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Year : 2020  |  Volume : 18  |  Issue : 4  |  Page : 305-308

Psychological resilience of COVID-19 frontline warriors: Need of the hour

Department of Community Medicine, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India

Date of Submission04-Aug-2020
Date of Decision27-Aug-2020
Date of Acceptance31-Aug-2020
Date of Web Publication19-Oct-2020

Correspondence Address:
Dr. D Vinoth Gnana Chellaiyan
D, Associate Professor, Department of Community Medicine, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_121_20

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Background: Amid the rapid rise of COVID-19 cases, risk of infection from patients, isolation, and other factors are taking its toll on the mental health status of the healthcare professionals. The frontline health workers in the COVID-19 pandemic are undergoing psychological turbulence handling the corona situation. Objectives: The present study assessed the self-reported mental health status of healthcare professionals and studied their perspectives of COVID-19 control. Materials and Methods: A descriptive study was conducted among healthcare professionals in India using a web-based online questionnaire. A total of 152 participants took part in the survey in April 2020. Self-reported mental health status was assessed using the DASS-21 scale. Mann–Whitney and Chi-square tests were applied. Results: The overall prevalence of depression, anxiety, and stress was 13.82%, 8.55%, and 23.68%, respectively. A higher prevalence of depression, anxiety, and stress was found in the frontline workers subgroup. The median (interquartile range) scores of frontline workers for depression, anxiety, and stress were 6 (10.5), 6 (8), and 10 (10), respectively. Fifty percent of the participants responded that quarantine and isolation was the best method for control of COVID-19 in Indian setting. Conclusion: The psychological disturbance was found among frontline health workers involved in the diagnosis and management of COVID-19. Psychological debriefing and regular mental status evaluation in addition to psychological counseling may be indispensable.

Keywords: Anxiety, coronavirus, COVID-19, depression, mental health, stress

How to cite this article:
Chellaiyan D V, Nirupama A Y. Psychological resilience of COVID-19 frontline warriors: Need of the hour. Curr Med Issues 2020;18:305-8

How to cite this URL:
Chellaiyan D V, Nirupama A Y. Psychological resilience of COVID-19 frontline warriors: Need of the hour. Curr Med Issues [serial online] 2020 [cited 2020 Dec 5];18:305-8. Available from: https://www.cmijournal.org/text.asp?2020/18/4/305/298585

  Introduction Top

On January 30, 2020, India confirmed its first case of COVID-19 in its southern state of Kerala in a student who had recently returned from Wuhan.[1] As of June 6, 2020, India has reported 236,657 COVID-19 cases.[2] The increasing burden of the disease is taking its toll on the mental well-being of healthcare professionals in the form of increased risk of infection, mental health issues, and isolation from their families. In addition to fear of a potential COVID-19 infection risk, COVID-19-related stigmatization against health workers was reported to have increased. Discrimination at their residence and neighborhood has happened in spite of their selfless effort in controlling the spread of coronavirus infection.[3],[4] The present study has been designed with the objective of assessing the psychological status of healthcare professionals involved in the diagnosis and management of COVID-19.

  Materials and Methods Top

A descriptive, web-based online survey was conducted between the 3rd and the 4th week of April 2020 among 152 healthcare professionals in India, consisting of doctors and paramedical staff aged more than 18 years from Indian states such as Tamil Nadu, Kerala, Andhra, Telangana, Maharashtra, West Bengal, and Haryana and Delhi.

Sample size and sampling method

Minimum required sample size for the study was calculated to be 124 using the formula 4pq/l2, where P (expected prevalence) was taken as 50%[5] and an allowable error (l) of 9%, assuming a confidence interval of 95%. Snowball sampling method was used for recruitments of the participants for the survey. A set of healthcare professionals were identified (who were personally contacted either via e-mail or over telephone), and the web survey link was circulated among them. Each member was to further disseminate the link personally to their colleagues working under similar circumstances.

  Study Tool Top

Data were collected from 152 participants using an online questionnaire. A web-based survey was considered ideal under the existing rules of lockdown and social distancing present in the country during the study period. The survey form was designed using Google Forms, featured 36 items under four sections; (1) participant information and informed e-consent, (2) basic profile and work experience, (3) perspectives toward COVID-19 control, and (4) comprehensive assessment of self-reported mental health status using the DASS-21[6] scale (DASS-21 was scored based on the following cutoffs:[1] depression: 0–9 - absent, >9 - present,[2] anxiety: 0–7 - absent, >7 - present,[3] stress: 0–14 - absent, >14 - present). The average duration required for survey completion was about 10–15 min. Participants were instructed to complete the survey individually and to respond keeping in mind their experiences in the past 3–4 weeks This time period is when COVID-19 pandemic was declared and the subsequent lockdown time period declared by the Government of India.

