Occurrences of post-traumatic stress disorder, anxiety, depression, and burnout syndrome in ICU staff workers after two-year of the COVID-19 pandemic: the international PSY-CO in ICU study

In December 2019, the coronavirus SARS-CoV-2 resulted in a worldwide outbreak of respiratory illness termed coronavirus disease 2019 (COVID-19), with clinical presentation ranging from asymptomatic disease to severe progressive pneumonia with multiorgan failure. Over 6,537,636 worldwide patients have died (October 12, 2022) [1‐3], and although overall mortality is around 3%, the mortality rate of patients admitted to the intensive care unit (ICU) ranges from 20% to more than 60% [1, 3‐7]). With few substantially disease modifying antiviral SARS-CoV-2 therapeutic agents, the current therapeutic strategy is based largely on symptomatic treatment and the prevention of transmission [8].

The COVID-19 pandemic presented with different intensities between countries. Therefore, some countries tried to fight and/or delay the start of the pandemic to reduce the peak infection rates of the disease. These actions aimed at reducing the overall pressure on national healthcare systems and was intended to decrease the COVID-19 mortality rate [9, 10].

Based on the experience of previous pandemics, countries reacted by applying different transmission prevention strategies to prevent or delay the spread of the disease [9‐11]. Therefore, measures such as border closure, school closure, restricting social gatherings (even shutdown of workplaces), limiting population movements, and lockdowns at the scale of cities or regions were put into action. In public hospitals, several measures were implemented to concentrate care resources on the potential wave of admissions of patients with severe forms of COVID-19. For this reason, the number of available beds in the ICU was frequently increased by up to two-fold [12, 13], and scheduled non-emergency surgical procedures were canceled. Frequently underutilized health care professionals (physicians such as anesthesiologists, and nurses of other units) were transferred to ICUs, and those of less busy units were transferred to busier ones.

All these measures lead to major daily-life changes that could be stressful to individuals. In the general population, it has been well documented that quarantine or confinement, or isolation may lead to the occurrence of post-traumatic stress disorder (PTSD) in about 30% of the exposed population [14]. Importantly, high levels of depressive symptoms have been reported in up to 9% of hospital staff [15]. Numerous symptoms, such as emotional disturbance, depression, stress, low mood, irritability, insomnia, and post-traumatic stress symptoms have been reported after quarantine or isolation [14].

In the ICU setting, it has been shown that the COVID-19 pandemic led to psychological consequences on caregivers. During the second wave in France (autumn 2020), Azoulay et al. reported symptoms of anxiety, depression, post-traumatic stress disorder, and burnout in 60.0%, 36.1%, 28.4, and 45.1%, respectively, in 845 health care providers (66% nursing staff, 32% medical staff, 2% other professionals [16]). However, because the pandemic has continued over a prolonged period, with potentially different impacts on the population and healthcare systems, and varying in intensity according to the vaccination rate, the present study aimed at assessing the occurrence of PTSD, anxiety, depression, and burnout syndrome (BOS) in ICU staff workers in Australia (Queensland), France and Hong Kong after the first year of the COVID-19 pandemic. The primary objective was to assess the prevalence of PTSD in ICU staff workers. The secondary objectives were to identify potential associated factors to the occurrence of PTSD and to assess the prevalence of anxiety, depression, BOS, and their related associated factors in the same cohort.

The flowchart is shown in Fig. 1. Among 701 responders (in 20 different centers), 585, 570, and 539 completed PCL-5, HADS, and MBI questionnaires, respectively. All questionnaires were completed by 525 responders (511 caregivers and 14 non-caregivers).

In the present study performed in 20 centers in Australia, France, and Hong Kong, 525 ICU staff workers responded to the PCL-5, HADS, and MBI questionnaires. PTSD was present in 16.8% of participants with the highest prevalence in Hong Kong (30.8%). Anxiety and depressive disorders were reported in 22.8 and 8.8% of responders, respectively. The common associated factors with PTSD, anxiety, and depression were being a non-caregiver worker and not having been regularly informed of the COVID-19 progression during the pandemic. Concerning BOS, not having been regularly informed of the COVID-19 progression was associated with higher scores for emotional exhaustion, depersonalization, and the loss of personal accomplishment, respectively.

