|Year : 2022 | Volume
| Issue : 2 | Page : 51-65
Prevalence and Associated Factors of Anxiety and Depression among Medical Interns during the Third Wave of COVID-19 Pandemic in Oman
Tamadhir Al-Mahrouqi1, Manar Ahmed Kamal2, Mohamed Elsayed3, Hamed Al-Sinawi4
1 Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Oman
2 Faculty of Medicine, Benha University, Benha, Egypt
3 Department of Psychiatry and Psychotherapy, Ulm University, Leimgrubenweg, Germany
4 Department of Behavioral Medicine, Sultan Qaboos University Hospital, Muscat, Oman
|Date of Submission||15-Nov-2021|
|Date of Decision||06-Dec-2021|
|Date of Acceptance||15-Dec-2021|
|Date of Web Publication||10-May-2022|
Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Oman. P.O. Box:1948, Postal Code: 130.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: Medical interns were among the frontline healthcare workers during the coronavirus disease 2019 (COVID-19) pandemic and represented a special group of key workers. They were both learners and care providers, experiencing great challenges during the pandemic. This study examined the prevalence of depression and anxiety symptoms among Omani medical interns during the COVID-19 pandemic and determined the independent predictors of depression and anxiety among the study sample. Methods: This online cross-sectional study was conducted among a random sample of Omani medical interns from 2020 to 2021, using a self-reported questionnaire that included the patient health questionnaire-9 (PHQ-9), generalized anxiety disorder-7 (GAD-7) information related to vaccination status and caring for patients with COVID-19. Results: A total of 193 interns participated in this study (81% females). The median age was 26 years. Female participants scored higher for both anxiety (P = 0.200) and depression scales (P = 0.183). Most of the participants (143, 74.1%) had a negative result following testing for severe acute respiratory syndrome-associated coronavirus 2 (SARS-CoV-2), with significant association with vaccination status (P = 0.004), especially for participants who had taken the first dose (51%). Participants who had the first dose of the vaccine significantly tested negative for SARS-CoV-2 (P = 0.053) compared to participants who had not had the vaccine. The GAD-7 and PHQ-9 showed that 150 (79%) and 91 (47%) participants had mild to severe anxiety and depression. Conclusion: The COVID-19 pandemic has directly contributed to the development of psychologic distress among medical interns, which can lead to adverse outcomes. This study emphasizes the importance of including disaster management and psychologic well-being training program during the internship to help medical interns better cope in crises, such as a pandemic.
Keywords: Anxiety, COVID-19, depression, medical interns, oman, vaccination
|How to cite this article:|
Al-Mahrouqi T, Kamal M, Elsayed M, Al-Sinawi H. Prevalence and Associated Factors of Anxiety and Depression among Medical Interns during the Third Wave of COVID-19 Pandemic in Oman. Int J Nutr Pharmacol Neurol Dis 2022;12:51-65
|How to cite this URL:|
Al-Mahrouqi T, Kamal M, Elsayed M, Al-Sinawi H. Prevalence and Associated Factors of Anxiety and Depression among Medical Interns during the Third Wave of COVID-19 Pandemic in Oman. Int J Nutr Pharmacol Neurol Dis [serial online] 2022 [cited 2022 May 22];12:51-65. Available from: https://www.ijnpnd.com/text.asp?2022/12/2/51/345016
| Introduction|| |
In December 2019, novel pneumonia caused by the severe acute respiratory syndrome-associated coronavirus 2 (SARS-CoV-2) virus was reported in Wuhan, China, quickly known as the coronavirus disease 2019 (COVID-19) pandemic. This pandemic placed considerable psychologic stress on healthcare workers, and those directly involved in diagnosing and treating patients with COVID-19 are at risk of developing psychologic distress and mental health problems. The ever-increasing number of confirmed and suspected cases of COVID-19, overwhelming workloads, depletion of personal protective equipment (PPE), lack of essential medications, and feelings of being inadequately supported may have contributed to the mental and psychologic burden. Several studies have found that healthcare providers with higher levels of clinical responsibilities and those infected had a higher incidence of anxiety and depressive symptoms and are at risk of physical and mental consequences directly resulting from providing care to patients with COVID-19.,
In developing countries with overburdened healthcare systems, surges of COVID-19 cases have led to anxiety and irritability among the medical personnel, which could be exacerbated by the lack of PPE available at hospitals. Much of the currently available literature on psychologic wellness during the COVID-19 pandemic has focused on nurses, physicians, and healthcare support staff. Physician and medical trainees represent a particular category of frontline healthcare workers, they are simultaneously learners and caregivers, and they have experienced significant challenges during the pandemic. However, there is limited understanding of the psychologic effects experienced by trainees during the pandemic. Notably, even before the COVID-19 pandemic, depression, and anxiety levels were higher among physician trainees than in the general population.
