Mental Health Impact Of COVID-19 Research Articles

Heterogeneous mental health consequences of COVID-19: Costs and benefits.

In this commentary, I argue that the mental health impact of COVID-19 will show substantial variation across individuals, contexts, and time. Further, one key contributor to this variation will be the proximal and long-term impact of COVID-19 on the social environment. In addition to the mental health costs of the pandemic, it is likely that a subset of people will experience improved social and mental health functioning. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Roadmap to strengthen global mental health systems to tackle the impact of the COVID-19 pandemic

BackgroundThe COVID pandemic has been devastating for not only its direct impact on lives, physical health, socio-economic status of individuals, but also for its impact on mental health. Some individuals are affected psychologically more severely and will need additional care. However, the current health system is so fragmented and focused on caring for those infected that management of mental illness has been neglected. An integrated approach is needed to strengthen the health system, service providers and research to not only manage the current mental health problems related to COVID but develop robust strategies to overcome more long-term impact of the pandemic. A series of recommendations are outlined in this paper to help policy makers, service providers and other stakeholders, and research and research funders to strengthen existing mental health systems, develop new ones, and at the same time advance research to mitigate the mental health impact of COVID19. The recommendations refer to low, middle and high resource settings as capabilities vary greatly between countries and within countries.DiscussionThe recommendations for policy makers are focused on strengthening leadership and governance, finance mechanisms, and developing programme and policies that especially include the most vulnerable populations. Service provision should focus on accessible and equitable evidence-based community care models commensurate with the existing mental health capacity to deliver care, train existing primary care staff to cater to increased mental health needs, implement prevention and promotion programmes tailored to local needs, and support civil societies and employers to address the increased burden of mental illness. Researchers and research funders should focus on research to develop robust information systems that can be enhanced further by linking with other data sources to run predictive models using artificial intelligence, understand neurobiological mechanisms and community-based interventions to address the pandemic driven mental health problems in an integrated manner and use innovative digital solutions.ConclusionUrgent action is needed to strengthen mental health system in all settings. The recommendations outlined can be used as a guide to develop these further or identify new ones in relation to local needs.

New Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders-The Perfect Storm.

