Before the emergence of the COVID-19 pandemic, the prevalence of depression and anxiety in the general population was 4.7% (Ferrari et al., 2013) and 7.8% respectively (Baxter et al., 2013). Among doctors, the prevalence of depression was 28.8% as seen in a global meta-analytic study (Mata et al., 2015). Doctors have always been a high-risk group for manifesting mental health conditions like depression and anxiety, also showing increased rates of suicidality (Dong et al., 2020).

The additional burden of the COVID-19 pandemic has contributed to an already stretched working culture of high pressure, long hours, limited resources and reduced staffing (Johns et al., 2022; Soroka, 2021; Xie et al., 2021). Since the beginning of the COVID-19 pandemic, there have been numerous studies exploring the mental wellbeing of healthcare professionals, including doctors. Rates of depression and anxiety symptoms vary among doctors with factors including gender, grade, specialty, family environment influencing resilience to work-related stressors (Blackmore et al., 2007; Hayes et al., 2017; Lemaire and Wallace, 2017).

The authors of a newly published review (Johns et al., 2022) have summarised the data on depression and anxiety for doctors since the beginning of the COVID-19 pandemic in 2020 to estimate the prevalence in this population.

Methods

A systematic review was conducted for the purpose of the study, by more than one researcher. The inclusion criteria were set in advance and the study design was registered with PROSPERO. The authors assessed the risk of bias of the relevant literature and excluded papers with a high risk of bias. Only studies that allowed point prevalence to be calculated were included to then estimate the overall pooled prevalence. A random effects meta-analysis was used, which is the most commonly employed model of meta-analyses for prevalence studies and is thought to be appropriate for these types of reviews. Additionally, sub-group analysis was conducted to explore the effect of isolated studies on the pooled effect and explain heterogeneity.

Results

Overall, a total of 33 studies were used in the synthesis, coming from four continents, with 31,447 participants for depression and 33,281 participants for anxiety. This systematic review estimated prevalence of depression and anxiety among doctors during the COVID-19 pandemic to be:

• Depression 20.5% (95% CI 16.0 to 25.3%)
• Anxiety 25.8% (95% CI 20.4 to 31.5%)

Point prevalence in included studies on depression started from 6.1%, reaching up to 73.4% prevalence rates. For anxiety, the range for point prevalence was 5.9% to 74.2%.

Lowest GDP was linked to increased rates of depression symptoms, and the lowest ratio of doctors to 10,000 patients predicted increased rates of anxiety.

Heterogeneity between studies was not significant for anxiety studies, although depression studies exhibited significant differences.

Conclusions

The authors concluded that worldwide, the prevalence of depression and anxiety among doctors during the COVID-19 pandemic is high. This conclusion is consistent with previous research studying healthcare workers at the beginning of the COVID-19 outbreak (Pappa et al., 2020). Doctors have unfailingly experienced higher levels of adverse mental health outcomes and these results also re-affirm previous observations.

There was no clear, significant increase in prevalence when comparing current data to pre-pandemic rates; however, there is a lack of similar studies with consistent outcome measures. Factors like low national GDP and a low number of doctors per 10,000 patients were found to be statistically significant for increasing depression and anxiety rates respectively.

These findings can help orchestrate health workforce support initiatives globally during crises.

Strengths and limitations

This systematic review provided a comprehensive and up-to-date synthesis of a large volume of data, which has recently emerged since the beginning of the COVID-19 pandemic. It is a unique study, offering pooled prevalence estimates and focusing on doctors specifically as a high-risk group of the health workforce cohort. However, there was a wide variation in point prevalence and pooled prevalence estimates had broad confidence intervals.

The use of the random effect model for meta-analysis allows for differences between studies, either related to population characteristics or study design (Riley et al., 2011). The authors also performed sub-group analysis to give further insight into the heterogeneity in prevalence for depression and anxiety separately. The factors considered in sub-group analysis were relevant and were discussed appropriately, including geographical region, doctors per 10,000 population, GDP per capita, risk of study bias, measure of depression or anxiety, severity threshold and survey timeframe (Johns et al., 2022). The reviewers expressed the degree of heterogeneity as I²; however, prediction intervals have been recommended as a preferred way of presenting the range of outcomes (Deeks et al., 2022). Possibly, including prediction intervals in this study could make the interpretation of results easier in a meta-analysis with studies of different sample sizes (IntHout et al., 2016).

Many of the possible limitations of a systematic review directly stem from the limitations of the individual studies included in its synthesis. Importantly, only studies with low or moderate bias risk were included, which improved the reliability of conclusions. Although care was taken to exclude studies with a high risk of bias using the JBI Checklist for Prevalence Studies tool, the authors noted that non-probability sampling was a limitation, which was likely used for convenience in primary studies (Galloway, 2005). Similarly, differences in methods used for measuring depression and anxiety symptoms between studies could be seen as a further limitation, and consistency in identification tools could facilitate replication of results in future work (Clover et al., 2020; Johns et al., 2022).

Implications for practice

Understanding the prevalence of mental health outcomes for doctors during health crises is important as it can demonstrate the magnitude of this phenomenon. Equally, it can also inform health authorities on the need for developing strategies to improve the wellbeing of doctors (Bakker, 2018). This, in turn, can improve patient safety and the delivery of care (Nieto et al., 2020). The conclusions drawn in this study have shown similar rates to the ones observed during previous outbreaks like the SARS epidemic in 2003-2004 (Maunder et al., 2004; Tam et al., 2004), although a direct comparison is difficult.

The authors also discussed the conclusions of a meta-analysis showing a general increase in the prevalence of depression and anxiety in the general population post-pandemic (Baxter et al., 2013). This could be related to the effects of the COVID-19 pandemic outside of the workspace, such as isolation, heath anxiety, extended restrictions, inactivity. All of these factors are likely to increase mental health adverse outcomes in populations beyond medical professionals (Johns et al., 2022). To characterise the relationship between the medical profession and depression or anxiety prevalence, it would be helpful to measure the differences in rates but also in severity of mental ill health symptoms between the general population and doctors. Equally, it would also be useful to have further large scale reviews of studies demonstrating the change or lack of, in mental health outcomes over time, as it is unclear whether there has been a statistically significant increase in prevalence among doctors since the pre-pandemic era. These studies would ideally have to employ consistent measures of participant symptoms to allow for comparison, which is difficult to be performed with current data, as explained by Johns et al. (2022). Future qualitative studies using semi-structured interviews could complement this work and add more insight into the reasons why doctors feel depressed or anxious during specific times.

In my personal experience as a doctor during the COVID-19 pandemic, I could add that work-related pressure and stress have been particularly high, but the lack of disruption in the work routine and lower levels of isolation have been protective factors for many in the profession. The relationship between mental health and the COVID-19 phenomenon may be better understood if seen in the wider context, taking into account both risk and protective factors in and out of the workplace.

Statement of interests

No conflict of interest.

Links

Primary paper

Johns, G., Samuel, V., Freemantle, L., Lewis, J., Waddington, L., 2022. The global prevalence of depression and anxiety among doctors during the covid-19 pandemic: Systematic review and meta-analysis. J. Affect. Disord. 298, 431–441. https://doi.org/10.1016/j.jad.2021.11.026

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