Consequently, comprehending the effect of the pandemic on trainees, as well as developing suitable strategies to address these burdens, is of extreme importance. Although the real effects of the COVID-19 pandemic on trainees cannot be determined until long after the pandemic has ended, the findings from this survey highlight the present challenges that physicians face under training. A recent study found that organizational and social support, clear communication, and developing a sense of control are all protective factors in minimizing unwanted mental health outcomes among healthcare workers during epidemics. Multiple recent reports also suggest that immediate organizational support is needed to address the challenges faced by frontline healthcare workers, including trainees. Support needed by frontline healthcare workers includes their basic needs, availability of PPE and psychosocial and mental health support. The purpose of this study is to determine the prevalence and determinants of anxiety and depression among medical interns during the COVID-19 pandemic. We hypothesized that unvaccinated medical interns handling and caring for patients with COVID-19 were likely to have poorer mental health outcomes and higher levels of anxiety and depression.
| Methods|| |
Research design and setting
A cross-sectional survey study designed to evaluate the prevalence and determinants of anxiety and depression among medical interns enrolled in the Omani internship program 2020 to 2021. According to the undersecretary of health at the Ministry of Health, the third wave of COVID-19 pandemic began in March 2021,, and the data collection was from March to May 2021.
Participants selection and data collection
All Omani medical interns enrolled in the Omani medical internship training program for 2020 to 2021 were invited to participate. Ethical approval was granted to conduct the study by the Medical Research Ethics Committee at Sultan Qaboos University Hospital (MREC 2416) in Muscat, Oman. Sultan Qaboos University is responsible for overseeing and coordinating the medical internship program in Oman. All the study procedures were conducted according to the principles of the Declaration of Helsinki. Data were collected through a self-administered online questionnaire distributed to all medical interns through the internship institutional mailing system. Chief medical interns in each training hospital were invited to an online zoom meeting to explain the aims of the study and facilitate data collection
The sociodemographic questionnaire
The sociodemographic information for each medical intern, including age, marital status, gender, presence of a physical or mental illness, living situation or financial difficulties, was obtained in this study. The questionnaire also enquired about the history of COVID-19 infection, vaccination status, handling and caring for patients with COVID-19, unintentionally infecting others such as family members or friends, having a family member or a friend pass away from COVID-19 and whether they had received disaster training.Measurement of depression
In this study, the patient healthcare questionnaire (PHQ-9) was used; this is a self-reported questionnaire consisting of nine questions used to screen symptoms of depression over the previous 2 weeks based on the DSM-IV criteria to diagnose depression. The scale rates the presence and frequency of depressive symptoms in each question on a 4-point Likert scale, ranging from 0 = not at all to 3 = nearly every day. The PHQ-9 has previously been validated in several studies, [10,11] including Oman. In the present study, a total score of 1 to 4 was considered minimal depression, 5 to 9 mild depression, 10 to 14 moderate depression, 15 to 19 moderately severe depression, and 20 to 27 severe depression.Measurement of anxiety
The generalized anxiety disorder-7 (GAD-7) is a self-reported questionnaire consisting of seven questions to detect GAD rapidly. The scale uses a 4-point Likert scale, ranging from 0 = not at all to 3 = nearly every day. The GAD-7 has a specificity of 82% and a sensitivity of 89% for detecting GAD, compared with a psychiatric interview. In the present study, a total score of 0 to 4 was considered minimal anxiety, 5 to 9 mild anxiety, 10 to 14 moderate anxiety, and 15 to 21 severe anxiety.
Sample size calculation
The total number of medical interns enrolled in Oman’s medical internship program from 2020 to 2021 was 250. The minimum required sample size was calculated using the OpenEpi® software (Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. www.OpenEpi.com). The sample size was calculated with a type 1 error of 5.0% (alpha = 0.05) and a 95% significance level to reach a power level of 80%, with a design effect of 1. Therefore, the minimum required sample size was 125.