Back to table of contents Previous article Next article CommentaryFull AccessNew Challenges in Addiction Medicine: COVID-19 Infection in Patients With Alcohol and Substance Use Disorders—The Perfect StormPrimavera A. Spagnolo, M.D., Ph.D., Chiara Montemitro, M.D., Lorenzo Leggio, M.D., Ph.D.Primavera A. SpagnoloSearch for more papers by this author, M.D., Ph.D., Chiara MontemitroSearch for more papers by this author, M.D., Lorenzo LeggioSearch for more papers by this author, M.D., Ph.D.Published Online:14 Jul 2020https://doi.org/10.1176/appi.ajp.2020.20040417AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Unfortunately for mariners, the total amount of wave energy in a storm doesn’t rise linearly with wind speed, but to its fourth power. The seas generated by a forty-knot wind aren’t twice as violent as those from a twenty-knot wind, they’re seventeen times as violent.—Sebastian Junger, The Perfect Storm: A True Story of Men Against the SeaThe spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes the COVID-19 disease, has caused one of the worst pandemics of the past century. Among many ongoing efforts, it is important to identify categories of patients who are more susceptible to COVID-19 infection and its sequelae. Here, we aim to raise awareness of patients with alcohol and substance use disorders. These disorders represent a dramatic public health crisis that is taking a massive toll on individuals and society. As the opioid epidemic has shown us, responding to this crisis is challenging because many factors (e.g., the neurobiology of alcohol and substance use disorders, the availability of and access to effective treatments, prevention strategies, and the sociocultural context) need to be addressed simultaneously. Given the COVID-19 pandemic, tackling the alcohol and substance use disorder crisis may be even more problematic because, as in a perfect storm, a combination of elements serves to worsen the already complex clinical conditions of patients with these disorders. The consequences of this storm may spread long after the pandemic is resolved and may affect a large proportion of the population, beyond individuals with current alcohol and substance use disorders.Individuals with alcohol and substance use disorders present specific medical risk factors, making them more vulnerable to COVID-19 infection and its sequelae. Both alcohol and drugs of abuse dampen the immune system response (1), increasing the risk of respiratory infections and their complications. Moreover, patients with alcohol and substance use disorders may be more prone to develop infection-related consequences, given the high rates of cardiovascular and pulmonary comorbidities linked to misuse of alcohol, opioids, and stimulants. There are also reports of cerebral involvement by COVID-19 (2) that could have an effect on mental state and/or alcohol and substance use, and it is conceivable that such direct interaction between the virus and the abnormal brain in patients with alcohol and substance use disorders may exacerbate both disorders. Furthermore, cannabis and nicotine consumption are linked to specific COVID-related risk factors, and smoking is often associated with prolonged respiratory symptoms that may overlap with COVID-19 symptoms, leading to misdiagnosis and unnecessary hospital admissions. Disruption of illicit drug markets and closure of liquor stores may result in increased risk of withdrawal, which, for alcohol in particular, may have life-threatening consequences but may also induce patients to engage in higher-risk behaviors to alleviate withdrawal (e.g., drinking toxic products containing ethanol; violating quarantine to seek drugs), which can further expose them to COVID-19 infection or other harms. People who inject drugs may suffer from low availability of sterile products, increasing risks of HIV and other infections (1). For these reasons, and given the high transmissibility of SARS-CoV-2, it is important to consider viral testing for individuals with alcohol and substance use disorders.The COVID-19 pandemic is also acting as a severe stressor, with millions of individuals experiencing fear, anxiety, and social isolation over a prolonged period. Protracted exposure to stress has long been known to increase symptom severity (e.g., craving, consumption) and risk of relapse in patients with alcohol and substance use disorders. Furthermore, a positive association has been reported between exposure to stress during both adolescence and adulthood and vulnerability to alcohol and substance use disorders (3). For example, higher use of alcohol and drugs has been found in survivors of traumatic events like Hurricane Katrina (4, 5) and the September 11, 2001, terrorist attacks (6, 7).Chronic stress may trigger alcohol and drug use by inducing profound adaptations in circuits implicated in networks involving motivation, reward, behavior, and cognitive control. These alterations can lead to impulsivity, poor decision making, malaise and negative emotional states, and decreased ability to regulate stress, all factors that contribute to increased risk for alcohol and substance use disorders. Importantly, dysfunctions in these circuits are also observed as a consequence of prolonged exposure to alcohol and drugs, indicating that stress and addictive agents interact synergistically to drive and maintain compulsive alcohol and drug use. It is crucial to consider that stress-, alcohol-, and drug-related alterations in the brain are all long lasting, thus indicating that their effects persist even when the stressor passes or when the individual reaches abstinence (8, 9). Specific examples of factors associated with stress and their consequences that contribute to alcohol and substance use disorders include pain perception (10, 11), social isolation, and access to appropriate treatments, as detailed next.Social isolation represents an important factor by which the COVID-19 outbreak will likely affect outcomes related to alcohol and substance use disorders. Prolonged exposure to social isolation, which itself can be considered a stressor, has been consistently linked with increased vulnerability to alcohol and drug use (12). Furthermore, there is evidence that the efficacy of several interventions for alcohol and substance use disorders, including Alcoholics Anonymous and Narcotics Anonymous, relies on providing social support to patients. With individuals required during the pandemic to spend more time in their residence, a surge in at-home alcohol drinking and drug use may occur, especially among those individuals already at risk. Also notable is the increased risk of domestic harms, including domestic violence, related to substance use, especially alcohol.Finally, we need to consider the challenges related to the availability of and access to treatments for individuals with alcohol and substance use disorders during the COVID-19 pandemic. These challenges are not new per se; in fact, evidence-based treatments are often not provided to individuals with these disorders (13). This significant medical and