Statistical analysis

The data obtained were compiled and entered in Microsoft Excel Spreadsheet and then analyzed using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Normality of the data was assessed using Shapiro–Wilk test for normality. Qualitative variables are described in proportions, while quantitative variables are described in mean and standard deviation (SD)/median and IQR. All required statistical tests were applied (Mann–Whitney test, Fisher's exact test, and Chi-square test) for data analysis. Significance of P value was taken as P < 0.05.

Ethical consideration

All those who were willing to give informed consent and completed the online survey were included in the study. The study was an online survey which was completely voluntary and anonymous, i.e., no personally identifiable data were collected such as name or address. IHEC was obtained postprotocol review, before commencement of the study. No financial compensation was provided, and informed consent was obtained from all participants through an online form at the beginning of the survey. Confidentiality of the data was maintained throughout all phases of the study, and the information so obtained was used only for research purposes.

  Results Top

Baseline characteristics

The study included a total of 152 participants. The age of the study participants ranged from 21 to 55 years, with a mean (SD) of 30.89 (±6.14) years. 70 (46.05%) of the study population were males, 63 (41%) were unmarried, and 118 (77.6%) were from a nuclear family. 78 (51%) of the participants had a work experience of more than 5 years and 25 (16.45%) had previous experience of working in epidemics/outbreaks. Of the 152 study participants, 62 (40.79%) were identified to be frontline workers who are directly involved in case finding, diagnosis, and treatment of COVID-19.

Perspectives of COVID-19 control

Fifty percent of the participants felt that quarantine and isolation was the best method for control of COVID-19 in a highly populous country like India, closely followed by rapid testing (22.37%), health education and social awareness (21.05%), and newer therapies such as plasma therapy or mass prophylaxis with hydroxychloroquine (7.89%). Opinions regarding efficient methods of COVID-19 control are summarized in [Figure 1].
Figure 1: Efficient methods of COVID-19 control perspective of health professionals (n = 152). Other measures suggested were disinfection of environment and fomites, providing public needs at doorstep, stringent lockdown, vaccines, universal mask usage, and good nutrition with immune boosting diet.

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Self-reported mental health status

The overall prevalence of self-reported depression was found to be 21 (13.82%), anxiety was 13 (8.55%), and stress was 36 (23.68%). The median (IQR) scores for depression were 6.0 (9.50), with scores ranging from 0 to 56; the median (IQR) scores for anxiety were 4.0 (7.50), with scores ranging from 0 to 44; and the median (IQR) scores for stress were 8.0 (10.0), with scores ranging from 0 to 56 [Figure 2].
Figure 2: Box plot distribution of depression, anxiety, and stress scores among frontline and other health workers (n = 152). *and° are outliers detected by the 1.5IQR rule, ie, values which was outside the range of 1.5 X Inter-quartile range.

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The participants were identified as two groups of frontline workers and health workers managing other patients working in the same hospital premises. Frontline workers were identified as those who declared themselves to be in direct contact with positive and suspect cases of COVID-19 (patient or body fluids or other anatomical specimen) and/or actively involved in the management including diagnosis, management, and control. The prevalence of depression, anxiety, and stress was found to be 17.7%, 9.7%, and 29.0%, respectively, among the frontline workers and 11.1%, 7.8%, and 20.0%, respectively, among the health workers who were not directly involved in COVID-19 management. The median (IQR) scores of other health workers, who are not directly involved in the COVID-19 diagnosis and management, were depression – 5 (8), anxiety – 2 (6), and stress – 8 (10). Even though a higher prevalence in depression, anxiety, and stress was noted among the frontline workers, the mean difference in DASS-21 scores between the two groups (using Mann–Whitney U-test) was not found to be statistically significant (Z = −1.532, −1.487, and − 1.386, respectively; P = 0.125, 0.137, and 0.166, respectively).

A statistically significant association was noted between years of work experience and the prevalence of depression or stress (Chi-square P = 0.012 and 0.027, respectively) [Table 1]. Report of any association of other variables with the prevalence of depression, anxiety, or stress is summarized in [Table 1].
Table 1: Association of selected variables with depression, anxiety, and stress (n=152)

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  Discussion Top

Even before the pandemic, the mental health of health workers has been a major concern. A study by Su et al.[5] conducted in 2009 in a Taiwanese regional general hospital reported nearly half of the staff to be having either a minor psychiatric disorder or depressive disorder. Another study done by Grover et al.[7] in North India in 2018 reported that 30.1% of participants found to have depression and 13% of participants found to have a high level of stress. The present study reported a prevalence of 13.8% for depression, 8.55% for anxiety, and 23.7% for stress. These findings are similar to the findings of Tan et al.'s study[8] in Singapore which reported that 14.5% of participants screened positive for anxiety, 8.9% for depression, and 6.6% for stress. Considering the existing literature and the findings from the present study, the mental health of healthcare professionals will always remain a concern, even more so at present with all the uncertainty, high infection risk, social stigma, and increased workload surrounding the COVID-19 pandemic.

