Tuesday, March 31, 2020

COVID-19 and Suicide--The Dark Side of Narrative and the Agony of Pandemic

(Pic credit here)

Hysteria, obsession, and what feels like the inescapable reality of a pandemic served up in a never ending stream of exclamation points. Thsi si what surrounds the masses in thsi era of pandemic:
The COVID-19 pandemic brings suffering, and instability, and dislocation, and trauma, and loss.  And it brings death.  It brings the death of individuals, it brings the statistics of death, it brings the ratings of death, it brings accountability for death.  It brings a constant chatter about death--death that has come, death that is here, death that is yet to come.
Death is both a physical manifestation of personal tragedy and loss; death is an abstraction that is used as an illustration, as a sign, as the symbol and harbinger of this or that. Death becomes the marker because of the identity between pandemic and death.  This is not the orderly death that can be understood by the application of the metrics of the cycle of life, a production line in the factory ordering undifferentiated passages from birth to death, nor is this death that is positioned at the end of ordinary medical protocols for the ordinary experiences of life.  It is the ultimate terror--it brings with it the potential of death, where everyone is potentially marked even as only some suffer directly or indirectly.  But in the process death becomes the air we breathe, it becomes the substance of the information we receive.  It is the subtext of all communication and the excuse for every action. We are choking on the fumes of death and touched by its drama as it is played out in personal tragedy projected through the miracle of technology to all corners of the earth.
Pix Credit HERE
Every one of us experiences death, engages with it, and participates in its passage from a potentiality on the horizon, to the whirlwind that uproots everything, to the detritus of an engagement around us that is indifferent to the way in which we clean it up.  Death comes in the petri dishes that cruise ships have sometimes become; it surrounds islands of isolation like the rising sea, always threatening to overwhelm those islands of isolation situated precariously between the satisfaction of prevention and the guilt of as passive witness of the flows of death swirling about them. witness. To avoid testing is to tempt Death, to test positive is to acquire a marker of death's potential. 

The last three paragraphs are histrionic; they read like a bad poem; they are suffocating. They mean to convey intensity, panic, emotion, alarm, and all of the other reactions appropriate to a crisis of this kind.  They are meant to contribute to a narrative that is useful for getting people to take the pandemic seriously, and to treat institutional instructions with even greater seriousness. News reports, governmental statements, the analysis of experts, the attention of social media--all of these add layers  that in the end read like a constantly reinforcing reminder of societal distress at a macro and micro level.  

But the effects of these narratives are not necessarily always positive. In its more negative forms it may be possible to surmise that these pandemic narratives spread death beyond the effects of the COVID-19 virus and its attacks on the human body.  It penetrates the human psyche and insinuates itself as a point of ecstasy of pandemic, of a euphoria that moves from light to darkness. The frenzy of death that throbs through the reporting of the pandemic and through the responsibility borne by those who confront the physicality of death, is both a great molder of societal response, of popular feeling, and when it manifests as despair, in suicide.   

Suicide is worthy of far greater attention in the midst of the many challenges of the pandemic.  It is an expression of personal agony, of illness, of despair, and of the power of the narratives of pandemic--and its expression through mechanisms of societal communication, policy and management--that is likely a far more powerful factor in the framework of epidemic response than one might gather from the single minded focus on the narratives of state and of those who seek to use their voices to move discourse towards particular ends.  It kills as surely as the virus at the heart of the pandemic. "Crisis hotlines nationwide are surging with calls from Massachusetts to Oregon, both of which are states with “shelter-in-place” orders implemented, keeping people out of work and isolated at home. In Portland, Police Chief Jami Resch said Tuesday suicide threats or attempts are up 41 percent from this time last year and have jumped 23 percent since 10 days before a declared state of emergency" (More People Died From Suicide Than Coronavirus In Tennessee This Week).

Beyond the certainty of the alignment of a sociology of pandemic and suicide, of the culture of response and of this terrible ending of life, there is little but the vast space of knowledge in need of production (two examples below: Anxiety and depression likely to spike among Americans as coronavirus pandemic spreads; and a study of the mental healthj effectys of the pandemic on front line medical personnel in Wuhan (Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019)).  

At the same time there are stories.  And these stories of those who in the face of epidemic chose that path are worthy of retelling.  A few of those stories follow. Suicide is an an abstraction; it is the sum of the stories of individuals confronted by a context of meaning, of significance, we have all helped to build.