public health issue is related to several distinct yet overlapping causes, which include stigma surrounding the misuse of alcohol and drugs, the lack of appropriate access to resources to combat addiction, and the limited education and training on alcohol and substance use disorders provided during medical school, residencies, and other clinical training programs. All of these issues may be further complicated during the COVID-19 pandemic. As a result, individuals suffering from alcohol and substance use disorders may be even more marginalized at a time when the urgency of addressing a serious and deadly pandemic may take priority over managing this chronic health condition. Patients with these disorders may fail to continue their usual treatment program or to initiate one, may not have easy access to medications to curb craving and withdrawal, and may experience large unmet needs because of service availability and financial barriers but also as a consequence of stigmatization. Furthermore, patients may experience decreased availability of both social and health care resources even after the COVID-19 pandemic resolves.In this context, we should use any means available to treat patients, including directing them to resources on the websites of the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Online mutual support programs could be effective in helping individuals with alcohol and substance use disorders (14). Online counseling and meetings with care providers can be very helpful when in-person treatment options are not available. Clinicians can use telemedicine to evaluate withdrawal symptoms and associated risks, avoiding frequent emergency department visits. Telemedicine can and should also be implemented to provide behavioral treatments with proven efficacy for patients with alcohol and substance use disorders (15) who are attempting to reduce or stop alcohol and/or drug misuse, as well as for those individuals working to maintain recovery or abstinence. However, patients with these disorders often suffer from low socioeconomic status and poor living conditions, and patients who are living in shelters or who cannot afford electronic devices may find it difficult to access telemedicine or other online services.Medications for alcohol and opioid use disorders and for smoking cessation should be prescribed remotely. The benefits from remote therapies include the application of targeted and effective personalized interventions, reducing the frequency of in-person visits as well as prescription refills (e.g., depot buprenorphine, as it offers the opportunity to limit treatment contacts to once a month). The amounts of take-home methadone should be increased, which is important because if patients need to wait in long lines and crowded spaces for methadone, it will be difficult to comply with physical distancing recommendations (which in turn will increase the risk of COVID-19 infection). Indeed, such approaches for methadone, as well as other approaches for patients with opioid use disorder (e.g., telemedicine-based prescription of buprenorphine), have been implemented during the pandemic. Although these measures are temporary, we hope that these changes may lead to long-term improvements in addiction medicine beyond the pandemic. Furthermore, harm reduction programs, including community-based programs offering naloxone distribution, should also be broadly implemented as part of the COVID-19 response.Finally, it is also important to keep in mind that, in addition to the potential harmful role of the ongoing pandemic for individuals with current alcohol and substance use disorders, the pandemic may play a critical role in promoting heavy alcohol drinking and misuse of drugs, increasing the risk of future development of these disorders. Indeed, stress and social isolation, as well as unemployment and related financial burden, may all represent critical risk factors for the general population in the development of these and other psychiatric disorders, which in turn may lead to alcohol and substance use disorders.In conclusion, patients with alcohol and substance use disorders face unique vulnerability factors during this dramatic global health crisis. Considering the current and long-term impact that the COVID-19 outbreak will have on individuals with alcohol and substance use disorders, it is critical to ensure that these patients continue to have access to available and appropriate treatments. Indeed, in these unprecedented times, treatment services for patients suffering from these disorders should be enhanced, and access should be prioritized and maintained.NIDA Intramural Research Program, Baltimore (all authors); National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research (Leggio), and National Institute of Neurological Disorders and Stroke Intramural Research Program (Spagnolo), Bethesda, Md.;Department of Neuroscience, Imaging, and Clinical Science, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy (Montemitro).Send correspondence to Dr. Leggio ([email protected]).The first two authors contributed equally to this commentary.All authors were supported by NIDA’s intramural research programs; Dr. Leggio was supported by the National Institute on Alcohol Abuse and Alcoholism; and Dr. Spagnolo was supported by the National Institute of Neurological Disorders and Stroke.The content of this commentary reflects the views of the authors and does not necessarily represent the official views of the funding organizations.Dr. Leggio receives royalties from Rutledge and an honorarium from the U.K. Medical Council on Alcohol for serving as editor-in-chief of Alcohol and Alcoholism. Drs. Spagnolo and Montemitro report no financial relationships with commercial interests.References1 Reece AS: Clinical implications of addiction related immunosuppression. J Infect 2008; 56:437–445Crossref, Medline, Google Scholar2 Li YC, Bai WZ, Hashikawa T: The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients. J Med Virol 2020; 92:552–555Crossref, Medline, Google Scholar3 Cerdá M, Tracy M, Galea S: A prospective population based study of changes in alcohol use and binge drinking after a mass traumatic event. Drug Alcohol Depend 2011; 115:1–8Crossref, Medline, Google Scholar4 Flory K, Hankin BL, Kloos B, et al.: Alcohol and cigarette use and misuse among Hurricane Katrina survivors: psychosocial risk and protective factors. Subst Use Misuse 2009; 44:1711–1724Crossref, Medline, Google Scholar5 Beaudoin CE: Hurricane Katrina: addictive behavior trends and predictors. 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Kalin, M.D.1 September 2020 | American Journal of Psychiatry, Vol. 177, No. 9Organization of mental healthcare in Bosnia and Herzegovina during coronavirus disease 2019 pandemicIndian Journal of Psychiatry, Vol. 62, No. 9 Volume 177Issue 9 September 01, 2020Pages 805-807 Metrics KeywordsAddiction PsychiatrySubstance-Related and Addictive DisordersCOVID-19CoronavirusTelehealthPDF download History Accepted 27 May 2020 Published online 14 July 2020 Published in print 1 September 2020