The collected data were summarized and presented in [Table 1],[Table 2],[Table 3],[Table 4],[Table 5]. Continuous non-normally distributed variables are presented as a median and interquartile range, and categorical variables are presented as numbers and percentages. As appropriate, statistical significance was evaluated using the Kruskal–Wallis test for continuous variables and the Chi-square test for categorical variables. The association between the variables was tested using the Spearman correlation analysis. Multinomial logistic regression models were conducted to determine the association between the predictor and dependent variables. The multinomial regression model had two main categories (received first dose, received two doses), whereas the reference category was “not vaccinated.„ We conducted statistical analyses using the Statistical Package for the Social Sciences (SPSS) software, version 25.0 (IBM Corp., Armonk, NY, USA).
|Table 1 Baseline demographic and clinical characteristics of the participants (n = 193)|
Click here to view
|Table 2 Prevalence of anxiety and depression among the participants (n = 193)|
Click here to view
|Table 3 Association between sociodemographic factors, anxiety, and depression (n = 193)|
Click here to view
|Table 4 Correlations between vaccination status and other factors (n = 193)|
Click here to view
|Table 5 Determinants of vaccination status with a multinomial logistic regression model (n = 193)|
Click here to view
| Results|| |
Baseline demographic and clinical characteristics
The total number of participants was 193 interns, of which 81% were females and 77% were singles. The median age was 26 years old, and age showed a significant association with vaccination status (P = 0.005). Most of the participants (74%) tested negative for SARS-CoV-2. It was noted that there was a significant association with vaccination status (P = 0.004), especially with participants who had taken the first dose of the vaccine (51%) and the two doses (36%), in comparison with participants who had not had any vaccines (13%). Medical comorbidities experienced by the interns were migraine and obesity (3%) were the most common, followed by irritable bowel syndrome (2.6%) and anemia disorders (2.1%). Major depressive disorder (5.2%) was the most common mental illness, followed by anxiety disorders (3.6%). Most of the participants lived with their families (72.5%), did not experience financial difficulties (76.2%), and were providing care for patients with COVID-19 (64.8%) [[Table 1]].
Prevalence of anxiety and depression
The GAD-7 scoring scale showed that 56% of participants had mild anxiety with a score of 5 to 9, followed by minimal anxiety (22.3%), moderate anxiety (14%), and severe anxiety (7.8%). The median GAD-7 anxiety score was 4, and the GAD-7 anxiety severity showed a significant association with vaccination status (overall P = 0.032). Question numbers 1, 4, 5, and 7 on the GAD-7 (feeling nervous, anxious, or on edge, trouble relaxing, being so restless that it is hard to sit still, and feeling afraid as if something awful might happen) showed significant association with vaccination status (overall P = 0.019, 0.009, 0.018, and 0.018), respectively [[Table 2]].
The PHQ-9 scoring scale showed that 52.8% of participants had minimal depression, followed by mild depression (20.2%), moderate depression (9.3%), moderately severe depression (11.4%), and severe depression (6.2%). In similarity with the GAD-7 anxiety score, the median PHQ-9 score was 4, and the PHQ-9 depression severity showed no significant association with vaccination status (overall P = 0.131) [[Table 2]].
Association between sociodemographic factors, anxiety, and depression
Regarding the association of sociodemographic factors with anxiety, participants with moderate and severe anxiety were younger than those with minimal and moderate anxiety (P = 0.304). Females were noted to have higher anxiety levels overall (P = 0.200). Single interns were more likely than married interns to experience anxiety (P = 0.788). The results showed a significant association between vaccination status, having a mental illness diagnosis, living situation, having financial difficulties, and anxiety (P = 0.032, 0.001, 0.001, 0.001, 0.001, respectively) [[Table 3]]. Regarding the association of sociodemographic factors with depression, participants with moderate and moderately severe depression were noted to be younger than those with minimal, mild, and severe depression (P = 0.067). Females were noted to have higher levels of depression (P = 0.183). Single interns were more likely than married interns to experience any grade of depression (P = 0.055). The results showed a significant association between marital status, COVID-19 infection, mental illness diagnosis, living situation, financial difficulties, and depression (P = 0.055, 0.001, 0.042, 0.022, 0.001, 0.001, respectively) [[Table 3]].