Nurse suicides rise in Europe amid stress of COVID-19 pandemic

By Allison Smith
31 March 2020
Last week, 34-year-old nurse Daniella Trezzi, who worked in the COVID-19 intensive care ward of San Gerardo hospital at Monza, near Milan, learned that she had been infected with the disease. Distraught at the idea that she could have spread the coronavirus to others before she learned that she carried the disease, and facing the relentless working conditions at a hospital in the epicenter of the pandemic in Europe, Trezzi tragically committed suicide.
The National Federation of Italian Nurses (FNOPI) said in a brief statement about her death that Ms. Trezzi and many nurses treating quarantined patients showing COVID-19 symptoms feel “heavy stress for fear of having infected others.” The Federation noted the “pain and dismay” of its members “at the news of her death.”
Trezzi had studied at the Università degli Studi di Milano-Bicocca and lived with her dog in Brugherio. She leaves behind a brother and many friends and colleagues. Her Facebook page, which was still accessible yesterday, made clear her love of nature and travel and her dedication to her chosen profession.
Daniela Trezzi
In the wake of Trezzi’s suicide, the FNOPI implored: “Each of us has chosen this profession for good and, unfortunately, also for bad: we are nurses. And nurses, all nurses, never leave anyone alone, even at risk—and this is evident—of their own lives. But that’s enough: we must not, we cannot, abandon the nurses.”
This tragedy points to the terrible human cost not only of the COVID-19 pandemic, but of decades of social austerity policies that have left hospitals across Europe understaffed, overworked and without life-saving protection equipment like masks to shield medical staff from the contagion.
Now, amid the greatest global pandemic since the Spanish flu of 1918–1919, millions of nurses and medical professionals internationally are working around the clock with little or no protective gear. Across Europe tens of thousands of medical staff have contracted the disease, and health workers represent a staggering one in eight of Spain’s now 85,195 COVID-19 cases. They share images of exhausted colleagues, as hospitals buckle under the stress of treating thousands of COVID-19 intensive care patients each day.
Medical staff undergo unbearable stress, helplessly watching COVID-19 patients die alone. Dr. Francesca Cortellaro, head of the emergency room of the Borromeo hospital, told Euronews: “Do you see the emergency room? COVID-19 patients enter alone, no relatives can attend, and when they are about to leave they sense it. They are lucid, they do not go to narcolepsy.”
The stress is intensified by the contradictory messages and policies from European governments, which repeatedly made false comparisons of COVID-19 to seasonal flu to downplay the illness and try to force workers back to work to boost corporate profits in the middle of the pandemic.
Monica Trombetta, a nurse working in Como, near Monza, told the press: “We’re very tired and afraid. Government decrees change every day. Personnel does not have clear guidelines for dealing with this new virus and feel a little abandoned—not by our hospital, but it’s just as a general feeling. Nurses are afraid to go home and potentially infect their relatives.”
Nurses—who by the very nature of their job, spend the most time with patients—are particularly vulnerable to suicidal feelings. Nurse suicides have become a global epidemic, with US female and male nurses committing suicide at rates of 11.97 and 39.8 per 100,000 respectively last year, even before the COVID-19 pandemic. In their extremely high-pressure environment, demands for optimal performance are a decisive factor in intensifying feelings of distress and depression.
In Britain, a young nurse in her 20s working at King’s College Hospital in London took her own life while treating COVID-19 patients last week. Her colleagues found her unresponsive in her ward, and doctors were unable to resuscitate her. Her next of kin have been notified, but the hospital did not release her identity.
Several British hospital trusts are reporting that up to 50 percent of their medical staff are at home, sick with COVID-19, leaving remaining staff wondering who will look after them and the massive daily influx of COVID-19 patients if they too fall ill with the virus.
Having infected hundreds of thousands of people, COVID-19 is ravaging hospitals in all of Europe. This exposes the malignant neglect of European officials for the fate of the broad mass of working people. Chancellor Angela Merkel called for Germans to accept that 70 to 80 percent of the population would get sick, and British officials calling for Britons to develop “herd immunity” by infecting almost the entire population with coronavirus. Based on these policies, they pressed for workers to continue working to churn out profits for big corporations.
Such proposals, which entail hundreds of millions catching COVID-19, would provoke a crisis hundreds or thousands of times more severe than the horrors already being visited on the population and health staff of northern Italy and other hard-hit regions. That such proposals are advanced by leading European governments make clear the political and moral degeneracy of the existing social system, and the callous indifference of the ruling class to the human tragedies that are unfolding.
Also last week in Italy, a 49-year-old nurse who worked in the COVID-19 ward of Jesolo hospital committed suicide, throwing herself into the Piave river in Cortellazzo, in the region of Venice.
The nurse, whose initials are S.L., had courageously volunteered to work with coronavirus patients and helped convert the Jesolo hospital into a COVID-19-only ward. S.L. lived alone and was at home for two days with fever, awaiting the results of a COVID-19 test, when she took her own life.
Paying his respects to S.L., her hospital director said: “She was a person dedicated to work, an irreplaceable resource for colleagues and for this health authority. Not by chance, as soon as we heard the news of her disappearance, colleagues at the hospital in Jesolo, who are busy these days on the coronavirus front, were deeply affected and shaken by the event. I express my deepest condolences and closeness to the family of ‘our nurse’ S.L.”


Suicide prevention groups report uptick in calls amid COVID-19 pandemic

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CHICAGO (WLS) -- Suicide prevention groups are seeing an uptick in calls during the COVID-19 pandemic and want to remind you that help is available while we deal with tough times.

Coronavirus Illinois Update: Latest news on COVID-19 cases, Chicago area impact

Last week, a 44-year-old woman took her life by jumping off of an Advocate Christ Medical Center parking garage. During this COVID-19 crisis, suicide prevention organizations are seeing an increase in calls.

"I think our whole entire industry is seeing an uptick," said Jonny Boucher, CEO of Hope for the Day. "Right now, people are reaching out whether it's through the lifelines, our website, Instagram, Facebook, Twitter."

Coronavirus testing: Where to get tested for COVID-19 in Illinois, Chicago area

Organizations like Hope for The Day are offering many online workshops to help. The Illinois Chapter of the American Foundation for Suicide Prevention is calling on family and friends to reach out to loved ones who are struggling.

"For those people who do deal with mental illnesses, this can add a lot of stress to the managing of their condition," said Tandra Rutledge, with the American Foundation for Suicide Prevention-Illinois Chapter. "We want them to know we are here for them, folks are not alone."

Experts say it's vital for people with mental illnesses to stay on medication and pursue online therapy.

For others, depression and anxiety may be hard to avoid during this pandemic, especially being isolated. Dr. Judy Moskowitz, a psychologist with Northwestern University Feinberg School of Medicine, said setting a schedule and making a list each day is key.

"Two or three things that you can do," said Dr. Moskowitz. "And when you accomplish them and cross them off, it a hit of positive emotion that can help you stay engaged and avoid getting too down."

Besides setting a schedule, experts advise people to limit their COVID-19 news intake.

"Turn it off," said Dr. Moskowitz. "If you check on it once a day that is probably plenty, and if something really big happens, you're going to hear about it."

Reading books, preferably fiction, playing board games and reaching out to friends online are all ways to avoid slipping into depression. If you are suicidal, call 1-800-273-TALK.


COVID-19: Man commits suicide over coronavirus scare

 © Provided by Khaleej Times COVID-19: Man commits suicide over coronavirus scare

Panic took over a man from Andhra Pradesh, India, who assumed he had contracted the deadly coronavirus and killed himself fearing he would also infect his family.
The new coronavirus: how it's transmitted

Balakrishnayya, 50, had visited hospital for his heart ailment when doctors there advised him to wear a mask as he showed symptoms of cold. The man got anxious and quickly concluded he was infected with the novel coronavirus which has killed over 1,000 in China and infected over 40,000 people worldwide.
According to reports in NDTV, the man who hailed from a village Srikalahasti in Chitoor, feared he would infect his family and other villagers. He locked his family in the house and committed suicide by hanging himself from a tree. "He had gone to hospital for checkup regarding heart ailment. The doctors told him to use a mask and he misunderstood he was infected with coronavirus," the man's son said.
He also said that his father watched many videos about the coronavirus outbreak and assumed his symptoms were that of the deadly infection. "He (his father) wouldn't let any of us come near him. I told him you don't have infection but he wouldn't listen. May be, if he got proper counselling, he would have listened," the son added.
* * *
Although there have been no cases of the novel coronavirus in Andhra Pradesh, the outbreak has caused panic after WHO declared it a global health emergency. In India, three people tested positive for coronavirus in Kerala and they are students who had returned from China's Wuhan, the epicentre of the outbreak.