Snapshot Impact of COVID-19 on Mental Wellness in Nonphysician Otolaryngology Health Care Workers: A National Study.

ObjectiveNonphysician health care workers are involved in high-risk patient care during the COVID-19 pandemic, placing them at high risk of mental health burden. The mental health impact of COVID-19 in this crucial population has not been studied thus far. Thus, the objective of this study is to assess the psychosocial well-being of these providers.Study DesignNational cross-sectional online survey (no control group).SettingAcademic otolaryngology programs in the United States.Subjects and MethodsWe distributed a survey to nonphysician health care workers in otolaryngology departments across the United States. The survey incorporated a variety of validated mental health assessment tools to measure participant burnout (Mini-Z assessment), anxiety (Generalized Anxiety Disorder–7), distress (Impact of Event Scale), and depression (Patient Health Questionnaire–2). Multivariable logistic regression analysis was performed to determine predictive factors associated with these mental health outcomes.ResultsWe received 347 survey responses: 248 (71.5%) nurses, 63 (18.2%) administrative staff, and 36 (10.4%) advanced practice providers. A total of 104 (30.0%) respondents reported symptoms of burnout; 241 (69.5%), symptoms of anxiety; 292 (84.1%), symptoms of at least mild distress; and 79 (22.8%), symptoms of depression. Upon further analysis, development of these symptoms was associated with factors such as occupation, practice setting, and case load.ConclusionFrontline otolaryngology health care providers exhibit high rates of mental health complications, particularly anxiety and distress, in the wake of COVID-19. Adequate support systems must be put into place to address these issues.

Comment on "Attitude, practice, behavior, and mental health impact of COVID-19 on doctors".