Correlations between vaccination status and other factors
Regarding the correlation analysis in [Table 4], a low positive correlation was noted between age (r = 0.13, P = 0.07), marital status (r = 0.17, P = 0.017), mental health conditions (r = 0.16, P = 0.02), living situation (r = 0.12, and P = 0.08), and vaccination status. A low negative correlation was noted between having a mental illness (r = −0.15, P = 0.02), unintentionally infecting others such as family members or friends (r = −0.11, P = 0.11), and vaccination status.
Determinants of vaccination status with a multinomial logistic regression model
[Table 5] summarizes the multinomial logistic regression model of participants’ vaccination status compared with various factors. For those who had received the first dose of the vaccine, age, marital status, diagnosed with COVID-19, having chronic physical disease, question number 2 in the GAD-7 (not being able to stop or control worrying), question number 7 in the GAD-7 (feeling afraid, as if something awful might happen), minimal anxiety, mild anxiety, and moderate anxiety all had a statistically significant association with vaccination status (P > 0.05). For those who had received two doses of the vaccine, age, diagnosed with COVID-19, having currently or previously handled COVID-19 patients, and question number 5 in the GAD-7 (being so restless that it is hard to sit still) had a statistically significant association with vaccination status (P > 0.05).
The odds ratio (OR) of age, COVID-19 infection, having chronic physical disease, mental illness, having financial difficulties, question number 3 in GAD-7 (worrying too much about different things), question number 4 in GAD-7 (trouble relaxing), question number 6 in PHQ-9 (feeling bad about yourself or that you are a failure or have let yourself or your family down), and question number 8 in PHQ-9 (moving or speaking so slowly that other people could have noticed, or the opposite being so fidgety or restless that you have been moving around a lot more than usual) indicated that participants who had received their first dose and those who had received two doses had lower OR scores than those in the no vaccine group. The OR of gender, marital status, chronic diseases, having a mental illness, living situation, having currently or previously handled COVID-19 patients, knowing a family
member or a friend who had passed away from COVID-19, receiving disaster training during medical school to deal with a pandemic, question number 1 in GAD-7 (feeling nervous, anxious, or on edge), question number 5 in GAD-7 (being so restless that it is hard to sit still), question number 6 in GAD-7 (becoming easily annoyed or irritable), minimal anxiety, mild anxiety, moderate anxiety, question number 3 in PHQ-9 (trouble falling or staying asleep, or sleeping too much), question number 5 in PHQ-9 (poor appetite or overeating), question number 7 in PHQ-9 (trouble concentrating on things, such as reading the newspaper or watching television), question number 9 in PHQ-9 (thoughts that you would be better off dead, or of hurting yourself), PHQ-9 depression severity and PHQ-9 depression scores indicated higher OR scores in participants who had received their first dose and had received two doses of the vaccine groups than participants in no vaccine group.
| Discussion|| |
The rapid spread of COVID-19 has induced anxiety and depression worldwide. [14,15] Therefore, it is important to investigate potential mental health disorders during the COVID-19 pandemic. In this study, a cross-sectional survey was used to measure the prevalence of anxiety and depression using the PHQ-9 and GAD-7 scales among medical interns in Oman during the COVID-19 pandemic. We also aimed to assess the influence of vaccination status on anxiety and depression symptoms.
Previous studies in Oman showed a 30% prevalence of psychologic distress among the public during the COVID-19 pandemic.
According to our results, the major depressive disorder was present in 5.2% of the study participants, and according to the GAD-7 scoring system, 56% of participants had mild anxiety. These results align with previous literature, which showed that healthcare workers might suffer from anxiety and depression. Recent studies showed a higher prevalence of anxiety and depression among women versus men during the COVID-19 pandemic, as noted in previous research. The prevalence of anxiety and depression was higher in women than men. According to our results, women had higher levels in all anxiety grades (P = 0.200) and also all grades of depression (P = 0.183).
Moreover, the results from this study showed a significant association between marital status, COVID-19 infection, having a mental illness, having financial difficulties with depression (P = 0.055, 0.001, 0.042, 0.022, 0.001, 0.001, respectively). The prevalence of anxiety in the current study was higher than those previously noted in other studies among medical students in Iran and China (38% and 24.9%, respectively). [20,21] The difference in the prevalence between regions could be attributed to a variety of reasons, such as gender variation, previous psychologic distress, the availability of adequate psychologic support in that region, the extent of exposure to patients with COVID-19 and the vaccination status.,,,, The prevalence of anxiety in our study was much higher than a similar study performed on dental interns in Saudi Arabia that showed only an 11.9% prevalence of depression. However, the Saudi Arabian study did report a bias, as the dental students were relieved from their clinical duties during the lockdown.
