Introduction

Coronavirus disease (COVID-19) is a respiratory illness caused by severe acute respiratory syndrome coronavirus 2¹. It is airborne and characterized by shortness of breath, fever, muscle pain, and dry cough². The World Health Organization declared the “pandemic” status in March 2020³.

On March 29, Mexican authorities announced implementing a hospital conversion model to coordinate and integrate hospitals’ response to the care of severe patients with COVID-19. The Hospital Infantil de México Federico Gómez would initially be the national health institute that would care for pediatric patients <18 years of age with severe COVID-19⁴.

In epidemics, mental health is often affected. Some common reactions include being afraid of getting sick or dying, having a beloved one who could be ill or die, uncertainty about the economic situation, boredom, loneliness, depression due to isolation, and the risk of physical or mental health deterioration in vulnerable people⁵.

When facing an unknown and potentially dangerous situation, it is normal to experience anxiety and decreased mood. The expectation is that these symptoms will not cause significant dysfunction and will improve. However, some people may develop more complex disorders and feel stressed, even when they are no longer in danger. In health emergencies, acute stress disorder (ASD) frequently occurs⁵. The following are the diagnostic criteria for this disorder:

In a review of the relationship between ASD and post-traumatic stress disorder (PTSD), it was concluded that 30-83% of people who were diagnosed with ASD subsequently developed PTSD⁷.

The objective of this study was to examine the frequency of ASD symptoms in health-care personnel (resident physicians, attending physicians, and nursing personnel) who were in contact with COVID-19 patients during the pandemic in the Hospital Infantil de México Federico Gómez.

Methods

An observational, cross-sectional, prospective, and descriptive study was carried out employing a virtual questionnaire addressed to health-care personnel (resident physicians, attending physicians, and nursing personnel), which was distributed by email from April 23 to May 23, 2020. The questionnaire contained an informed consent form specifying that the information would be handled anonymously and confidentially. If at least nine symptoms of ASD were detected, an email address was solicited to provide information regarding treatment. The questionnaire was approximately 20 min long and consisted of multiple-choice questions in which sociodemographic factors were explored. The ASD scale is a screening test of 19 items scored on a Likert-type scale, which describes symptoms regarding the criteria of recurrence, avoidance, arousal, and dissociative cognitive alterations. This test was also applied in the same format. Based on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders)⁷, a cutoff point ≥27 on criterion B suggests a diagnosis of ASD. In contrast, a score >56 indicates that the person is at greater risk of PTSD⁸.

Results

ASD scale results

Based on criterion B, 88% of the total population obtained scores that met the criteria for the diagnosis of ASD, of which 13.6% obtained a score indicating a significant risk of eventually developing PTSD (Table 2).

Discussion

This study found that 88.8% of health care workers met the criteria for suspected ASD. This result is slightly higher than the results of other studies. For example, in a systematic review conducted to understand the impact of epidemics on health care workers’ mental health, a prevalence of ASD between 31% and 82% was reported⁹. In a study on stress-related disorders during the COVID-19 pandemic, 40% of health care workers met PTSD criteria, while 97.9% reported at least one symptom¹⁰.

Regarding the difference between the prevalence of ASD in health care workers compared to the general population in the context of COVID-19, a study in the Chinese population in Wuhan examined the symptoms of post-traumatic stress in the general population. The authors found that 7% of the participants presented post-traumatic stress symptoms, most of them associated with ASD¹¹. This figure is considerably lower than that found in studies of the prevalence of ASD in health care workers⁹,¹⁰.

When comparing the ASD scale scores between groups, no statistically significant differences in the overall score were found in the present study. However, resident physicians showed the highest scores on each of the symptom subsets.

In Mexico, medical residents’ training is a process that can be considered stressful on its own. Residents face long workdays combined with a heavy burden of caregiving and academic activities and decreased sleep and recreational activities. The COVID-19 health emergency has increased the work demand and the need for updating for residents. Moreover, they may also face other stress factors, such as fear of infecting their beloved ones, being away from their families, economic problems, a stigma for dealing with COVID-19 patients, fear of getting infected, and the uncertainty of dealing with a new disease. In a study conducted in Shanghai, some psychopathological symptoms were recorded in 385 first year medical residents. Data collection began in October 2019 and ended in February 2020, when the pandemic peaked in China. Depression scores increased by 61%, while anxiety scores increased by 64%¹².