Sir, The article by Chatterjee et al.[1] tries to explore the mental health impact of COVID-19 pandemic on doctors. This is an extremely important issue in the ongoing state of pandemic as doctors and health-care workers across the country are facing unprecedented challenges and pressures, and yet, they are trying their best to serve the society in the best possible manner. However, we have a few concerns regarding this study. The authors had planned to assess the knowledge, attitude, and practice of doctors about COVID-19. However, except the first question, there were no further questions exploring either knowledge about or attitude toward COVID-19 among doctors. The rest of the questions explored duty hours, availability of protective gear, practice of preventive measures, and other aspects. The authors have not mentioned about the online survey platform used to conduct the survey. This would have been an interesting piece of information as they later mentioned that the data was entered into Microsoft Excel datasheet. This is difficult to follow as most of the online survey engines provide collected data as prefilled downloadable datasheets, and in fact, some of them also present analysis and pie charts within their platforms. The standard deviation (S.D) is larger than mean in case of depression and anxiety subscale ([Table 2] of the article by Chatterjee et al.[1]) which indicates a high possibility of data being skewed or presence of outliers. This shall have serious implications on some of other analyses carried out later, i.e., t-test and logistic regression. These tests are based on the assumption that the data has normal distribution.[2] The results of these tests shall not hold true if this assumption is violated. After looking at these values of S.D, the authors could have carried out a test to check for normal distribution of the data. The authors are incorrect in reporting that 42.8% of the respondents had one or more comorbidities. Figures presented in Table 1 of the article[1] show that 94.1% of the participants (all of them are doctors) have at least one among the three serious comorbidities, namely hypertension, diabetes mellitus, or chronic obstructive pulmonary disease, and in fact, more than half of them (57%) suffer from all the three. These figures are far higher than the prevalence of either of these illnesses among Indian adults.[345] Proportion of individuals having all the three simultaneously is likely to be far lesser. This suggests that the authors have got a sample of a relatively sick group of doctors who are likely to develop a complicated illness in case they contract coronavirus infection. Further, while reporting comorbidities and carrying out the Chi-square test, the authors have created numerous categories due to which eight cells among the 2 × 8 table for this section have a value of n <5, which again violates basic assumption for Chi-square test. It would have been better to combine some of these categories to avoid small numbers in cells. Alternatively, Fisher's exact test could have been carried out.[6] Furthermore, the sociodemographic details of respondents have been presented repeatedly across Tables 1, 3 and 4 in the article.[1] This could have been avoided. The authors have not mentioned if the study was approved by the Institutional Ethics Committee (IEC). We hope that this is only a faux pas and the approval of IEC was actually obtained. Finally, in the list of references, the sixth reference refers to an entire issue of a journal. It would have been prudent to clearly mention one or more articles from which the cited information was taken. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Authors' responses to the comments on "Attitude, practice, behavior, and mental health impact of COVID-19 on doctors".

Sir, We would like to thank the authors for their valuable comments and queries on the article by us, Chatterjee et al.,[1] titled “Attitude, practice, behavior, and mental health impact of COVID-19 on doctors.” Though not in specific, comprehensively knowledge and attitude were assessed with the questions such as – “when you heard about COVID-19,” inquiring “whether doing duty,” “the duty hours,” “whether involved in high-risk procedures,” “feeling proud to be a doctor,” and “being ostracized by the society.” We collected data using Google Form and then transferred them to excel and subsequently to SPSS version 25 (IBM Corp., Armonk, NY, USA).[2] The higher standard deviation in depression and anxiety subscale points that it is spread out over a large range of values around mean, depending on responses. Here, running a normality test would have been better. However, more than the between-group difference, the goal was to find out the predictive factors of depression, anxiety, and stress. There were typographical errors in Table 1 (corrigendum attached) and another in the reference number 6,[3] both of which are corrected in this reply. We found that 87 doctors had no comorbid illness and 9 doctors have all the major three comorbidities (diabetes mellitus, hypertension, and chronic obstructive pulmonary disease).Table 1: CorrigendumThe study has been approved by the institutional ethics committee. The repetitiveness of the table was done for better comprehensibility. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Mental Health Impact of Covid-19 on Students in the USA: A CrossSectional Web-Based Survey

Background: The COVID-19 crisis has become the largest crisis in modern times and has particularly impacted students due to school closures, prolonged social isolation, and anxieties related to their future and health. All these factors may have caused significant stress and led to anxiety and depression in students. The purpose of this study was to study the prevalence and severity of COVID-19 associated mental health morbidity in students in the United States (US). Methods: A online cross-sectional survey was conducted using two instruments – the Perceived Stress Scale-4 (PSS-4) and the Patient Health Questionnaire for Depression and Anxiety-4 (PHQ-4). The survey was administered in the months of March to June during the COVID-19 pandemic to both high school and undergraduate college students. Results: In total, 369 students agreed to participate: 51.8% were male, 44.1% were college students. An elevated perceived stress level (PSS- 4 > 8) and a positive mood disorder (PHQ-4 > 4) was present in 49.6% and 56.6% of respondents, respectively. The mean (SD) PSS scores in males and females were 6.7 (2.7) and 8.2 (2.9) respectively among all the respondents, while the mean (SD) PHQ scores in males and females were 3.7 (3.2) and 5.3 (3.2) respectively. Prevalence of anxiety and depression in the respondents was 35.0% and 36.3% respectively. Females students reported higher PSS and PHQ scores compared to male students. There is a significant correlation between PSS and PHQ (r=0.66) Conclusion: The COVID-19 pandemic has resulted in an extremely high level of stress and mental health morbidity in both high school and college students, and this is more pronounced in females. Specific screening measures and interventions to improve the mental health of students is urgently warranted with a focus on females.

