Analysis of anxiety，depression，and their contributing factors in medical staff during quarantine after completing medical aid work during the COVID-19 epidemic

LIU Li，ZHOU Jian，WANG Bei，QIN Tifang，TIAN Yuexiang，LI Haihong

（1.Department of Emergency，Affiliated Hospital of Integrated Traditional Chinese and Western Medicine Nanjing University of Chinese Medicine Jiangsu Province Hospital of Chinese and Western Medicine，Nanjing，Jiangsu，210028；2.Department of Nursing，Affiliated Hospital of Integrated Traditional Chinese and Western Medicine Nanjing University of Chinese Medicine Jiangsu Province Hospital of Chinese and Western Medicine，Nanjing，Jiangsu，210028；3.Department of General Surgery，Affiliated Hospital of Integrated Traditional Chinese and Western Medicine Nanjing University of Chinese Medicine Jiangsu Province Hospital of Chinese and Western Medicine，Nanjing，Jiangsu，210028）

ABSTRACT：Objective To analyze the anxiety，depression，and their contributing factors in medical staff during quarantine after completing medical aid work during the COVID-19 epidemic.Methods A retrospective review was performed.The mental health status and associated contributing factors of the medical staff were surveyed using the pre-selected questionnaire.The threepart pre-selected questionnaire consisted of general information，the 7-item Generalized Anxiety Disorder（GAD-7）scale，and the 9-item Patient Health Questionnaire（PHQ-9）.Results A total of 121 questionnaires were received by the open-electronic-questionnaire platform，and 120 valid questionnaires were finally obtained.The mean GAD-7 score was（3.58 ± 4.21）points，and 36（30.00%）medical staff had anxiety-related symptoms.The mean PHQ-9 score was（2.54±3.59）points，and 29（24.17%）medical staff had depression-related symptoms.The presentation of fear of being infected with COVID-19 was the main factor contributing to the occurrence of depression symptoms during quarantine［OR=0.32，95%CI（0.12，0.85），P=0.023］.Conclusion Fear of being infected with COVID-19 was the main reason for depression.It is of great significance to maintain the mental health of medical staff during quarantine.

KEY WORDS：anxiety；depression；mental health；COVID-19；nursing management

1 Introduction

COVID-19 is caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2，previously known provisionally as the 2019 novel coronavirus.Possible aerosol transmission exists when enduring exposure to a high concentration of virus droplets in a relatively closed environment.［1-3］The National Health Commission of the People's Republic of China has incorporated COVID-19 into class B infectious diseases and taken prevention and control measures commensurate with those of class A infectious diseases.

After the first team of 24 medical staff from Nanfang Hospital volunteered in the aid work on Wuhan City，medical aid teams from across numerous provinces arrived to support the diagnosis and treatment of COVID-19.Health care workers in these medical aid teams were at high risk of experiencing unprecedented psychological pressure，such as burnout，irritability，anxiety，depression，and traumatic stress，because of the disruption to fami-ly and social networks，long working hours，crosscultural adaptation，and isolated working environment，among other factors.［4-7］Without appropriate support，severe psychological problems could develop and continue to affect the future mental health and routine medical work of these staff.

The purpose of this study was to explore the mental health status of medical staff during a 2-week quarantine after completing medical aid work in Hubei Province in March 2020.In addition，it also aimed to analyze the contributing factors of anxiety and depression during quarantine，aiming to provide appropriate psychological care and support for staff to recover their mental health as soon as possible.

2.Methods

2.1 Study design and participants

This retrospective review was performed based on the Strengthening the Reporting of Observational Studiesin Epidemiology （STROBE）guidelines.The Institutional 91Review Board approved the study and waived patient consent for this retrospective review.The mental health status and associated contributing factors of the medical staff at our hospital were surveyed using the pre-selected questionnaire.Inclusion criteria were medical staff，defined as doctors，nurses，and laboratory professionals who participated in the medical aid work to counteract COVID-19 in Hubei Province in March 2020 and received medical observation in the designated area after completing medical aid work.After excluding those who did not meet these inclusion criteria，this study included a total of 121 medical staff.

