintenance of interpersonal distancing. Western literature suggests that HCWs
are often bound by the provincial order not to work at multiple places during
pandemic resulting in financial difficulties.3 4 Further, front-line HCWs often are
unable to impersonalise oneself while taking care for their infected colleagues and
feel helpless for not being able to avert the mortality of their colleagues; senior
physicians have also reported déjà vu experience and flashbacks (of their
colleagues getting died) during pandemic.25
Personal protective equipment-related issues
It is not uncommon that front-line HCWs have to work with a limited supply of
personal protective equipment (PPE).3 5 25 Such a scenario leads to fear and
apprehension among the HCWs. The situation is often compounded by unclarity
regarding which PPEs are adequate in a particular setting (screening OPD, low-risk
wards, high-risk wards, ICUs, and so on) leading to confusion and worries. On the
other hand, working under the restriction of PPEs (particularly mask) has also been
reported to be a major cause of distress among the HCWs. Literature suggests that
PPE comes as a major hindrance to properly communicate with the patient and
one’s colleagues; moreover, working long hours with the PPEs also leads to
significant burnout.5 31

Stigma
Perceived stigma among the HCWs has been reported to be a major mediator for
psychiatric problems during the period of the pandemic. Studies conducted during
SARS/MERS found that the prevalence of significant perceived stigma among the
HCWs ranged from 20% to 50%.28 35 37 Literature suggests that perceived
stigma is correlated with the stress (scores of PSS-10), mental health score (and
36-Item Short Form Survey),28 burnout25 and PTSD score.3

Isolation/quarantine
Isolation/quarantine is an important measure to curtail the infection amidst the
pandemic.36 Front-line HCWs often have to work in the isolated wards where they
happen to be the sole care providers for the patients.4 In the absence of much
required interpersonal communication and social support, HCWs suffer the
burnout and also experience the lack of self-control. Additionally, front-line HCWs
often have to stay in quarantine (if suspected of exposure to infection) or in
isolation (if contracted the infection) which deprive them of much-needed social
support from their hospital colleagues and family members resulting in many
psychiatric problems.9 10 12

Lack of support from organisation and colleagues

Literature suggests that HCWs often suffer from job-related insecurities, especially
those who are asked to stay at home.5 The former may have a perception of being
non-essential for the institute. Further, HCWs (especially nursing staff and other
paramedical staff) may feel that they are lacking the necessary skills to tackle such
a novel infection25; they often have fear of being scrutinised by their superiors and
might be blamed for any error; they also feel the necessity of hand-holding and
role-modelling by their seniors at the workplace.3 10 Further, HCWs need support
from their administration concerning their family matters, finances, incentives and
recognition for their efforts.33
Moreover, mental health issues of the HCWs during such a crisis are often
overlooked. The much required periodic screening for any mental health problems
usually is elusive. And usually, there is no provision of mental health services for
them to seek help from.11 It is not uncommon for the HCWs to access resource
material or seek online/telephonic counselling to allay their mental health
problems.7 8

Role conflict
The available literature suggests that many a time HCWs suffer from a role conflict
(between their role as health professionals and the role as a parent or family
personnel). They frequently fear or remain apprehensive of being a contagion for
their family members.3 25 Literature suggests that front-line HCWs having
children report higher rates of anxiety, depression and distress. This may lead to
avoidant coping strategies and absenteeism at the workplace, which adversely
affect an organisation’s performance.10 27

Crowd behaviour
Literature suggests that pandemic caused by a novel agent that has no definite cure
could lead to widespread anxiety/panic. This is often amplified by the
misinformation/rumour circulated in the social media leading to a panic situation in
the community—‘panicdemic’.6 In such a scenario, often ‘emotions go viral’ in
the society which could lead to mental stress in an individual including the HCWs
(emotional contagion). It can also heighten stigma towards the HCWs,38 resulting
in increased mental health stress among the HCWs.