This study focused on interns because this age group is more vulnerable to anxiety and depression, probably for having more concerns about the future or due to distress caused by their easy access to social media. We asked each participant in our study about their vaccination status, one of the strengths of this study. In a cross-sectional study performed in Jordan during the vaccination campaign in April 2021, about 52.9% of the study participants reported suffering from anxiety, with 80% feeling reassured after the vaccination. [17,30] A previously performed cross-sectional study in Germany showed that COVID-19 associated anxiety led to greater vaccination acceptance in the study participants. In the current study, mild to severe anxiety was noted in 62 participants who received the first dose of the vaccine versus the 50 participants who received both doses of the vaccine and 28 participants who did not receive any vaccine. A similar pattern was observed for mild to severe depression, in which 51 participants who received the first dose of the vaccine had mild to severe depression, whereas 28 participants who received both doses of the vaccine and 12 participants who did not receive the vaccine had mild to severe depression. This pattern suggests that the participants’ uncertainty during the vaccination status might contribute to higher anxiety or depression symptoms. Another factor that might account for the higher prevalence of anxiety and depression in this age group might be higher education. Hence, we advise the broader implementation of appropriate treatment strategies during the pandemic, such as tele-counseling for the treatment of anxiety and depression symptoms. Previous evidence indicates its effectiveness in Omani medical doctors during the pandemic.The current study did have some limitations. We focused on a single risk group in a country through a cross-sectional approach. A multicenter approach may help to verify the results. It would help detect any transcultural aspects that might influence the prevalence or the severity of potential mental health disorders among vulnerable groups, such as interns or healthcare professionals. Moreover, a questionnaire-based online survey was used to collect the data, which is associated with a risk of bias. Follow-up studies would assist in assessing the long-term impact of the situation.
The COVID-19 can cause various psychologic disorders. Globally, the mental health of individuals could be affected by the spread of infection. Therefore, it is essential to detect and treat anxiety and depression among healthcare professionals, including interns, at the earliest possible stage. Medical students must undergo disaster training programs during medical school, and that psychologic well-being and resilience training programs are provided during the internship training year.
Ethics approval: Ethical approval for the study was obtained from the Medical Research Ethics Committee at Sultan Qaboos University Hospital (MREC 2416) in Muscat, Oman.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lai J, Ma S, Wang Yet al
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:1-12.
Dubey S, Biswas P, Ghosh Ret al
Psychosocial impact of COVID-19. Diabetes Metab Syndr Clin Res Rev 2020;14:779-88.
Bettinsoli ML, Di Riso D, Napier JLet al
Mental health conditions of Italian healthcare professionals during the COVID-19 disease outbreak. Appl Psychol Heal Well-Being 2020;12:1054-73.
Kannampallil TG, Goss CW, Evanoff BA, Strickland JR, McAlister RP, Duncan J. Exposure to COVID-19 patients increases physician trainee stress and burnout. PLoS One. 2020;15:1-12.
Dyrbye LN, Leep Hunderfund AN, Winters RCet al
The relationship between burnout and help-seeking behaviors, concerns, and attitudes of residents. Acad Med 2021;96:701-8.
Dzau VJ, Kirch D, Nasca T. Preventing a parallel pandemic — a national strategy to protect clinicians’ well-being. N Engl J Med 2020;383:513-5.
De Brier N, Stroobants S, Vandekerckhove P, De Buck E. Factors affecting mental health of health care workers during coronavirus disease outbreaks (SARS, MERS & COVID-19): a rapid systematic review. PLoS One 2020;15:1-19.
Dr Mohammed Al Hosni − The Undersecretary of Health − The Ministry of Health. Oman declares third wave of Covid-19 as cases reach daily high for 2021. The National [Internet]. Available at https://www.thenationalnews.com/gulf-news/oman-declares-third-wave-of-covid-19-as-cases-reach-daily-high-for- 2021-1. 1189287. [Accessed date Mar 23, 2021].
Dr Mohammed Al Hosni − The Undersecretary of Health − The Ministry of Health. Oman in third wave of COVID-19 outbreak. 2021. Available at https://www.gulf-insider.com/oman-in-third-wave-of-covid-19-outbreak/. [Accessed date March 19, 2021].