The present study was performed during the second year of the COVID-19 pandemic in 3 different countries with different impacts of this pandemic, different strategies to prevent contamination, and different population vaccination rates. These factors could explain the different prevalences of PTSD, anxiety, and depression reported in previous studies that were essentially performed in European countries during the first and second waves. The FAMIREA group performed two studies in the first and second waves in 21 and 16 centers involving 845 (70% responders) and 1058 (67% responders healthcare professionals, respectively [16, 23]. The prevalences of PTSD were successively 32.0 and 28.4% with anxiety and depression reported in 50.4 to 60.0% and 30.4 to 36.1%, during the first and second waves, respectively. During the second wave, the authors reported a burnout syndrome in 45.1% using an overall score [23].

In January 2021, a single center study involving 136 healthcare workers (84 nurses, 52 physicians) in a temporary ICU during the pandemic in Milano Fiera, Lombardy reported 60% burnout syndrome, 53% anxiety (especially in nurses), and 45% depression [24]. In June–July 2020, a cross-sectional study involving 709 healthcare providers from 9 English ICUs reported 40% PTSD, 11% severe anxiety, and 6% severe depression. In May 2020, a cross-sectional study involving 352 Swiss ICU healthcare workers reported 22% PTSD, 46% anxiety, and 46% depression [25].

The present study reports lower prevalences of PTSD, anxiety, and depression than the previous ones performed in the first two waves of the pandemic. Our findings could mean that the impact of COVID-19 pandemic has been blunted overtime. Indeed, the present findings are close to those observed at baseline prior to the COVID-19 pandemic [16, 23, 26]. Another explanation could be related to different cultures, different impact of the pandemic and policies on restriction, lockdown, and vaccine strategies in Hong Kong Australia, and France [27‐29].

The present study also reported that ICU staff workers in contact with COVID-19 patients are at lower risk of psychological consequences than those not in charge of these patients. This paradoxical phenomenon has been regularly reported in previous studies [14]. Indeed, being far from the patients with no information and education about the disease could lead to fear, anxiety, stress, and other psychological consequences. The absence of information about local progression of the pandemic was also associated with BOS in its 3 dimensions (emotional exhaustion, depersonalization, and loss of personal accomplishment).

In contrast to the previous studies, a quantitative approach to BOS was performed. A threshold of MBI is classically used for diagnosing BOS. However, this dichotomous analysis has been challenged because MBI aggregate 3 different and independent part of the diagnosis. In 2016,

the cut-off scores were removed by the MBI Manual 4th edition because they have no diagnostic validity [30]. Even with this difference, the present study reported similar associated factors with the 3 different parts of BOS (lack of information about local progression of the pandemic and lack of theoretical or practical training on COVID-19 patient management). The present study highlighted several factors associated with PTSD, anxiety, depression, and symptoms of BOS. Moreover, it involved ICUs from different continents. Hong Kong was firstly impacted by the pandemic. France was also severely impacted by the first two waves with some ICU overwhelming episodes. Australia and particularly Queensland closed their borders and had limited transmission and cases in the early stages. Finally, the courses of vaccination covert were different according to the general health strategy against the COVID-19 pandemic. These differences could partly explain the heterogeneous findings of the present study.

We must acknowledge some limitations. First, the participation rate was only 16%, which is consistent with cross-sectional surveys. We did not send personal reminders to respect responder anonymity. Another reason may be the timing of our study (after the third wave, February–July 2021) that was perhaps too far from the start of the pandemic with participant weariness leading to a low response rate. The present study, therefore, likely reported the chronic states of stress, anxiety, depression, and BOS in ICU staff. Second, the cross-sectional survey design only led to isolating associated factors with PTSD, anxiety, depression, and BOS. For isolating risk factors of these psychological disorders, cohort or case–control designs might have been more appropriate. Third, the sample of the present study was not well balanced with a preponderance of French participation. Fourth, non-care giving staff was also underrepresented in this study. Finally, it is well known that the demands of working in ICUs could lead to psychological disorders such as PTSD, anxiety, depression and BOS. As no baseline assessment of these disorders was conducted before the pandemic, we cannot rule out the fact the present study reported only the baseline psychological state [26].

Our findings confirmed that ICU staff workers continue to suffer from psychological disorders. Even if some factors are linked to the COVID-19 pandemic (fear of managing COVID-19 patients), the lack of theoretical and practical training in the management of COVID-19 patients as well as the lack of information on the current status of the pandemic within the ICU were associated with a higher prevalence of PTSD, anxiety, depression, and BOS. These findings suggest the importance of good communication amongst staff in the ICU for staff wellbeing.