2.2 questionnaire

The three-part pre-selected questionnaire consisted of general information，the 7-item Generalized Anxiety Disorder（GAD-7）scale，and the 9-item Patient Health Questionnaire（PHQ-9）.General information included gender，age，education level，occupation，department，medical history of anxiety or depression，and chief factors of concern during quarantine.The GAD-7 scale and PHQ-9 scale，both developed by Spitzer et al.［8-10］，were used to evaluate the severity of anxiety symptoms and depressive symptoms，respectively.Each item of the two scales was rated on a 4-point Likert scale as 0（not at all），1（several days），2（more than half the days），and 3（nearly every day）.A total score of 0-4 points on the GAD-7 scale was considered normal，5-9 points mild anxiety，10-14 points moderate anxiety，and 15-21 severe anxiety，with a Cronbach's α coefficient of 0.854.The total score on the PHQ-9 scale was interpreted as no depression（0-4），mild（5-9），moderate（10-14），severe（15-19），or extremely severe depression（20-27），with a Cronbach's α coefficient of 0.832.

2.3 Data collection

All questionnaires were answered via a professional open-electronic-questionnaire platform（Wen Juan Xing：https：//www.wjx.cn/），with detailed questionnaire instructions.The WeChat link and quick response codes of questionnaires were generated and sent to all medical staff who met the strict inclusion criteria.The respondents filled in and submitted the questionnaire using smart terminals，such as computers or mobile phones.The same internet protocol address or the same mobile phone number could only fill in the questionnaire once.The researcher provided a detailed explanation of the purpose of the study and the concepts in the questionnaire to avoid confusion or errors.

2.4 Statistical analysis

SPSS Statistics 25.0（IBM Corp.，Armonk，NY，USA）was used to process and analyze the data.Continuous variables were presented as the mean±standard deviation，and categorical variables were expressed as numbers and percentages.The differences in anxiety and depression among subgroups were analyzed by the χ2-test or Fisher's exact test.Logistic regression analysis was performed using all variables to identify the contributing factorssignificantly impacting the mental health status of the medical staff during the quarantine period（P＜ 0.05）.

3 .Results

From March 17 to March 31，2020，a total of 121 questionnaires were received by the open-electronic-questionnaire platform，and 120 valid questionnaires were finally obtained.The effective recovery rate was 99.17%.Medical staff were predominantly female （70.83%） and nurses（72.50%），with a mean age of（33.37 ± 6.00）years，and from the department of tuberculosis，intensive care unit，surgery，or others.Only 4.17% of the staff had a previous history of anxiety or depression.During quarantine，the chief contributing factors were fear of being infected with the virus（54.17%），change of lifestyle（42.50%），worry about family members（32.50%），concerns during quarantine（30.00%），and fear of a COVID-19 outbreak（29.17%）.Demographic and general information about the staff is presented in Table 1.

The mean GAD-7 score was（3.58 ± 4.21）points，and 36（30.00%）medical staff had anxiety-related symptoms.Mild anxiety symptoms were seen in 27 staff（22.50%），moderate symptoms in 7 staff（5.83%），and severe symptoms in 2 staff（1.67%）.In univariate analyses，the appearance of anxiety symptoms was not associated with the presented variables，including gender，age，occupation，education，department，previous history，and chief factors of concern during quarantine.It seemed that the relatively younger staff and nurses were more likely to suffer anxiety symptoms，but no statistical differences among all 120 staff were observed.

The mean PHQ-9 score was（2.54±3.59）points，and 29（24.17%）medical staff had depression-related symptoms.Mild depression symptoms were seen in 24 staff（20.00%），moderate symptoms in 4 staff（3.33%），and severe symptoms in 1 staff（0.84%）.Fear of being infected with the virus was strongly associated with the occurrence of depression（p=0.015）.The results of the anxiety and depression scores and univariate analyses are listed in Table 1.