OCD and COVID-19: a new frontier.

(1)To learn how to identify OCD in the context of COVID-19 and consider the differences between following government guidelines and OCD.(2)To consider the presentation of OCD in context of COVID-19, with regard to cognitive and behavioural processes.(3)Review factors to be considered when embarking on CBT for OCD during the pandemic.(4)Considerations in CBT for OCD, including weighing up costs and benefits of behavioural experiments or exposure tasks in light of our current understanding of the risks associated with COVID-19.

Letter to editor: Re: "Primary care physician's approach for mental health impact of COVID-19": Case of migrant workers mental health.

Dear Editor, We read the article by Rohilla[1] with great interest where the authors have described that how our primary care physician colleagues can share the responsibility and can manage the psychological burden of the COVID-19 pandemic. In addition to the many special groups identified by authors,[1] we would like to highlight the psychological issues related to needs of a very important subgroup, that is, “Migrant workers.”[23] The migrant population is already very vulnerable and in addition to the recent outbreak of COVID-19 has brought tremendous challenges for this population.[4] Migration is a process in which people move to another place with the hope of making their lives better. Unskilled and uneducated people lacking job opportunities in local areas often migrate temporary from remote places to larger cities in India. Nationwide lockdown and travel restrictions placed in order of containing virus spread resulted in unbearable social stigma, isolation, income loss, fear and risk for mental health concerns, including suicide.[56] Recently, an editorial “Mental health of migrant laborers in COVID-19 pandemic and lockdown: Challenges ahead” and another article “COVID-19 pandemic: Mental health challenges of internal migrant workers (IMW) of India” draws timely attention to the increased risk and rates of mental health problems among IMWs in India.[37] Mental health problems can have biological, social, and environmental influences in etiopathogenesis and all these are at heightened interplay during the COVID-19 pandemic for IMWs.[8] The attempts of virus containment affected all components of the social system and thus mental health of internal migrant workers globally but particularly in India. The present COVID-19 pandemic has created extremely challenging social situations. It resulted into more significant social exclusion and risk for mental health problems. Due to inherent vulnerability, migrant workers are at higher risk.[9] Four components of the social-ecological model, individual (intrapersonal), interpersonal relationships, community, and societal policies influence the mental health of an individual.[10] It is essential to recognize that the risk of increased mental health issues that have mainly originated due to social factors and distress should be handled in the context of social-ecological approaches of mental health intervention.[11] The need for mental health care has been sensed by the providers and government officials in several countries, including India. To address the present epidemic related challenges, as an alternative to the face-to-face, mental health services, interventions are being planned and need to be offered in an online mode [Table 1]. In the setting of online mode, psychiatric services offered by trained mental health professionals can be considered the main component to overcome the mental health-related problems.Table 1: Suggestions for addressing concurrent mental health issues of migrants in social ecological health care frameworkFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Primary care physician's approach for mental health impact of COVID-19.

As the world struggles to control coronavirus infection with the exhausting capacity of health care systems globally, the role of primary care physician and family physician becomes more important as the first point of contact with the community. Limited availability of mental health services in India requires general practitioners to deal with psychological disorders arising due to infection outbreak and its restrictive control strategies. This article discusses what and how primary physicians can manage the psychological burden of a pandemic, and therefore, reducing the reliance on mental health specialist.

Mental health impact of COVID-19: Australian perspective.

Australia's response to the coronavirus outbreak has widely been considered to be among the most successful in the world. A bipartisan “national government” akin to that in wartime, a fairly unified COVID response by the federal and all the state governments, international border closures and quarantine, some of the best coronavirus testing in the world, and widespread public acceptance of physical distancing, all contributed to Australia being able to call itself the “lucky country” in its successful navigation of the COVID crisis. The country clearly had a plan for the mental health consequences of COVID. The impacts of lockdown were identified early, and steps taken to mitigate them. There was no spike in tertiary mental health presentations. Telehealth was embraced, support services mobilized, and public awareness of mental health issues made part of the conversation. While anxiety seemed raised nationwide, much of this lays at a subclinical level, manifesting through activities such as increased consumption of alcohol. Management of the burden of increased nationwide anxiety was carried out through online-based nongovernmental organizations, often directly recommended by the government itself.