South Korean In Charge of COVID-19 Commits Suicide; Unknown If It’s Due to Work

News broke just recently regarding a male official from South Korea’s Ministry of Justice committing suicide.
He had committed suicide from a bridge across the Han River.
According to Naver News, the man was an employee at the Office of Emergency Safety Planning which spearheads the national emergency and disaster management in South Korea.

South Korean In Charge of COVID-19 Commits Suicide; Unknown If It’s Due to Work

Lest you’re unaware, the Office of Emergency Safety Planning is involved and in charge of containing the COVID-19 outbreak in South Korea.
According to Naver News, the man could be seen in CCTV footage driving his car before crashing into the railing of the Donjak Bridge.
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Shortly after, he is seen jumping from the bridge into the Han River. Unfortunately, he died at around 5am South Korean time or around 4am Singapore time.

Body Found Hours Later

The search for his body took a few hours, and it was found at around 8am Singapore time by the Banpo rescue team.
Amidst all the speculations, we can’t be sure whether his reason for committing suicide was due to his work as there are no clear links at this time.
South Korea’s Ministry of Justice and the relevant authorities are currently looking into and investigating why the man committed suicide.
They will also be looking into whether his death was due to his work.

Peter Stubley

Thomas Schaefer served as finance minister for the German state of Hesse for a decade before his death: EPA
Thomas Schaefer served as finance minister for the German state of Hesse for a decade before his death: EPA
The finance minister of the German region of Hesse has died in an apparent suicide which the state governor suggested was linked to worries over the coronavirus pandemic.
Thomas Schaefer, a member of Chancellor Angela Merkel’s Christian Democratic Union, was found on railway tracks at Hochheim, near Frankfurt, on Saturday.
Police and prosecutors said that the evidence, including witness statements and examination of the scene, led them to conclude the 54-year-old killed himself.
State governor Volker Bouffier said Schaefer had worked “literally day and night” to deal with the Covid-19 crisis.
“We have to assume that he was very worried,” said Mr Bouffier. “Above all, there are great concerns about whether it will be possible to meet the huge expectations of the population – especially financial aid.
“I have to assume that these concerns overwhelmed him. He obviously couldn’t find a way out. He was desperate and left us. His death is also a great loss for this country.”
Schaefer had been Hesse’s state finance minister for a decade and was seen as a potential candidate for the region’s next governor.
The Hesse CDU party said in a statement that it was in mourning, adding: “We heard with dismay the news of his sudden and unexpected death. Our thoughts are with his family and relatives.”
Germany has reported 455 deaths and more than 58,000 confirmed cases of Covid-19 since the start of the outbreak.
Seven days ago the German chancellor went into quarantine after a doctor who gave her a vaccine tested positive for the virus.
The country has banned public meetings of more than two people and imposed tight border restrictions in an attempt to slow the spread of the outbreak.
Additional reporting by agencies


A 38-year-old Wilson Borough man who had become increasingly despondent over the COVID-19 pandemic and who had recently lost his job shot his longtime girlfriend then himself on Monday afternoon, police report.
Roderick Bliss, of the unit block of North 17th Street, died at the scene and his death was ruled a suicide, Northampton County Coroner Zachary Lysek said. The 43-year-old woman suffered a gunshot wound to the back and is being treated in the intensive care unit at St. Luke’s University Hospital in Fountain Hill, police Chief Chris Meehan said. She is expected to survive, Meehan added.
Police were called at 1:19 p.m. to 54 N. 17th St. for a report of shots fired with injuries, Meehan said. After locating Bliss’ body they recovered a semiautomatic pistol nearby, Meehan said. The woman was conscious and alert and was able to tell officers that Bliss shot her, Meehan said.
On Tuesday, the woman, who police did not name, was able to speak to police in more detail. Officers interviewed others as well, Meehan said.
“In the days prior to the shooting, Bliss had become increasingly upset over the COVID-19 pandemic," Meehan wrote about the disease caused by the coronavirus. "Minutes before the shooting Bliss was extremely upset about the pandemic and the fact that he had recently lost his job.
“He went into the basement and came outside onto the rear porch with the victim. While holding the handgun, Bliss told the victim, ‘I already talked to God and I have to do this.’ The victim ran off the porch and he shot at her four times striking her once. Bliss then shot himself.”
It wasn’t immediately clear if Bliss lost his job due to the economic downturn as communities sheltered in place as the pandemic took hold, Meehan said.
Borough police were assisted by the coroner’s office, the borough fire department and Suburban EMS, Meehan said.


Anxiety and depression likely to spike among Americans as coronavirus pandemic spreads

Stress, anxiety and depression are normal and expected now.

