Mental health of surgeons during the COVID-19 pandemic: An urgent need for intervention

Abstract

Surgeons working during the coronavirus disease 2019 (COVID-19) pandemic are facing unprecedented challenges, such as risk of infection, shortage of personal protective equipment, socioeconomic challenges, the decreased ability to obtain family support, and the cancellation of elective operations with redeployment of surgeons to other departments.1Balasubramanian A. Paleri V. Bennett R. Paleri V. Impact of COVID-19 on the mental health of surgeons and coping strategies.Head Neck. 2020; 42: 1638-1644Crossref PubMed Scopus (42) Google Scholar,2Hong Z. Li N. Li D. et al.Telemedicine During the COVID-19 pandemic: experiences from Western China.J Med Internet Res. 2020; 22e19577Crossref PubMed Scopus (146) Google Scholar In addition, surgeons working in Libya during the civil war conflict are at greater risk of physical and verbal abuse by the militias during the conflicts of the civil war; for example, when the relatives or friends of these militias are injured/diseased or even die in the hospital, they attack surgeons and physicians who were caring for that patient, especially in working settings that suffer from a shortage of equipment and resources during the COVID-19 pandemic.3Elhadi M. Msherghi A. COVID-19 and civil war in Libya: the current situation.Pathog Glob Health. 2020; 114: 230-231Crossref PubMed Scopus (10) Google Scholar Thus, surgeons working in Libya are at greater risk of mental illness owing to the civil war, financial crisis, lack of training, shortage of personal protective equipment, and risk of COVID-19 infection. Therefore, we aim to provide an overview of the mental health status among surgeons during COVID-19. An online, anonymous, cross-sectional survey was conducted using email and mobile messages among surgical staff and residents working in Libyan hospitals during May 2020 to measure their anxiety and depressive symptoms and to provide an overview of physical and verbal abuse. The survey included basic demographic characteristics, the incidence of physical and verbal abuse owing to the civil war conflict, and history of COVID-19 infection. The second part of the survey included a mental health assessment comprising a self-administered, 9-item Patient Health Questionnaire (PHQ-9)4Kroenke K. Spitzer R.L. Williams J.B. The PHQ-9: validity of a brief depression severity measure.J Gen Intern Med. 2001; 16: 606-613Crossref PubMed Scopus (21637) Google Scholar,5Levis B. Benedetti A. Thombs B.D. DEPRESsion Screening Data (DEPRESSD) Collaboration. Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis.BMJ. 2019; 365: l1476Crossref PubMed Scopus (526) Google Scholar with ≥15 as the cutoff score for depressive symptoms and the 7-item, Generalized Anxiety Disorder scale (GAD-7)6Spitzer R.L. Kroenke K. Williams J.B. Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7.Arch Intern Med. 2006; 166: 1092-1097Crossref PubMed Scopus (12708) Google Scholar with ≥15 as the cutoff score for anxiety symptoms. A total of 309 participant surgeons, 201 (65%) surgery residents and 108 (35%) surgical staff from Libyan hospitals, have completed the survey. The mean age of participants (SD) was 32.8 (7.1). Among study participants, 212 (68.6%) were men, and 97 (31.4%) were women. Table I illustrates the basic study characteristics of the participants along with association with depressive and anxiety symptoms. Based on the cutoff scores of the PHQ-9 and the GAD-7 to determine the presence of depressive and anxiety symptoms, 36 (11.7%) participants reached the cutoff score for a diagnosis of depressive symptoms as determined by a PHQ-9 score ≥15, while 47 (15.2%) reached the cutoff score for anxiety symptoms as determined by a GAD-7 score ≥15. The mean (SD) score for the PHQ-9 was 11.1 (2.9), while the mean (SD) for the GAD-7 was 10.7 (3.5).Table IBasic characteristics of study population and psychologic status association (N = 309)Characteristicsn (%)Depressive symptomsAnxiety symptomsPHQ-9 ≥15PHQ-9 <15χ2P valueGAD-7 ≥15GAD-7 <15χ2P valueAge (y)1.807.1796.720.01∗Significant at (P < .05). <35229 (74.1)30 (83)199 (72.9)42 (89)187 (71.4) ≥3580 (25.9)6 (17)74 (27.1)5 (11)75 (28.6)Sex-male212 (68.6)22 (61)190 (69.6)1.063.30230 (64)182 (69.5)0.588.443 Female97 (31.4)14 (39)83 (30.4)17 (36)80 (30.5)Marital status n (%)0.04.8410.855.355 Single185 (59.9)21 (58)164 (60.1)31 (66)154 (58.8) Married124 (40.1)15 (42)109 (39.9)16 (34)108 (41.2)Living arrangement0.327.5680.351.553 Alone44 (14.2)32 (89)40 (14.7)8 (17)36 (13.7) Within family265 (85.8)4 (11)233 (85.3)39 (83)226 (86.3)Y of experience1.775.1833.251.071 <5201 (65)27 (75)174 (63.7)36 (77)165 (63) ≥5108 (35)9 (25)99 (36.3)11 (23)97 (37)Surgical specialty3.871.86915.965.043∗Significant at (P < .05). General and GI surgery74 (23.9)8 (22)66 (24.2)4 (9)70 (26.7) Trauma and emergency100 (32.4)10 (28)90 (33)20 (43)80 (30.5) Orthopedic40 (12.9)6 (17)34 (12.5)9 (19)31 (11.8) Urology10 (3.2)2 (6)8 (2.9)3 (6)7 (2.7) Head and neck9 (2.9)2 (6)7 (2.6)3 (6)6 (2.3) Cardiothoracic6 (1.9)1 (3)5 (1.8)06 (2.3) Plastic surgery4 (1.3)04 (1.5)04 (1.5) Neurosurgery6 (1.9)06 (2.2)06 (2.3) Other60 (19.4)7 (19)53 (19.4)8 (17)52 (19.8)Smoking0.802.372.21.145 Yes79 (25.6)7 (19)72 (26.4)8 (17)71 (27.1) No230 (74.4)29 (81)201 (73.6)39 (83)191 (72.9)Living in conflict area2.560.110.793.373 Yes101 (32.7)16 (44)85 (31.1)18 (38)83 (31.7) No208 (67.3)20 (56)188 (68.9)29 (62)179 (68.3)Verbal abuse episode0.302.5831.308.253 Yes167 (54)21 (58)146 (53.5)29 (62)138 (52.7) No142 (46)15 (42)127 (46.5)18 (38)124 (47.3)Physical abuse episode1.85.1740.029.865 Yes50 (16.2)3 (8)47 (17.2)8 (17)42 (16) No259 (83.8)33 (92)226 (82.8)39 (83)220 (84)GI, gastrointestinal.∗ Significant at (P < .05). Open table in a new tab GI, gastrointestinal. Among the study participants, 101 (32.7%) live in a conflict area, 167 (54%) have had an episode of verbal abuse by militia or armed forces during the civil war conflict, and 50 (16.2%) have encountered physical abuse by these militias or armed forces while treating injured militia patients, their relatives, or friends. Regarding abuse and threatening behavior, 21 (6.8%) reported being frightened and threatened with a weapon, 13 (4.2%) experienced a sharp object being thrown, and 18 (5.8%) experienced a blow from a hand and/or kicking. Sixteen (5.2%) reported severe, life-threatening injuries; indeed, their life was in endangered because of physical abuse. Among the participants, 91 (29.4%) reported an adverse consequence of abuse in terms of their family or quality of life. Only age and surgical specialty were associated with anxiety symptoms (P < .05) The sex of the responder, marital status, living arrangements, smoking, living in a conflict area, and verbal and physical abuse did not appear to be associated with depressive or anxiety symptoms. Our study demonstrated a high prevalence of anxiety and depressive symptoms among surgical staff during COVID-19. In addition, we demonstrated a great number of abuse episodes among surgical staff in Libya. The working style of surgeons is another risk factor for increased psychological pressure. Surgical staff suffer from the risk of infection and cross-contamination, which increases the psychological burden that may result in more anxiety and depression. Additionally, as the COVID-19 pandemic has affected surgical training, there is a high burden of stress regarding their future career opportunities especially in the surgery trainees. It is therefore necessary to pay particular attention to the psychological status of surgical staff and to implement strategies aimed to provide psychological and socioeconomic support. Psychotherapy sessions have been proposed as a method to ensure that the mental health status of both the medical and especially surgical staff will not affect their performance.7Folkman S. Greer S. Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other.Psychooncology. 2000; 9: 11-19Crossref PubMed Scopus (386) Google Scholar The authors declare that they have no competing interests.