Misinformation
It is not uncommon that during the pandemic, especially during the early part of it,
many misinformation and rumour are circulated in the social media, and so
on.39 For instance, the limited number of PPEs, which leads to apprehension and
fear among the HCWs; flaws in the PPEs being used; and any infection contracted
by HCWs are highlighted disproportionately.3 34 This leads to mental health stress
and exacerbates anxiety, depression and distress among the HCWs.6

Potential measures to address the mental health needs of the front-

line HCWs

Effective risk communication to the HCWs

During the pandemic, especially during the early part, HCWs often suffer from
uncertainties and fear, which become prominent if the risk is not effectively
communicated (including measures to be taken to avoid infection) to the front-line
HCWs by the higher authorities.3 5 Authorities/team leaders, by sharing succinct
messages and authentic information, and regularly interacting (through the real or
virtual platform) with their HCWs, could allay uncertainties and fear among the
HCWs and bring about a sense of trust.

Involving mental health professionals in the core leadership

Having the mental health professionals (MHP) on board would ensure that the
mental health issues of the HCWs are not getting overlooked.8 11 40 Some of the
important steps to ameliorate mental health problems among the HCWs include
regular screening for the mental health problems, normalising the psychological
response to stress, having reflective approach towards one’s emotion and
cognition, peer training in identifying burnout and delivering informal counselling,
psychologically oriented meetings among the HCWs and the team leaders, and
ensuring availability and accessibility of professional mental health services
available and accessible for the HCWs.

Tangible support to HCWs from the leadership including regular communication

During pandemic, front-line HCWs often experience a sense of mistrust and
helplessness. It can adversely affect their attitude towards work and lead to stress,
thereby deteriorating the organisation’s performance.3 32 For instance, doubt
regarding the efficacy of the right kinds of the PPEs to be used if properly clarified
by a senior colleague/doctor, which may include seniors wearing the same PPEs
(role-modelling) and working with them, could allay fear, anxiety and stress
among the HCWs. Tangible support to the HCWs such as listening to their
grievances, making the working environment conducive for working (eg,
establishing a bathroom in the hospital premise, where an HCW can take a bath
before leaving for their home, could significantly reduce the fear of being a
contagion for their family members) and extending support related to the finances
and specific family needs can bring about a sense of trust and self-efficacy among
the HCWs.

Mental health support and services to the HCWs

Making availability of the mental health resource materials (including webinars);
training in stress management (at the workplace or home) and problem-solving;
arranging for confidential telephonic calls/online counselling or consultation with
the mental health expert3 8; and arranging for a visit to a mental health expert
could, to a large extent, reduce the mental health problems among the front-line
HCWs. Amidst COVID-19, some of these steps have been taken by various
international and national agencies.41–43

Involving HCWs in developing strategies

Literature suggests that involving HCWs (front-line and so-called non-essential
HCWs) in planning and strategising for the pandemic can pay huge dividends.
Apart from being clinically effective in fighting against the pandemic, it could also
help in boosting the self-esteem of the HCWs (front-line and non-essential), and
make them feel to be the part of the team, build their trust and promote a positive
outlook about the work. Further, it results in decreased job-related stress,
uncertainties, fear, anxiety and depression among the HCWs.10 32

Mitigate the psychological impact of the isolation/quarantine

HCWs and their contacts (colleagues and family members) often have to undergo
quarantine or isolation during the pandemic. This may give rise to a sense of guilt
for being a contagion for others, and also a sense of self-blame for causing
understaffing at the workplace and adding to the workload of their colleagues.
Further, isolation and quarantine also lead to severe restriction in one’s activities
which often leads to worries and stress related to not being able to perform one’s
professional and familial duties.4 9 10
By making quarantine/isolation less restrictive, arranging for telephonic/digital
communication between the HCWs and their colleagues or family members, and
through minor gestures (for instance, making a pizza available for a person in
quarantine/isolation has been shown to decrease the mental health stress arisen
during isolation3), psychological impact of the quarantine/isolation can be
mitigated.