New York Gov. Andrew Cuomo recently announced that New York State plans to set up a free mental health service in which people can speak to mental health professionals about the emotional toll of the COVID-19 crisis.
Cuomo called on mental health professionals to consider donating their time to conduct free sessions over the phone or via video for patients in need of mental health counseling.
Mental health problems such as anxiety and depression are likely to spike among Americans in the coming weeks because of the uncertainty created by the pandemic.
COVID-19 has evoked fear in our lives in a way that hasn't been felt since the 9/11 terrorist attack. The sight of empty grocery store shelves, streets void of pedestrians, overflowing emergency rooms and thousands sequestered at home paints a picture of our new reality. Empty store shelves alone can be deeply distressing for many who fear that food supplies will run out, triggering all sorts of negative emotions.
Stress, anxiety and depression are normal and expected in the context of this pandemic. Experts, however, are particularly worried about people who are predisposed to depression and anxiety. The unique and unprecedented threat of COVID-19 has exacerbated anxiety, depression and potential for hysteria in our most vulnerable -- the mentally ill.
Psychologists describe fear as an expected response to a known threat, such as the seasonal flu, while anxiety is a response to a vague threat.
Dr. Alexander Sanchez, a psychiatrist working in New York City, told ABC News, “This is a new challenge and the most worrying aspect is the uncertainty."
At this time, nearly 7 million people in the U.S. are affected by generalized anxiety disorder and about 6 million with panic disorder. These numbers are expected to go up in the next few months.
“I expect an increase in anxiety and depressive symptoms to come when the experience of social distancing and isolation becomes more routine, Sanchez said. “We are trying to adjust to a new way of maintaining social connections virtually. There will be some psychic pain while we adjust."
When asked to pinpoint the primary root of anxiety, Dr. Armando Gonzalez, also known as Dr. Mondo, who a licensed marriage and family therapist practicing in Sacramento, California, told ABC News: “There's no doubt uncertainty is always the lynchpin to anxiety and panic."
He added, "In addition to panic around catching the virus or passing it on, the financial impact has become a cause for panic too."
Small businesses are struggling to stay afloat and many workers are not able to perform their jobs under current shelter-in-place orders. The mounting unknowns, mixed with the financial crisis that is sure to ensue, is at the root of a rise in anxiety, Mondo said.
Moreover, experts say obsessive compulsive disorder (OCD) will also be on the rise.
Cleaning and washing compulsions are two features of OCD, which can easily be exacerbated by the threat of infection. Mental health professions in psychiatry, primary care and even dermatology should be alerted to potential issues in patients with OCD.
In addition, the current outbreak may exacerbate psychosis-like symptoms as well as lead to non-specific mental issues (e.g., mood and sleep disturbances, phobias and panic-like symptoms).
The Centers for Disease Control and Prevention says anxiety and depression may worsen for people who are most susceptible to COVID-19, such as older individuals and those with chronic diseases.
“The elderly are more anxious because of their risk factors in regards to catching the virus," according to Mondo.
For other age groups, there's a level of heightened stress and uncertainty around when this might end and the financial impact it will have, Mondo noted.
As more people are asked to stay at home and self-quarantine, feelings of loneliness and isolation will be common. But experts say there are several strategies that may help people cope.
The National Alliance of Mental Illness (NAMI) recommends maintaining a sense of normality and routine that mirrors life’s daily patterns and practices. Structure and routine are helpful for people with mental health vulnerabilities, especially during times of uncertainty.
NAMI says to maintain a regular routine and keep up with morning rituals. Dressing in regular work attire and taking regular breaks are important. If working from home, NAMI encourages creating a structured, dedicated work environment and building in self-care as well as daily benchmarks of achievement.
“We are social creatures, we need each other. The creativity we have used to connect virtually is cause for hope, but at the end of the day, virtual meetings are still synthetic connection," said Mondo.
With the inevitable rise in mental health problems in the coming weeks, states are relying on tele-health to meet the mental health needs of the population.
“The health care world is working to expand tele-health at a breakneck pace to meet the needs of the community," said Sanchez. “It helps reduce the unnecessary use of personal protective equipment by health care workers and prevent the transmission of disease to patients in office waiting rooms or public transit."
The New York State Psychiatric Association is working with Gov. Cuomo to encourage participation in free tele-health services.
“We need to remember that this is temporary -- we have been challenged before and have met and exceeded those challenges as a society," said Sanchez.
Complete a survey at health.ny.gov/assistance for mental health services.
For mental health crisis, Call the NAMI HelpLine at 800-950-NAMI (6264) Monday through Friday, between 10:00 am and 6:00 pm EST for mental health resources.
Visit NAMI.org for additional information on how to seek mental health help.
If you are a loved one is experiencing suicidal thoughts in response to the outbreak, call The National Suicide Prevention Lifeline at 1-800-273-8255 for free and confidential emotional support 24 hours a day, 7 days a week.
Yalda Safai MD, MPH, is a psychiatry resident in New York City and contributor to ABC News Medical Unit.

