Introduction
During the COVID-19 pandemic, frontline healthcare workers are at higher risk for mental health disorders because they face increased infection risk, a heavier workload, and potentially, life or death decisions [
1‐
6]. At the beginning of the COVID-19 pandemic, the WHO recognized the high burden of COVID-19 pandemic on healthcare workers and called for action to address the immediate needs to protect healthcare workers from risks of infection [
7]. However, it is equally important to protect healthcare workers from risks of mental health problems. The severity of healthcare workers’ mental health problems is illustrated clearly in a meta-analysis on 65 studies, which showed that the prevalence of anxiety, depression, and stress were 31.8, 40.3, and 11.4% among healthcare workers during COVID-19 [
2].
Besides emergency healthcare workers, eye care professionals may be one of the groups of highest COVID-19 infection risk due to physical proximity to patients’ nose and mouth during eye examinations. Thus, eye care professionals may be especially at risk for stress and mental health issues. However, no existing literature has studied the mental health impacts of COVID-19 on eyecare professionals as a targeted population [
3,
5,
8‐
11]. The current study fills this gap and examines risk factors for mental health issues among eyecare professionals during the COVID-19 pandemic.
The challenges specific to eye care professionals during the COVID-19 pandemic are dictated by the position of the eyes, a short distance from the nose and mouth, with physical connection between the ocular surface and the nasopharynx via the nasolacrimal duct. Because of the short inter-personal distance with patients, major components of eye examination, such as slit lamp biomicroscopy, retinoscopy, indirect and direct ophthalmoscopy, and contact lens manipulation, can pose increased infection risk for eye care professionals. Furthermore, eye care professionals have to deal with a series of ocular manifestations associated with COVID-19, such as conjunctivitis, a symptom frequently reported in patients with COVID-19 [
12,
13]. It is not surprising that the first doctor who reported COVID-19, Dr. Wenliang Li, was an ophthalmologist in China, who died due to professional contacts with COVID-19 patients. Protection against infection is often lacking among eye care professionals. Besides regular use of personal protective equipment, eye care professionals had to be creative to protect themselves in examinations unique to the discipline, such as creating a shield over the slit lamps and phoropter. All of these factors can impose extra stress on eye care professionals during the COVID-19 pandemic, with the potential to cause mental health issues among this population.
The pandemic related mental health problems are not only impacting professional healthcare workers, but potentially also impacting prospective healthcare professionals in training. Mental health difficulties are already alarmingly prevalent among college students, particularly in the United States, with every eight in ten students experiencing frequent stress episodes in 2019 [
14]. The top contributors to mental health difficulties in college students have been reported as pressure to succeed, educational performance, and post-college graduation plans [
15]. These challenges are expected to be similar, and perhaps even greater among students in professional schools. Negative impacts of COVID-19 on mental health have been reported in both college students [
16,
17] and health care students [
18,
19]. However, no studies have specifically reported the mental health impacts of the COVID-19 pandemic among professional eye-care students. The current research filles this gap by including eyecare students in our study of mental health impacts of the COVID-19 pandemic.
In order to protect eyecare professionals and students from mental health problems such as depression, anxiety, and psychological stress during the COVID-19 pandemic, it is important to identify factors associated with the risk for these mental health issues among this population. For example, what demographic sectors within eyecare professionals are at greater risk for mental health issues? What life-situations act as risk factors or protective factors for mental health issues among this population? Understanding these questions can help inform the design of targeted interventions for mental health problems in the eyecare profession.
The goal of the current study was to identify risk factors for mental health issues during the COVID-19 pandemic among eyecare professionals. We utilized a cross-sectional survey among eyecare doctors, staff, and students in the U.S. and Canada to answer this question. We included validated scales to measure depression, anxiety, and psychological stress as outcomes in the survey, and included demographic measures, professional contact with patients, as well as childcare responsibilities as potential predictors. We also recorded self-reported pre-pandemic stress level, and state level COVID-19 cases during the pandemic as control variables.
Discussions
Using validated questionnaires, this study focused on symptoms of depression, anxiety, and stress and revealed a high prevalence (38.4%) of probable depression and anxiety problems among eye care professionals and students. In addition, the linear and logistic regression analyses showed that being female, young, Black, or Asian predicted more mental health issues during the COVID-19 pandemic, while having greater proportions of childcare responsibilities at home, as well as more frequent interactions with patients protected against depression.
Torjesen reported a survey conducted by British Medical Association in May 2020 [
26], which found that 41% of medical doctors were dealing with depression, anxiety, stress, burnout, emotional distress, or mental health condition worsened by work; 29% of respondents said these got worse during the pandemic [
26]. Our finding that 38.4% of the surveyed eyecare professionals, staff, and students reported symptoms of depression, anxiety, or both during the COVID-19 pandemic is consistent with previous findings. However, future studies are needed to determine whether eye care professionals have worse mental health during the pandemic than other medical doctors.
Our finding that that female and younger eye care professional showed greater depression or anxiety symptoms during the COVID-19 pandemic is consistent with recent findings [
3,
4,
27‐
30]. Li et al. showed that young physicians in China have higher mental stress [
4], and Pieh et al. found that the COVID-19 pandemic seems particularly stressful for younger adults (< 35 years), and women [
27]. In addition, Power et al. concluded that the psychosocial effects of COVID-19 disproportionately affect young people [
28]. They reported that both immediate and longer-term factors through which young individuals were affected include social isolation, changes to the delivery of therapeutic services, and almost complete loss of all structured occupations (school, work, and training) [
28]. Lai et al. reported female health care providers were more likely to experience stress and anxiety during the COVID-19 pandemic [
3,
31]. Almeida et al. conducted a narrative review of published articles on women’s mental health and COVID-19 [
30]. They concluded that women have a higher prevalence of risk factors known to intensify during a pandemic, including chronic environmental strain and stress [
32], preexisting depressive and anxiety disorders [
33], and domestic violence [
34]. Thus, mental health interventions among eyecare professionals need to pay special attention to the younger and/or female sector of this population, which may include students and early-career eyecare professionals.