Ensuring availability of PPEs including developing less restrictive PPEs

Ensuring availability of the PPEs for the HCWs reduces the chances to get exposed
to infection during patient care, and boosts their confidence to work without any
fear, especially when many rumours centre around the unavailability of PPEs and
its ineffectiveness circulates in the media.5 25
On the other hand, PPEs also act as the major hindrance for HCWs during caring
for their patient. Acting as a barrier, it limits the interpersonal communication
among the HCWs and the patients.3 5 It also leads to burnout, fatigue and job-
related stress among the HCWs. Hence, innovations should be made to design less
restrictive, flexible and easily wearable and removable PPEs.

Better information and e-resource system

A public health information system that is authentic and updated with wide
dissemination could significantly reduce the psychological impact of
misinformation/rumour on the mental health of the HCWs and the public.6 39 Fake
news has shown to be associated with violence against HCWs or being ill treated.
During isolation or social distancing, the internet serves as the major platform
through which important information and resource materials (textual, audio, video)
can be accessed, which can help in attaining and maintaining positive mental
health .7 11 44 Lately, many international and national agencies including
academic institutes have taken steps to generate e-resources for skill development
among the HCWs and also addressing their mental health needs.

Implications in the context of COVID-19 from Indian perspectives

Although India (along with some of the South Asian, African and American
countries) got affected by COVID-19 relatively late as compared with the Western
Pacific and European countries,45 the spread of the COVID-19 has been rampant.
As of 22 April 2020, more than 20, 000 confirmed cases and 559 deaths have been
reported from the country.46 Like the global trend, a sizeable proportion of the
front-line HCWs have also fallen prey to the COVID-19. To curtail the spread of
the infection, the government was prompt to put in place surveillance across the
national transit points and has implemented strictest measures including a
nationwide complete lockdown (already spanned to 4 weeks) and mandatory social
distancing. Consequently, uncertainties, movement restriction, difficulty in
procuring the essential stuff and accessing other essential services (eg, transport,
health services, and so on) are prevalent across the nation. This situation is
compounded by the rounds of misinformation/rumour across the social media
resulting in the stigma against the HCWs, and incidents of violence and ill
treatment against them.47 48 Concerns regarding the availability of PPEs, course
of the pandemic and isolation/quarantine are adversely affecting the mental health
of the HCWs.
A few pieces of literature from India have have highlighted the impact on mental
health of COVID-19.13 34 49 50 Governments (central and state) have also taken
some of the noteworthy steps to mitigate the psychological impact of the COVID-
19 among the patients, general public and HCWs, such as legal measures to
prevent violence against or ill treatment with the HCWs. Similarly, safety and risk
cover for the front-line HCWs are being ensured by the government, making the
PPEs available and the insurance of a sum of 5 million rupees (Indian national
rupees), respectively.51 But the ground-level implementation and the extent to
which it allays the fear, anxiety and stress among the HCWs are yet to be
evaluated.
Steps that need to be taken to avoid the spread of myths and rumours related to
COVID-19 (such as drinking cow’s urine, taking alcohol cures COVID-19, using
turmeric can boost immunity, non-vegetarian food consumption (meat) can lead to
infection, and so on) and correcting the misinformation along with widely
disseminating the correct information to the public are of paramount importance,
otherwise all these would add to the pre-existing anxiety related to COVID-19 in
the general public. Further, there should be some regulations on the news agencies
also, along with some fixed protocol of reporting the news related to COVID-19,
including the number of cases and deaths, to avoid any panic reactions among the
public. More of the motivational and morale-boosting programmes of the public
and HCWs should be undertaken actively to allay their anxiety. The government
should take proactive measures to take full responsibility for the HCWs and their
family members given any untoward incident related to COVID-19. In some states,
the local authorities had declared monetary benefits and advanced monthly salaries
to the HCWs (state of Haryana, and so on). All these boost the morale of the
HCWs and they do not feel neglected by the government.
Similarly, proactive steps have been taken by the GoI in risk communication to the
public/HCWs (through advertisement, online information portals and smart
applications (Aarogya Setu Mobile App52)). Additionally, government and
academic institutes have tried to address the mental health needs of the patients and
the public by releasing the resource materials, conducting webinars and setting up
help-line numbers; however, specific measures that address the mental health
needs of the front-line workers are relatively scarce.
Learning from the experiences of the other countries and based on the findings of
the available literature, some of the recommended measures to mitigate the
psychological impact of COVID-19 among the HCWs are as follows: ensuring
responsible media reporting and bringing about an attitudinal change among the
public towards the HCWs; provision of screening for the mental health disorders,
assessing the mental health needs, and institute-level mental health support and
services for the front-line HCWs; researching the magnitude of mental health
problems; and involving MHPs in the planning and implementation of the policies,
and proactive role and leadership on part of the MHPs.