To further identify the contributing factors significantly impacting the mental health status of the medical staff during the quarantine period，we performed binary logistic regression analyses.The results were the same as those identified by the univariate analyses；the manifested anxiety symptoms were not associated with gender，age，occupation，education，department，previous history，and the chief factors of concern.The presentation of fear of being infected with COVID-19 was the main factor contributing to the occurrence of depression symptoms during quarantine（odds ratio 0.32，95% confidence interval 0.12，0.85，p=0.023）.The results of binary logistic regression analyses on the contributing factors are shown in Table 2.

Table 1 Demographic information，anxiety and depression scores

Table 2 Binary logistic regression analyses for the contributing factors

4 Discussion

4.1 The relationship between anxiety or depression and basic personal conditions of medical staff during quarantine after completing medical aid work during the COVID-19 epidemic

This study showed that of the 120 medical staff who completed the GAD-7 and PHQ-9 questionnaires during quarantine，30.00% experienced anxiety symptoms and 24.17% experienced depression symptoms，despite successfully completing medical aid work in Hubei Province during the COVID-19 epidemic.When a highly infectious disease breaks out in any country or region，a stress response occurs in people in the quarantine zone，as well as in medical staff and rescue teams in close contact with patients diagnosed with the infectious disease.［11］The outbreak of the COVID-19 epidemic was an emerging，rapidly evolving situation，which placed medical staff across the world in an unprecedented situation.However，a number of the medical staff lacked full knowledge，mental preparation，and treatment experience to deal with the COVID-19 epidemic.［11］A previous report showed that sleep quality was severely affected by anxiety symptoms in 70 medical staff infected with COVID-19.［12］Moreover，for the clinical nursing staff，especially young nurses，some might lack the awareness of the risk and complexity of disaster rescue，despite showing excellent clinical nursing skills.［13］Without the psychological preparation to face a severe epidemic，some health care staff might experience psychological problems.Therefore，sufficient professional and psychological training is essential before taking part in medical aid work，which could improve the clinical abilityand mental preparation in response to the sudden outbreak of the COVID-19 epidemic.［11］Previously，some cross-sectional studies showed that medical staff with a high education level could master the necessary theoretical knowledge and skills relatively quickly and accurately and promptly adjust their psychological status.［14-15］

4.2 Fear of being infected with COVID-19 was the main reason for depression

This study found a statistically significant difference in the incidence of depression among the medical staff during quarantine after their aid work in Hubei Province.Fear of being infected with COVID-19 was the main influencing factor of depression among the medical staff during this period.The symptoms of anxiety and depression were more obvious than those experienced in daily work.The main reasons were as follows：first of all，medical workers were more likely to have close contact with COVID-19-infected patients，which increased the risk of infection；Secondly，medical staff might be worried about some subjective factors，such as inconvenient food procurement，income problems，elderly care，children's education，and other quarantine issues，aggravating the degree of psychological distress.Meanwhile，there was no specific treatment for the continuous discovery of the epidemic transmission mode.［16］Moreover，COVID-19 had a long incubation period and must be excluded by repetitive results of nucleic acid tests.［16］All these factors could inevitably cause anxiety or depression among medical staff during quarantine.

At present，most researchers have focused on the factors related to anxiety and depression among frontline medical staff in Hubei Province，with no study on the psychological state of these workers during medical quarantine after completing medical aid work.Thus，as frontline medical staff，this paper emphasized the psychological status of medical staff during medical quarantine based on our experience.When finishing the medical aid work，medical workers left the local hospital and accepted medical observation in the designated area.During the 2-week quarantine，anxious and depressive emotions appeared due to fear of being infected，change of lifestyle，worry about family members，concerns during quarantine，and fear of a COVID-19 outbreak.Although medical staff tried to selfresolve the adverse psychological problems，these feelings of unease were unavoidable.Thus，it is imperative to address the physical and mental health of medical staff during quarantine after completing medical aid work，assess anxious and depressive emotions，resolve any negative problems，and provide the support necessary to return to normal life and work as soon as possible.［17-18］

4.3 Appropriate measures for medical staff to prevent or resolve anxiety and depression

4.3.1 Self-relaxation therapy

4.3.1.1 Mindfulness decompression therapy：Medical staff could practice mindfulness breathing， mindfulness yoga， meditation， and other forms of relaxation through online teaching，both as a "psychological nursing" self-intervention and to reduce the incidence of respiratory infection.［19］

4.3.1.2 Exercise decompression therapy：Appropriate scientific exercise could reduce negative psychological emotions.For instance，"Baduanjin" is a traditional rehabilitation gymnastics with positive impacts on cognitive function.［20］Despite the limited range of activity during medical quarantine，medical staff could learn yoga，aerobics，and similar activities through the online live video platform to regulate cardiopulmonary functions and achieve self-cultivation.