Original Investigation
March 23, 2020

Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

JAMA Netw Open. 2020;3(3):e203976. doi:10.1001/jamanetworkopen.2020.3976
Key Points español 中文 (chinese) Question  What factors are associated with mental health outcomes among health care workers in China who are treating patients with coronavirus disease 2019 (COVID-19)?
Findings  In this cross-sectional study of 1257 health care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in multiple regions of China, a considerable proportion of health care workers reported experiencing symptoms of depression, anxiety, insomnia, and distress, especially women, nurses, those in Wuhan, and front-line health care workers directly engaged in diagnosing, treating, or providing nursing care to patients with suspected or confirmed COVID-19.
Meaning  These findings suggest that, among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and front-line health care workers have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.
Importance  Health care workers exposed to coronavirus disease 2019 (COVID-19) could be psychologically stressed.
Objective  To assess the magnitude of mental health outcomes and associated factors among health care workers treating patients exposed to COVID-19 in China.
Design, Settings, and Participants  This cross-sectional, survey-based, region-stratified study collected demographic data and mental health measurements from 1257 health care workers in 34 hospitals from January 29, 2020, to February 3, 2020, in China. Health care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 were eligible.
Main Outcomes and Measures  The degree of symptoms of depression, anxiety, insomnia, and distress was assessed by the Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale–Revised, respectively. Multivariable logistic regression analysis was performed to identify factors associated with mental health outcomes.
Results  A total of 1257 of 1830 contacted individuals completed the survey, with a participation rate of 68.7%. A total of 813 (64.7%) were aged 26 to 40 years, and 964 (76.7%) were women. Of all participants, 764 (60.8%) were nurses, and 493 (39.2%) were physicians; 760 (60.5%) worked in hospitals in Wuhan, and 522 (41.5%) were frontline health care workers. A considerable proportion of participants reported symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Nurses, women, frontline health care workers, and those working in Wuhan, China, reported more severe degrees of all measurements of mental health symptoms than other health care workers (eg, median [IQR] Patient Health Questionnaire scores among physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007; median [interquartile range {IQR}] Generalized Anxiety Disorder scale scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] Insomnia Severity Index scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001; median [IQR] Impact of Event Scale–Revised scores among those in Wuhan vs those in Hubei outside Wuhan and those outside Hubei: 21.0 [8.5-34.5] vs 18.0 [6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside Hubei; P < .001). Multivariable logistic regression analysis showed participants from outside Hubei province were associated with lower risk of experiencing symptoms of distress compared with those in Wuhan (odds ratio [OR], 0.62; 95% CI, 0.43-0.88; P = .008). Frontline health care workers engaged in direct diagnosis, treatment, and care of patients with COVID-19 were associated with a higher risk of symptoms of depression (OR, 1.52; 95% CI, 1.11-2.09; P = .01), anxiety (OR, 1.57; 95% CI, 1.22-2.02; P < .001), insomnia (OR, 2.97; 95% CI, 1.92-4.60; P < .001), and distress (OR, 1.60; 95% CI, 1.25-2.04; P < .001).
Conclusions and Relevance  In this survey of heath care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 in Wuhan and other regions in China, participants reported experiencing psychological burden, especially nurses, women, those in Wuhan, and frontline health care workers directly engaged in the diagnosis, treatment, and care for patients with COVID-19.
Since the end of December 2019, the Chinese city of Wuhan has reported a novel pneumonia caused by coronavirus disease 2019 (COVID-19), which is spreading domestically and internationally.1 The virus has been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this report, we will refer to the disease, COVID-19. According to data released by the National Health Commission of China, the number of confirmed cases in mainland China has increased to 80 151 as of March 2, 2020,2 and confirmed cases have been reported in more than a dozen other countries. Moreover, person-to-person transmission has been recorded outside mainland China.3 On January 30, 2020, the World Health Organization held an emergency meeting and declared the global COVID-19 outbreak a public health emergency of international concern.4
Facing this critical situation, health care workers on the front line who are directly involved in the diagnosis, treatment, and care of patients with COVID-19 are at risk of developing psychological distress and other mental health symptoms. The ever-increasing number of confirmed and suspected cases, overwhelming workload, depletion of personal protection equipment, widespread media coverage, lack of specific drugs, and feelings of being inadequately supported may all contribute to the mental burden of these health care workers. Previous studies have reported adverse psychological reactions to the 2003 SARS outbreak among health care workers.5-8 Studies showed that those health care workers feared contagion and infection of their family, friends, and colleagues,5 felt uncertainty and stigmatization,5,6 reported reluctance to work or contemplating resignation,6 and reported experiencing high levels of stress, anxiety, and depression symptoms,7 which could have long-term psychological implications.7 Similar concerns about the mental health, psychological adjustment, and recovery of health care workers treating and caring for patients with COVID-19 are now arising.
Psychological assistance services, including telephone-, internet-, and application-based counseling or intervention, have been widely deployed by local and national mental health institutions in response to the COVID-19 outbreak. On February 2, 2020, the State Council of China announced that it was setting up nationwide psychological assistance hotlines to help during the epidemic situation.9 However, evidence-based evaluations and mental health interventions targeting front-line health care workers are relatively scarce.
To address this gap, the aim of current study was to evaluate mental health outcomes among health care workers treating patients with COVID-19 by quantifying the magnitude of symptoms of depression, anxiety, insomnia, and distress and by analyzing potential risk factors associated with these symptoms. Participants from Wuhan city (the capital of Hubei province) and other areas inside and outside Hubei province in China were enrolled in this survey to compare interregional differences. This study aimed to provide an assessment of the mental health burden of Chinese health care workers, which can serve as important evidence to direct the promotion of mental well-being among health care workers.
Study Design
This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. Approval from the clinical research ethics committee of Renmin Hospital of Wuhan University was received before the initiation of this study. Verbal informed consent was provided by all survey participants prior to their enrollment. Participants were allowed to terminate the survey at any time they desired. The survey was anonymous, and confidentiality of information was assured.