Conclusions
The current review was aimed to highlight the psychological impact of the
pandemic on the front-line HCWs. The magnitude of mental health problems
among the HCWs is huge; some of the common conditions are burnout, anxiety,
depression, stress-related disorders, and so on. It is mediated by various biological,
psychological and socioenvironmental factors. Lack of the effective
communications, tangible support from the higher authority, misinformation,
unavailability of PPEs, stigma and job-related stress are some of the major
contributory factors for the development of the mental health problems among the
HCWs.
Learning lessons from the previous pandemics and from the other countries that
have successfully tackled COVID-19 and acting by it could mitigate the
psychological impact of COVID-19 among the HCWs to a great extent. More
research, especially from low and middle-income countries such as India, is
required to design interventions tailored towards the need of the HCWs.

Acknowledgments
The authors are grateful to Dr Omkar Awadhiya, senior resident, Department of
Internal Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, for
providing some of the important insights about the mental health issues of the
front-line HCWs during the COVID-19 service delivery.
Biography
•

Dr Snehil Gupta obtained his MBBS degree from Veer Surendra Sai Medical
College and Hospital, Burla, Sambalpur (Odisha), India in 2012. He got training in
psychiatry (M.D.) from the premier institute of the country at All India Institute of
Medical Sciences (AIIMS), Delhi in India. After completing his MD in psychiatry,
he worked as a senior resident (three years teaching programme) in the same
institute till September 2019. He is currently serving (since October 2019) as the
Assistant Professor, at the Department of Psychiatry at AIIMS, Bhopal (Madhya
Pradesh) in India. He heads the common mental disorders (CMD) clinic of the
Department of Psychiatry, AIIMS Bhopal. His main research interests include
common mental disorders (CMD), women mental health, yoga and mental health,
and public mental health.

Footnotes
Contributors: SG drafted the manuscript and SS critically reviewed the manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency
in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Article information
Gen Psychiatr. 2020 Oct; 33(5): e100284.
Published online 2020 Aug 7. doi: 10.1136/gpsych-2020-100284
PMCID: PMC7415074
Snehil Gupta 1,* and Swapnajeet Sahoo2
1
Department of Psychiatry, All India Institute of Medical Sciences, Bhopal, India,
2
Department of Psychiatry, Post Graduate Institute of Medical Education and Research,
Chandigarh, India,
Corresponding author.
Correspondence to
Dr Snehil Gupta; moc.liamg@1612lihens
Received 2020 May 30; Revised 2020 Jul 1; Accepted 2020 Jul 1.
Copyright © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No
commercial re-use. See rights and permissions. Published by BMJ.
This is an open access article distributed in accordance with the Creative Commons Attribution
Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build
upon this work non-commercially, and license their derivative works on different terms, provided
the original work is properly cited, appropriate credit is given, any changes made indicated, and the
use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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