4.3.1.3 TikTok therapy：Staff could watch short videos for positive energy to enhance quality-oflife during quarantine，learn to produce videos on TikTok，record the journey of fighting the epidemic and post it on this online platform to share with others.

4.3.1.4 Painting therapy：Research showed that painting therapy could effectively weaken the effects of anxiety in patients.［21］In the process of creative painting，medical staff could pour the repression in their subconscious into painting and experience feelings of satisfaction.

4.3.2 Social support therapy

Hospital had worked in many ways to meet the needs of support teams during quarantine.For example，the hospital created a warm and positive quarantine environment according to the medical staffs'different needs and provided us personal items and disinfection materials.In addition，the hospital assisted the quarantine hotel in developing a nutritionally balanced "anti-epidemic menu." Meanwhile，a WeChat group named the "Crisis Intervention Hotline Group" was set up to carry out crisis intervention psychological consultation and share psychological status with team members，which could actively provide psychological counseling.Furthermore， through Weibo（microblogging），WeChat public accounts，and other online platforms，the hospital regularly sent knowledge about COVID-19 prevention and control.It also delivered the "3-Question Daily"，"Medicinal Food Daily，" and "Daily Lesson of Hospitalassociated Infection" to the medical staff during quarantine.The health of medical staff should be reported to the office automation system daily.This measure could ensure that medical staff alleviate their psychological pressure，improve their confidence to fight the epidemic，and receive the latest information on the prevention and control of the epidemic，as well as the health of their colleagues.

The hospital also worked toward strengthening the role of families during COVID-19 and formulated the plan of visiting frontline medical staff for COVID-19 treatment.A "daily connection" hotline was set up to provide psychological counseling for their families，and information about the quarantine period of medical staff was delivered，which reassured their family members.The system of "one-to-one" liaison officers was established to ensure the implementation of "one person，one family，one letter，" "one person，one family，one unit，" and "one person，one family，one team".Letters asking people to care for the families of the team members fighting the epidemic " were issued to encourage the units and the communities from which they derived.The hospital improved the disease-resistance family information files，implemented a precise matchmaking service，and enabled each medical staff to communicate closely with their specified family members.Moreover，the hospital supplied masks，disinfectants，fresh fruits，vegetables，milk，eggs，and other daily necessities and issued temporary economic benefits to the family members.The hospital also opened the Green Life channel for the family members of medical staff during quarantine.Furthermore，the hospital established outstanding deeds in epidemic work，actively created a good atmosphere of talent guidance and hard work，and affirmed the value of medical staff in fighting the epidemic through the "Anti-Epidemic Medical Staff's Demeanor Exhibition，" "Anti-Epidemic Diary，"and" Anti-Epidemic Letters."Meanwhile，according to the Notice on further implementation of COVID-19 prevention and personnel incentive measures at the national and provincial levels，issued by the Commission of Health，the hospital provided anti-epidemic staff with government-affiliated and other policy incentives.

5 Limitations of the study

The limitations of this study were as follows：limited samples and variables were applied in this study；there was no control group in this study；the questionnaire variables were subjective and presented potential selection bias.

6 .Conclusion

It is of great significance to maintain the mental health of medical staff during quarantine.Identifying the factors that cause anxiety and depression in medical staff during quarantine after completing medical aid work to counteract the COVID-19 epidemic can ensure appropriate psychological care and support to recover mental health as soon as possible.The whole society should raise attention toward the mental health of frontline medical staff during quarantine and，ultimately，provide a good social environment to anti-epidemic medical staff during the transition from quarantine.