The study is a cross-sectional, hospital-based survey conducted via a region-stratified, 2-stage cluster sampling from January 29, 2020, to February 3, 2020. During this period, the total confirmed cases of COVID-19 exceeded 10 000 in China. To compare the interregional differences of mental health outcomes among health care workers in China, samples were stratified by their geographic location (ie, Wuhan, other regions inside Hubei province, and regions outside Hubei province). Because Wuhan was most severely affected, more hospitals in Wuhan were sampled. Hospitals equipped with fever clinics or wards for COVID-19 were eligible to participate in this survey. A total of 20 hospitals in Wuhan (10 designated by the local government to treat COVID-19 and 10 nondesignated), 7 hospitals in other regions of Hubei province, and 7 hospitals from 7 other provinces with a high incidence of COVID-19 (1 hospital from each province) were included. In total, 34 hospitals were involved. Milestone events during the outbreak of COVID-19 and the duration of this study are presented in the eFigure in the Supplement.
One clinical department was randomly sampled from each selected hospital, and all health care workers in this department were asked to participate in this study. The target sample size of participants was determined using the formula N = Zα2P(1 − P) / d2, in which α = 0.05 and Zα = 1.96, and the estimated acceptable margin of error for proportion d was 0.1. The proportion of health care workers with psychological comorbidities was estimated at 35%, based on a previous study of the SARS outbreak.7 To allow for subgroup analyses, we amplified the sample size by 50% with a goal of at least 1070 completed questionnaires from participants.
Outcomes and Covariates
We focused on symptoms of depression, anxiety, insomnia, and distress for all participants, using Chinese versions of validated measurement tools.10-13 Accordingly, the 9-item Patient Health Questionnaire (PHQ-9; range, 0-27),10 the 7-item Generalized Anxiety Disorder (GAD-7) scale (range, 0-21),11 the 7-item Insomnia Severity Index (ISI; range, 0-28),12 and the 22-item Impact of Event Scale–Revised (IES-R; range, 0-88)13 were used to assess the severity of symptoms of depression, anxiety, insomnia, and distress, respectively. The total scores of these measurement tools were interpreted as follows: PHQ-9, normal (0-4), mild (5-9), moderate (10-14), and severe (15-21) depression; GAD-7, normal (0-4), mild (5-9), moderate (10-14), and severe (15-21) anxiety; ISI, normal (0-7), subthreshold (8-14), moderate (15-21), and severe (22-28) insomnia; and IES-R, normal (0-8), mild (9-25), moderate (26-43), and severe (44-88) distress. These categories were based on values established in the literature.10-13
The cutoff score for detecting symptoms of major depression, anxiety, insomnia, and distress were 10, 7,14 15, and 26, respectively. Participants who had scores greater than the cutoff threshold were characterized as having severe symptoms.
Demographic data were self-reported by the participants, including occupation (physician or nurse), sex (male or female), age (18-25, 26-30, 31-40, or >40 years), marital status, educational level (≤undergraduate or ≥postgraduate), technical title (junior, intermediate, or senior), geographic location (Wuhan, Hubei province outside Wuhan, or outside Hubei province), place of residence (urban or rural), and type of hospital (secondary or tertiary). The different technical titles of respondents refer to the professional titles certificated by the hospital. Participants were asked whether they were directly engaged in clinical activities of diagnosing, treating, or providing nursing care to patients with elevated temperature or patients with confirmed COVID-19. Those who responded yes were defined as frontline workers, and those who answered no were defined as second-line workers.
Statistical Analysis
Data analysis was performed using SPSS statistical software version 20.0 (IBM Corp). The significance level was set at α = .05, and all tests were 2-tailed. The original scores of the 4 measurement tools were not normally distributed and so are presented as medians with interquartile ranges (IQRs). The ranked data, which were derived from the counts of each level for symptoms of depression, anxiety, insomnia, and distress, are presented as numbers and percentages. The nonparametric Mann-Whitney U test and Kruskal-Wallis test were applied to compare the severity of each symptom between 2 or more groups. To determine potential risk factors for symptoms of depression, anxiety, insomnia, and distress in participants, multivariable logistic regression analysis was performed, and the associations between risk factors and outcomes are presented as odds ratios (ORs) and 95% CIs, after adjustment for confounders, including sex, age, marital status, educational level, technical title, place of residence, working position (first-line or second-line), and type of hospital.
Demographic Characteristics
In the study, among the 1830 health care workers (702 [38.4%] physicians and 1128 [61.6%] nurses) asked to participate, 1257 respondents (68.7%) completed the survey. The occupational and geographic data of nonrespondents were similar to those of respondents (eTable 1 in the Supplement). Of the 1257 responding participants, 493 (39.2%) were physicians, and 764 (60.8%) were nurses. The response rates for physicians and nurses were 70.2% and 67.7%, respectively. Of the participants, 760 (60.5%) worked in Wuhan, 261 (20.8%) worked in Hubei province outside Wuhan, and 236 (18.8%) worked outside Hubei province. Most participants were women (964 [76.7%]), were aged 26 to 40 years (813 [64.7%]), were married, widowed, or divorced (839 [66.7%]), had an educational level of undergraduate or less (953 [75.8%]), had a junior technical title (699 [55.6%]), and worked in tertiary hospitals (933 [74.2%]). A total of 522 participants (41.5%) were frontline health care workers directly engaged in diagnosing, treating, or caring for patients with or suspected to have COVID-19. Nearly all participants (1220 [97.1%]) lived in urban areas (Table 1).
Severity of Measurements and Associated Factors
A considerable proportion of participants had symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]). Nurses, women, frontline workers, and those in Wuhan reported experiencing more severe symptom levels of depression, anxiety, insomnia, and distress (eg, severe depression among physicians vs nurses: 24 [4.9%] vs 54 [7.1%]; P = .01; severe anxiety among men vs women: 10 [3.4%] vs 56 [5.8%]; P = .001; severe insomnia among frontline workers vs second-line workers: 9 [1.7%] vs 3 [0.4%]; P < .001; severe distress among workers in Wuhan vs Hubei outside Wuhan and outside Hubei: 96 [12.6%] vs 19 [7.2%] among those in Hubei outside Wuhan and 17 [7.2%] among those outside Hubei; P < .001) (Table 2). Compared with those working in tertiary hospitals, participants working in secondary hospitals were more likely to report severe symptoms of depression (53 [5.6%] vs 25 [7.7%]; P = .003), anxiety (48 [5.1%] vs 18 [5.5%]; P = .046), and insomnia (10 [1.0%] vs 2 [0.6%]; P = .02) but not distress (Table 2).
Scores of Measurements and Associated Factors