Considering the present situation, the present study was designed to have a better understanding of the impact of a stressful work environment on health workers. The study is not without its limitations; being a web-based survey designed to reach a more varied participant base while maintaining the norms of social distancing, it comes with all the biases encountered in a survey such as self-selection bias, sampling bias, or nonresponse bias. DASS-21, by nature, is a screening tool which does not provide an objective assessment of the mental health status. Still, it is one of the best study tools available in the present situation and healthcare setting. Influence of regional differences in disease burden or deaths on the psychological behavior of the health workers should also be considered.


From our study finding, the burden of psychological turbulence identified could be addressed by the modification of work patterns. Having rotational shifts, distribution of workload by the diversion of patients to other hospitals with facilities, and upscaling of COVID-19 treating facilities might be considered. Regular monitoring of psychological status should be included in the routine health checkups, and psychological therapy sessions by psychiatrists should be made accessible to the health workers.

  Conclusion Top

The findings from the present study indicates a visibly high prevalence of depression, anxiety, and stress among frontline workers directly involved in case finding, diagnosis, and management of COVID-19 when compared to other health workers. Being psychologically and emotionally stable is extremely necessary to be understanding and empathetic to the fears and concerns of the patients, even more so while dealing with the current situation. Fears and concerns about the disease itself should not cloud the judgment of healthcare workers and result in discrimination or unfair denial of healthcare to the needy. To avoid an unpleasant work environment, it is necessary to take effective measures to maintain the positive mental health of healthcare professionals. Along with having a better understanding of the COVID-19 situation, it is also crucial to take care of the mental health of all the health workers involved in the same. Identifying the problems and finding solutions for the same are the necessity of the hour.


All study participants are acknowledged.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

All authors of this manuscript declare that this scientific study is in compliance with standard reporting guidelines set forth by the EQUATOR Network. The authors ratify that this study required Institutional Review Board/Ethics Committee review, and hence prior approval was obtained IRB Min. No. IHEC/2020-0001083. We also declare that we did not plagiarize the contents of this manuscript and have performed a Plagiarism Check.

  References Top

Press Information Bureau. Update on Novel Coronavirus: One Positive Case Reported in Kerala; 2020. Available from: https://pib.gov.in/PressReleseDetail.aspx?PRID=1601095. [Last accessed on 2020 Aug 27].  Back to cited text no. 1
MoHFW | Home [Internet]. Available from: https://www.mohfw.gov.in/.[Last accessed on 2020 Jun 06].  Back to cited text no. 2
Press Information Bureau. MHA Directs All States/UTs to Provide Necessary Police Security to Doctors and Medical Staff Fighting COVID-19; 2020. Available from: https://pib.gov.in/PressRelease Page.aspx?PRID=1613432. [Last accessed on 2020 Aug 27].  Back to cited text no. 3
Press Information Bureau. Ensure Adequate Security to Healthcare Professionals, Medical Staff and Frontline Workers to prevent violence against them: Union Home Minister; 2020. Available from: https://pib.gov.in/PressReleasePage.aspx?PRID=1617162. [Last accessed on 2020 Aug 27].  Back to cited text no. 4
Su J, Weng H, Tsang H, Wu J. Mental health and quality of life among doctors, nurses and other hospital staff. Stress Health 2009;25:423-30.  Back to cited text no. 5
DASS-21. Depression Anxiety Stress Scales (DASS). Available from: https://www.psytoolkit.org/survey-library/depression-anxiety- stress-dass.html. [Last accessed on 2020 Apr 27].  Back to cited text no. 6
Grover S, Sahoo S, Bhalla A, Avasthi A. Psychological problems and burnout among medical professionals of a tertiary care hospital of North India: A cross-sectional study. Indian J Psychiatry 2018;60:175-88.  Back to cited text no. 7
[PUBMED]  [Full text]  
Tan BY, Chew NW, Lee GK, Jing M, Goh Y, Yeo LL, et al. Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med 2020;173:317-20.  Back to cited text no. 8


  [Figure 1], [Figure 2]

  [Table 1]


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