Regarding dissociative symptoms, a statistically significant difference was found in the item of emotional distancing, which was more frequently reported within the groups of resident physicians and nursing personnel. Dissociative symptoms correspond to defense mechanisms that can occur in traumatic situations, which are presented as isolating or separating oneself from the traumatic event to experience less anxiety. Emotional distancing is also present in the burnout syndrome. This syndrome is characterized by emotional exhaustion, depersonalization, and low self-realization in individuals who work for the care or helping others. In medical or paramedical personnel, this syndrome can be more severe since many accidents or iatrogenic events can occur due to the profession’s nature. Furthermore, the patients may be treated with less quality and warmth than they deserve, which affects the healing process¹³. It would be worthwhile to investigate the prevalence of burnout in this population, particularly concerning the pandemic’s work situation.

Particularly, throughout their training, health care workers are taught that maintaining a certain emotional distance may be necessary to avoid becoming paralyzed by stress, to be functional and objective in a moment of crisis, and to be able to help patients. Furthermore, sometimes, the expression of emotions in medical practice can be perceived as unprofessional, so many health workers learn to suppress and ignore these emotions. Persistent avoidance of emotions can prevent health-care providers from genuinely engaging with patients and their feelings, which is the basis for empathy¹⁴.

A statistically significant difference was found in the item avoiding conversations on the event; a trend was also found in the item avoiding thinking about the topic. Both items showed a higher frequency in resident physicians. The avoidance symptoms correspond to defense mechanisms that keep the traumatic event out of conscious thinking to diminish the anxiety presented when remembering or thinking about them. It has been described that avoidance predicts stress and depression in the future. This coping strategy is most often seen in individuals less acquainted with the proper handling of adversity. In a study of 112 pediatric residents at a tertiary level care pediatric hospital in Mexico, 71.4% were found to use avoidance strategies¹⁵.

This study also stands out that arousal symptoms were the most frequently reported symptoms in all the groups. A trend was found in the difficulty of sleep and difficulty concentrating; both symptoms were presented more often in resident physicians. The arousal symptoms refer to a constant feeling of having to be in “fight, flight, paralysis” mode, which is typically part of the healthy response to a threat, while in the case of ASD, this feeling persists even when there is no threat. The manifestations include an exaggerated startle response to minimal stimuli, irritability, sleep disturbances, decreased concentration, or a hypervigilance state. One of the factors that can contribute to these symptoms is that COVID-19 is a new disease. The continuous discoveries on this disease radically change care protocols and cause a sense of uncertainty and the constant expectation of being in front of the unknown¹⁶.

This article has several strengths and limitations. This study is the first in our country specifically focused on exploring acute stress symptoms in health care workers during the COVID-19 pandemic context. In this sense, one of the study limitations is that most of the responses were obtained during May’s 1^st week. That is when the pandemic was not yet at its peak in our country, and the Hospital Infantil de México Federico Gómez was not receiving a significant number of cases yet. It would be worthwhile to conduct repeated measurements in this population at different points during the pandemic to have a better point of comparison, then apply an ASD scale and determine how often people who presented ASD developed posttraumatic stress during the COVID-19 pandemic.

Another limitation of the study is that the ASD scale only provides information about whether the participants meet criterion B for diagnosis. Therefore, we cannot assume that people who tested positive on this scale have the disorder’s diagnosis. Criterion A is met since the population is directly exposed to a traumatic event (in this case, treating patients with COVID-19); criterion C indicates that the disorder’s duration (symptoms of criterion B) should be from 3 days to 1 month after exposure to the event. Considering that the answers were obtained within this period, we believe that this criterion can be met. However, it is not possible to determine if criterion D was met, which tells us that the disturbance causes clinically significant discomfort or impairment in social, occupational, or other important areas of functioning since this factor was not explicitly examined. It is also not possible to determine whether criterion E was met. In this item, the disturbance cannot be attributed to a substance or other medical condition’s physiological effects and is not better explained by a brief psychotic disorder. This information could be completed by the follow-up of participants who met criterion B.

Due to the high risk of contagion, another limitation is that the information was obtained from a virtual questionnaire, so there could be various biases. In contrast, answering the virtual questionnaire was easier without exposing people to contagion.

Multiple factors could be related to the frequency of acute stress in these groups. Therefore, it is necessary to investigate the importance of risk and protective factors present in this population and explore other psychopathologies such as depression or substance abuse.

More than half of the health care workers at a tertiary level pediatric hospital experienced ASD during the COVID-19 National Safe Distance Strategy. There are different factors related to the type of work that health care workers perform, which can be associated with acute stress symptoms. Further research should be conducted on this population to develop strategies to reduce the risk of ASD within and outside the pandemic context.