The median (IQR) scores on the PHQ-9 for depression, the GAD-7 for anxiety, the ISI for insomnia, and the IES-R for distress for all respondents were 5.0 (2.0-8.0), 4.0 (1.0-7.0), 5.0 (2.0-9.0), and 20.0 (7.0-31.0), respectively. Similar to findings in severity of symptoms, participants who were nurses, women, frontline health care workers, and working in Wuhan had higher scores in all 4 scales compared with those who were physicians, men, second-line health care workers, and working in Hubei province outside Wuhan or outside Hubei province (eg, median [IQR] PHQ-9 scores among physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007; median [IQR] GAD-7 scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] ISI scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001; median [IQR] IES-R scores among those in Wuhan vs those in Hubei outside Wuhan and those outside Hubei: 21.0 [8.5-34.5] vs 18.0 [6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside Hubei; P < .001) (Table 3). Compared with health care workers in tertiary hospitals, those in secondary hospitals reported higher scores on scales measuring symptoms of depression, anxiety, and insomnia (median [IQR] PHQ-9 score, 4.0 [1.0-7.0] vs 5.0 [2.0-9.0]; P < .001; median [IQR] GAD-7 score, 3.0 [0-7.0] vs 4.0 [1.0-7.0]; P = .005; median [IQR] ISI score, 4.0 [2.0-9.0] vs 6.0 [2.0-10.0]; P = .008). There were no differences in hospital status for scores of distress (median [IQR] IES-R score: workers in tertiary hospitals, 19.0 [7.0-32.0]; workers in secondary hospitals, 20.0 [6.0-31.0]; P = .46). However, frontline health care workers from tertiary and secondary hospitals reported equally high scores on all 4 scales (eg, median [IQR] PHQ-9 score, 5.0 [2.0-8.0] vs 6.0 [3.0-9.0]; P = .08) (Table 4). In pairwise comparisons, participants from Hubei province outside Wuhan and participants outside Hubei province reported similar levels of symptoms of depression, anxiety, insomnia, and distress but were all lower than that of health care workers in Wuhan, the origin of the epidemic (eTable 2 in the Supplement). Analyses of scores of 3 factors (avoidance, intrusion, and hyperarousal) derived from the IES-R are presented in eTable 3, eTable 4, and eTable 5 in the Supplement.
Risk Factors of Mental Health Outcomes
Multivariable logistic regression analysis showed that, after controlling for confounders, being a woman and having an intermediate professional title were associated with severe symptoms of depression, anxiety, and distress (eg, severe depression among women: OR, 1.94; 95% CI, 1.26-2.98; P = .003; severe anxiety among those with intermediate professional titles: OR, 1.82; 95% CI, 1.38-2.39; P < .001). Compared with working in a tertiary hospital, working in secondary hospitals was associated with more severe symptoms of depression (OR, 1.65; 95% CI, 1.17-2.34; P = .004) and anxiety (OR, 1.43; 95% CI, 1.08-1.90; P = .01). Working outside Hubei province was associated with a lower risk of feeling distressed than working in Wuhan (OR, 0.62; 95% CI, 0.43-0.88; P = .008). Compared with working in second-line positions, working in the frontline directly treating patients with COVID-19 appeared to be an independent risk factor for all psychiatric symptoms after adjustment (depression, OR 1.52; 95% CI, 1.11-2.09; P = .01; anxiety, OR 1.57; 95% CI, 1.22-2.02; P < .001; insomnia, OR 2.97; 95% CI, 1.92-4.60; P < .001; distress: OR, 1.60; 95% CI, 1.25-2.04; P < .001) (Table 5).
This cross-sectional survey enrolled 1257 respondents and revealed a high prevalence of mental health symptoms among health care workers treating patients with COVID-19 in China. Overall, 50.4%, 44.6%, 34.0%, and 71.5% of all participants reported symptoms of depression, anxiety, insomnia, and distress, respectively. Participants were divided in 3 groups (Wuhan, other regions in Hubei province, and regions outside Wuhan province) to compare interregional differences. Most participants were female, were nurses, were aged 26 to 40 years, were married, and worked in tertiary hospitals with a junior technical title. Nurses, women, those working in Wuhan, and frontline workers reported more severe symptoms on all measurements. Our study further indicated that being a woman and having an intermediate technical title were associated with experiencing severe depression, anxiety, and distress. Working in the front line was an independent risk factor for worse mental health outcomes in all dimensions of interest. Together, our findings present concerns about the psychological well-being of physicians and nurses involved in the acute COVID-19 outbreak.
In this study, a significant proportion of participants experienced anxiety, depression, and insomnia symptoms, and more than 70% reported psychological distress. In a previous study during the acute SARS outbreak, 89% of health care workers who were in high-risk situations reported psychological symptoms.8 The psychological response of health care workers to an epidemic of infectious diseases is complicated. Sources of distress may include feelings of vulnerability or loss of control and concerns about health of self, spread of virus, health of family and others, changes in work, and being isolated.15 The fact that COVID-19 is human-to-human transmissible,1,3 associated with high morbidity, and potentially fatal16 may intensify the perception of personal danger. Additionally, predictable shortages of supplies and an increasing influx of suspected and actual cases of COVID-19 contribute to the pressures and concerns of health care workers.17
Of note, 76.7% of all participants were women, and 60.8% were nurses (90.8% of whom were female). Our findings further indicate that women reported more severe symptoms of depression, anxiety, and distress. Frontline nurses treating patients with COVID-19 are likely exposed to the highest risk of infection because of their close, frequent contact with patients and working longer hours than usual.18,19 Moreover, 71.5% of all nurses had junior titles, indicating that most had fewer years of work experience. During the SARS outbreak, a study conducted among health care workers in emergency departments also showed that nurses were more likely to develop distress and use behavioral disengagement than physicians.15 Frontline nurses treating patients with SARS were physically and psychologically challenged when committing themselves to providing high-quality nursing care for patients.19-22 Moreover, at the early stage of the SARS epidemic, nurses may have been less likely to be warned about exposure or provided with adequate protections.22 Particular attention is warranted regarding the mental health well-being of women and nurses treating patients with COVID-19.
Another finding in our study was that, compared with those in Hubei province outside Wuhan and those outside Hubei province, health care workers in Wuhan reported more severe symptoms of depression, anxiety, insomnia, and distress. Multivariable logistic regression analysis showed that working outside Hubei province was associated with lower risk of experiencing distress. These findings indicated more stress among health care workers in Wuhan, the origin and epicenter of the epidemic in China. In addition, working as a frontline health care worker with direct engagement of patients with COVID-19 was an independent risk factor for all symptoms. As frontline health care workers in Wuhan were at especially high risk for symptoms of depression, anxiety, insomnia, and distress, their mental health may require special attention.