Attitude, practice, behavior, and mental health impact of COVID-19 on doctors.

Background:COVID-19, like every other pandemic, has imposed an unprecedented threat to doctors' physical and mental health. Literature in this area is sparse. The present study has been done to explore the knowledge, attitude, and behavior of doctors regarding this pandemic and how it influences their depression, anxiety, and stress level.Materials and Methods:This online survey has been done for 10 days. Data were collected on background characteristics, knowledge, attitude, and behavior of the respondents in a semi-structured pro forma, and psychiatric morbidity was measured by the Depression, Anxiety, and Stress Scale-21. A total of 152 complete responses have been received. The data were assessed using SPSS software.Results:Out of 152 study participants, 34.9% were depressed and 39.5% and 32.9% were having anxiety and stress, respectively. Significant predictors for psychiatric morbidities were experience in health sector, duty hours, use of protective measures, and altruistic coping. Multivariable logistic regression showed most of the factors to be significantly associated with depression, anxiety, and stress level.Discussion:Doctors who were working during COVID pandemic have a high prevalence of psychiatric morbidity. Age and having multiple comorbidities are significant predictive factors. Adequate protective measures should be warranted. Altruistic coping and a sense of greater goal are significant among the doctor community, in this pressing time. The doctors are pushing themselves to the best of their capacity and also protecting their patients' best interest. A large-scale, multicentric study will probably give a larger picture and will guide us for better service planning and delivery.

COVID-19: Survey of doctors.

Sir, We compliment Chatterjee et al.[1] for studying attitude, practice, behavior, and mental health impact of COVID-19 in doctors in West Bengal. We are concerned, however, that their sample of 152 subjects, not stratified for any important population demographic, is unlikely to be representative of the tens of thousands of doctors who practice in the state. Furthermore, because the sample was obtained through E-mails and appeals on social media, and not through a recognized method of sampling, there could have been substantial sampling bias that would compromise the validity of the study. This method of sampling also does not have a clearly defined sampling frame, and so it is unclear to what population the results of the study can be generalized. We are also concerned that the authors appear to have used the Depression Anxiety Stress Scales (DASS)-21 as a diagnostic instrument with no validated cutoffs stated in their paper. Thus, for example, their categorization of respondents into depressed and nondepressed categories lacks validity. Finally, although the DASS-21 has 3 subscales, the authors reported a single value of Cronbach's alpha for the instrument; they should have reported Cronbach's alpha for each subscale separately because this test of internal consistency assumes unidimensionality in the items of the scale.[2] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Mental Health Impact of COVID-19 on Healthcare Workers in the USA: A Cross-Sectional Web-Based Survey

The COVID-19 crisis has become the largest crisis in modern times and particularly impacted healthcare workers (HCW) leading to extreme stress due to risk of exposure and health concerns. A web-based survey was conducted using two instruments – the Perceived Stress Scale-4 (PSS-4) and the Patient Health Questionnaire for Depression and Anxiety-4 (PHQ-4). The survey was administered in the months of March to June during the COVID-19 pandemic to both doctors (MD) and nurses (RN). A total of 569 HCWs completed the questionnaire (50% RNs and 30% MDs). About 42% HCWs screened positive for a mood disorder depression/anxiety based on PHQ-4 of >4, and 49% respondents had an elevated stress level (PSS-4 of >8). A significant gender influence was seen; 69% of HCWs in the high-stress group were female, as compared to 29% males. Gender influence in both PSS-4 and PHQ-4 was found to be statistically significant (p<0.001). Significantly higher PHQ-4 and PSS-4 scores were found in RNs compared to MDs. There was a strong correlation between PSS and PHQ scores (r = 0.705). The COVID-19 pandemic has resulted in an extremely high level of stress and mental health morbidity, especially among nurses and females.