Adewuya AO, Ola BA, Afolabi OO. Validity of the patient health questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. J Affect Disord 2006;96:89-93.
Becker S, Al Zaid K, Al Faris E. Screening for somatization and depression in Saudi Arabia: a validation study of the Phq in primary care. Int J Psychiatry Med 2002;32:271-83.
Al-Ghafri G, Al-Sinawi H, Al-Muniri Aet al
Prevalence of depressive symptoms as elicited by Patient Health Questionnaire (PHQ-9) among medical trainees in Oman. Asian J Psychiatr 2014;8:59-62.
Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-7.
Lima CKT, Carvalho PM, de M, Lima I, de AASet al
The emotional impact of Coronavirus 2019-nCoV (new coronavirus disease). Psychiatry Res 2020;287:112915.
Hahad O, Gilan DA, Daiber A, Münzel T. Public mental health as one of the key factors in dealing with COVID-19. Gesundheitswesen 2020;82:389-91.
Al Sinawi H, Al Balushi N, Al-Mahrouqi Tet al
Predictors of psychological distress among the public in Oman amid coronavirus disease2019 pandemic: a cross-sectional analytical study. Psychol Heal Med 2021;26:131-44.
World Health Organization. Mental health and psychosocial considerations during the COVID-19 outbreak, 18 March 2020. Geneva: World Health Organization.
Liu D, Ren Y, Yan F, Li Y, Xu X, Yu X, et al
.. Psychological impact and predisposing factors of the coronavirus disease 2019 (COVID-19) pandemic on general public in China. SSRN Electron J [Internet]. 2020 Mar 7 [cited 2021 Aug 28]; Available from: https://papers.ssrn.com/abstract=3551415https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3551415
Albert PR. Why is depression more prevalent in women? J Psychiatry Neurosci 2015;40:219-21.
Nakhostin-Ansari A, Sherafati A, Aghajani F, Khonji MS, Aghajani R, Shahmansouri N. Depression and anxiety among iranian medical students during COVID-19 pandemic. Iran J Psychiatry 2020;15:228-35.
Zhou SJ, Wang LL, Qi Met al
Depression, anxiety, and suicidal ideation in Chinese University students during the COVID-19 pandemic. Vol. 12, Front Psychol 2021;12:3389.
Hou F, Bi F, Jiao R, Luo D, Song K. Gender differences of depression and anxiety among social media users during the COVID-19 outbreak in China: a cross-sectional study. BMC Public Health 2020;20:1648.
Necho M, Tsehay M, Birkie M, Biset G, Tadesse E. Prevalence of anxiety, depression, and psychological distress among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Int J Soc Psychiatry 2021;00207640211003121.
Cellini MM, Serwint JR, Chaudron LH, Baldwin CD, Blumkin AK, Szilagyi PG. Availability of emotional support and mental health care for pediatric residents. Acad Pediatr 2017;17:424-30.
Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020;368:1-4.
Moccia G, Carpinelli L, Savarese G, Borrelli A, Boccia G, Motta O, et al
.. Perception of health, mistrust, anxiety, and indecision in a group of Italians vaccinated against COVID-19. Vaccines 2021;9.
Khanagar SB, Alfadley A. Psychological impact of the COVID-19 pandemic on dental interns in Riyadh, Saudi Arabia: a cross-sectional survey. Int J Clin Pediatr Dent [Internet]. 2020;13:508-12. Available from: file:///pmc/articles/PMC7887169/
Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. Psychiatry Res 2020;288.
Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020;33:19-21.
Hatmal MM, Al-Hatamleh MAI, Olaimat ANet al
Side effects and perceptions following COVID-19 vaccination in Jordan: a randomized, cross-sectional study implementing machine learning for predicting severity of side effects. Vaccines 2021;9.
Bendau A, Plag J, Petzold MB, Ströhle A. COVID-19 vaccine hesitancy and related fears and anxiety. Int Immunopharmacol 2021;97:107724.
Zhang Y, Ma ZF. Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: a cross-sectional study. Int J Environ Res Public Health 2020;17.
Al-Alawi M, McCall RK, Sultan Aet al
Efficacy of a six-week-long therapist-guided online therapy versus self-help internet-based therapy for COVID-19-induced anxiety and depression: open-label, pragmatic, randomized controlled trial. JMIR Ment Heal 2021;8:e26683.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]