This study has several limitations. First, it was limited in scope. Most participants (81.2%) were from Hubei province, limiting the generalization of our findings to less affected regions. Second, the study was carried out during 6 days and lacks longitudinal follow-up. Because of the increasingly arduous situation, the mental health symptoms of health care workers could become more severe. Thus, long-term psychological implications of this population are worth further investigation. Third, this study was unable to distinguish the association of symptoms with being a clinician in this region vs simply living in this region (because there was no comparator group) and was also unable to distinguish preexisting mental health symptoms vs new symptoms. Fourth, although the response rate of this study was 68.7%, response bias may still exist if the nonrespondents were either too stressed to respond or not at all stressed and therefore not interested in this survey.
In this survey study of physicians and nurses in hospitals with fever clinics or wards for patients with COVID-19 in China, health care workers responding to the spread of COVID-19 reported high rates of symptoms of depression, anxiety, insomnia, and distress. Protecting health care workers is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented, with women, nurses, and frontline workers requiring particular attention.
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Article Information
Accepted for Publication: March 2, 2020.
Published: March 23, 2020. doi:10.1001/jamanetworkopen.2020.3976
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Lai J et al. JAMA Network Open.
Corresponding Authors: Zhongchun Liu, MD, Department of Psychiatry, Renmin Hospital of Wuhan University, 238 Jiefang Rd, Wuhan 430060, China (zcliu6@whu.edu.cn); Shaohua Hu, MD, Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, Hangzhou 310003, China (dorhushaohua@zju.edu.cn).
Author Contributions: Drs Liu and S. Hu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Lai, Ma, and Y. Wang contributed equally and share first authorship. Drs Liu and S. Hu contributed equally as senior authors.
Concept and design: Liu, S. Hu.
Acquisition, analysis, or interpretation of data: Lai, Ma, Y. Wang, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang.
Drafting of the manuscript: Lai, Ma, Y. Wang, Liu, S. Hu.
Critical revision of the manuscript for important intellectual content: Lai, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang, Liu, S. Hu.
Statistical analysis: Ma, Y. Wang, Liu, S. Hu.
Obtained funding: Liu, S. Hu.
Administrative, technical, or material support: Lai, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang.
Supervision: G. Wang, Liu, S. Hu.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by grants 2018YFC1314600 and 2016YFC1307100 from the National Key Research and Development Program of China.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank all the participants who contributed to our work.
Li  Q, Guan  X, Wu  P,  et al.  Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia  [published online January 29, 2020].  N Engl J Med. 2020. doi:10.1056/NEJMoa2001316PubMedGoogle Scholar
The National Health Commission of China. Updates on the novel coronavirus outbreak up to March 2, 2020. Accessed March 3,2020. http://www.nhc.gov.cn/xcs/yqtb/202003/c588ee20113b4136b27f2a07faa7075b.shtml
Rothe  C, Schunk  M, Sothmann  P,  et al.  Transmission of 2019-nCoV infection from an asymptomatic contact in Germany  [published online January 30, 2020].  N Engl J Med. 2020. doi:10.1056/NEJMc2001468PubMedGoogle Scholar
World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). Published January 30, 2020. Accessed February 2, 2020. https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)
Maunder  R, Hunter  J, Vincent  L,  et al.  The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital.  CMAJ. 2003;168(10):1245-1251.PubMedGoogle Scholar
Bai  Y, Lin  CC, Lin  CY, Chen  JY, Chue  CM, Chou  P.  Survey of stress reactions among health care workers involved with the SARS outbreak.  Psychiatr Serv. 2004;55(9):1055-1057. doi:10.1176/appi.ps.55.9.1055PubMedGoogle ScholarCrossref
Lee  AM, Wong  JG, McAlonan  GM,  et al.  Stress and psychological distress among SARS survivors 1 year after the outbreak.  Can J Psychiatry. 2007;52(4):233-240. doi:10.1177/070674370705200405PubMedGoogle ScholarCrossref
Chua  SE, Cheung  V, Cheung  C,  et al.  Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers.  Can J Psychiatry. 2004;49(6):391-393. doi:10.1177/070674370404900609PubMedGoogle ScholarCrossref
The State Council of China. A notification to set up nationwide psychological assistance hotlines against the 2019-nCoV outbreak. Published February 2, 2020. Accessed March 3, 2020. http://www.gov.cn/xinwen/2020-02/02/content_5473937.htm
Zhang  YL, Liang  W, Chen  ZM,  et al.  Validity and reliability of Patient Health Questionnaire-9 and Patient Health Questionnaire-2 to screen for depression among college students in China.  Asia Pac Psychiatry. 2013;5(4):268-275. doi:10.1111/appy.12103PubMedGoogle ScholarCrossref
He  XY, Li  CB, Qian  J, Cui  HS, Wu  WY.  Reliability and validity of a generalized anxiety scale in general hospital outpatients.  Shanghai Arch Psychiatry. 22(4):200-203. doi:10.3969/j.issn.1002-0829.2010.04.002Google Scholar
Yu  DS.  Insomnia Severity Index: psychometric properties with Chinese community-dwelling older people.  J Adv Nurs. 2010;66(10):2350-2359. doi:10.1111/j.1365-2648.2010.05394.xPubMedGoogle ScholarCrossref
Wu  KK, Chan  KS.  The development of the Chinese version of Impact of Event Scale–Revised (CIES-R).  Soc Psychiatry Psychiatr Epidemiol. 2003;38(2):94-98. doi:10.1007/s00127-003-0611-xPubMedGoogle ScholarCrossref
Tong  X, An  D, McGonigal  A, Park  SP, Zhou  D.  Validation of the Generalized Anxiety Disorder-7 (GAD-7) among Chinese people with epilepsy.  Epilepsy Res. 2016;120:31-36. doi:10.1016/j.eplepsyres.2015.11.019PubMedGoogle ScholarCrossref
Wong  TW, Yau  JK, Chan  CL,  et al.  The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope.  Eur J Emerg Med. 2005;12(1):13-18. doi:10.1097/00063110-200502000-00005PubMedGoogle ScholarCrossref
Wang  W, Tang  J, Wei  F.  Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China.  J Med Virol. 2020;92(4):441-447. doi:10.1002/jmv.25689PubMedGoogle ScholarCrossref
Chan-Yeung  M.  Severe acute respiratory syndrome (SARS) and healthcare workers.  Int J Occup Environ Health. 2004;10(4):421-427. doi:10.1179/oeh.2004.10.4.421PubMedGoogle ScholarCrossref
Li  L, Cheng  S, Gu  J.  SARS infection among health care workers in Beijing, China.  JAMA. 2003;290(20):2662-2663. doi:10.1001/jama.290.20.2662
ArticlePubMedGoogle ScholarCrossref
Shih  FJ, Gau  ML, Kao  CC,  et al.  Dying and caring on the edge: Taiwan’s surviving nurses’ reflections on taking care of patients with severe acute respiratory syndrome.  Appl Nurs Res. 2007;20(4):171-180. doi:10.1016/j.apnr.2006.08.007PubMedGoogle ScholarCrossref
Chan  S.  Nurses fighting against severe acute respiratory syndrome (SARS) in Hong Kong.  J Nurs Scholarsh. 2003;35(3):209. doi:10.1111/j.1547-5069.2003.00209.xPubMedGoogle ScholarCrossref
Tzeng  HM.  Fighting the SARS epidemic in Taiwan: a nursing perspective.  J Nurs Adm. 2003;33(11):565-567. doi:10.1097/00005110-200311000-00005PubMedGoogle ScholarCrossref
Mok  E, Chung  BP, Chung  JW, Wong  TK.  An exploratory study of nurses suffering from severe acute respiratory syndrome (SARS).  Int J Nurs Pract. 2005;11(4):150-160. doi:10.1111/j.1440-172X.2005.00520.xPubMedGoogle ScholarCrossref

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