In addition, we found that both Black and Asian eye care professionals demonstrate greater depression symptoms and higher psychological stress than other race groups. Racial inequality and racism likely have contributed to these effects: Incidence rate and severity of COVID-19 are higher in the African American population, which could contribute to heightened stress and mental health issues among Black eye care professionals [
35,
36]. Liu et al. showed that Asian young adults reported lower level of mental health symptoms than young adults of other racial background in the early phase of the COVID-19 pandemic [
37]. However, the anti-Asian sentiment in America that has become associated with the origin of COVID-19 may have contributed to an increasing impact on Asian Americans as the pandemic progressed, and our survey may have picked up on this effect that was previously undetectable, since our data were collected in June–July 2020 while data in Liu et al. were collected in April–May 2020. More recently, Hahm et al. investigated the prevalence of COVID-19 related discrimination and reported that 68% of Asian and Asian American (A/AA) young adults reported that they or their family experienced COVID-19-related discrimination and approximately 15% of respondents reported verbal or physical assaults [
38]. Thus, more attention needs to focus on the mental health issues in the Asian subpopulation among eyecare professionals during the COVID-19 pandemic.
The results on job category are mixed: While we found students to be more susceptible to depression and psychological stress than faculty and staff in the eye care profession in linear regressions, even when age is controlled for, this result did not appear in logistic regressions. The finding that ophthalmologists were at lower risk for anxiety only emerged in logistic regression but was only marginally significant in linear regression. Therefore, we recommend caution in interpreting these results regarding the association between job categories within eye professionals and mental health risk. There is one caveat: Given the consistent finding that younger age is a risk factor for mental health issues, students are still especially vulnerable to mental health issues due to their younger age.
The current research also identified two counter-intuitive effects: More frequent interactions with patients protected against depression symptoms and having a greater proportion of childcare responsibilities at home also protected against depression. Our initial predictions were the opposite. We predicted that childcare responsibilities would impose extra stress and challenge to the ophthalmic personnel during the COVID-19 pandemic based on previous research; for example, Almeida et al. proposed that parenting might be substantially more stressful during a pandemic because of the additional time required for caring for children and providing social support [
30]. However, other research has also reported positive effects of family interactions and support on mental health [
39‐
41]. During the particular social context of the COVID-19 pandemic, our findings show that eyecare workers did benefit from having a greater portion of the childcare responsibilities at home, potentially due to the beneficial effect of family interactions in caring for children. In terms of the finding that greater interactions with patients protected against depression symptoms, it is at odds with previous findings that work responsibilities could contribute to mental health problems, such as over-work and relationship with employers [
42,
43]. On the other hand, during a time of social isolation caused by the COVID-19 pandemic and stay at home orders, the social benefits provided by interactions with patients may outweigh the potential negative impact of work-related stress. Indeed, our study showed that during the early phases of the COVID-19 pandemic, eyecare workers benefited from patient interactions even though these interactions were part of their work responsibilities.
During the COVID-19 pandemic, multiple efforts have already been put in place to reduce stress and manage mental health symptoms for health care workers, including: a hotline for health care worker [
44], mental health support initiatives and lessons [
45], social support [
46], remote consultations [
47], establishing principles of mental health care [
48], implementation of tele-education [
49], etc. The fact that 38% of eyecare professionals in the current study still demonstrate potential clinical depression and anxiety indicate that further monitoring and specific interventions on mental health for eye care practitioners are needed during the COVID-19 pandemic.
This study has a few limitations. First, this study might underestimate the impact of the COVID-19 pandemic on mental health because the study was conducted before the United States reached the peak of COVID-19. By the end of this study, July 8, 2020, total cases at USA exceeded 3,000,000 [
20]. However, case number continued to increase to 4,000,000 by July 24, 2020 and over 5,000,000 by August 9, 2020 [
20]. One might expect mental health to worsen with greater daily infections occurring in the United States. Our study group conducted another study to determine the longitudinal effect of COVID-19 pandemic on mental health symptoms and the effect of vaccination status on mental health in ophthalmic personnel [
50,
51]. Another limitation is the potential selection bias in the sample. Because participants were self-selected into the study, those with even more severe mental health problems may not have participated the study. Alternatively, self-selection may have acted in the opposite direction, so that those who were less impacted by COVID-19 may not have felt motivated to respond to the survey. Finally, the survey study had a response rate of 25%, and recruited a convenient sample of participants through professional connetions, which may not provide great representation of eyecare professionals in general. Although high response rate in external surveys is difficult to achieve, with an average response rate about 10–15% [
52], future research should strive to use random samples to achieve greater representativeness and generalizability.
In summary, this study is the first to examine mental health of eye care professionals in the United States during the COVID-19 pandemic, to the best of our knowledge. The findings of this study showed a high prevalence of mental health problems and revealed disparities in mental health among eye care personnel and students: Female, younger, Black and Asian populations are particularly vulnerable to these mental health issues. These findings shed important light on our understanding of how the COVID-19 pandemic impacts mental health among eye-care professionals, and particularly provides insights on the disproportionate impact among minority groups in this population. Based on these findings, we recommend that policies and strategies to improve mental health should be developed to help eyecare professionals and students cope with the negative impacts of the COVID-19 pandemic. In addition, we recommend that greater resources be allocated to developing and implementing effective mental health interventions that will particularly benefit female, younger, and racial minorities among eyecare professionals and students.
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