960192

research-article2020
ISP0010.1177/0020764020960192International Journal of Social PsychiatryElkholy et al.

E CAMDEN SCHIZOPH

Original Article

International Journal of

Mental health of frontline Social Psychiatry

1­–10
© The Author(s) 2020
healthcare workers exposed to Article reuse guidelines:
sagepub.com/journals-permissions

COVID-19 in Egypt: A call for action DOI: 10.1177/0020764020960192

https://doi.org/10.1177/0020764020960192
journals.sagepub.com/home/isp

Hussien Elkholy1,2, Fairouz Tawfik1 , Islam Ibrahim1,

Waleed Salah El-din3, Mohamed Sabry4, Suzan Mohammed5,
Mohamed Hamza6, Mohamed Alaa7, Al Zahraa Fawzy8,
Rasha Ashmawy9, Maha Sayed1 and Abdel Nasser Omar1

Abstract
Background: World Health Organization (WHO) declared Coronavirus disease 2019 (COVID-19) as a pandemic in
March 2020. Such widespread outbreaks are associated with adverse mental health consequences.
Aims: To evaluate mental health outcomes among Egyptian healthcare workers (HCW) treating patients with confirmed
or suspected Coronavirus Disease 2019 (COVID-19) to direct the promotion of mental wellbeing, by screening for
symptoms of anxiety, insomnia, depression and stress, and analyzing potential risk factors.
Methods: This cross-sectional, hospital-based survey study collected demographic data and mental health measurements
from 502 HCW dealing with COVID-19. HCW were surveyed in 20 hospitals (Fever, Chest, and Quarantine hospitals)
in different parts of Egypt, in April and May 2020.
Results: Among the 502 HCW surveyed; 60.0% were physicians, 16.1% were specialized nurses, and 23.9% were non-
specialized nurses. About 35.3% worked in chest hospitals, 17.5% in fever hospitals, and 47.2% in quarantine hospitals.
A considerable proportion of HCW had symptoms of anxiety, insomnia, depression, and stress. Females were at higher
risk of experiencing symptoms of severe anxiety (odds ratio [OR], 1.85; 95% CI, 1.12–3.05; p = .016), severe depression
(OR, 2.013; 95% CI, 1.17–3.4; p = .011), and severe stress (OR, 2.68; 95% CI, 1.5–4.6; p < .001). Fever hospital workers
were at higher risk of severe depression (OR, 1.52; 95% CI, 1.11–2.09; p < .01), compared to Quarantine hospital
workers.
Conclusion: Ensuring proper mental health support for HCW is an important component of public health measures for
addressing the COVID-19 epidemic and safeguarding the continuity of appropriate medical service.

Keywords
COVID-19, mental health, depression, anxiety, insomnia, healthcare workers

Introduction 1
 epartment of Neurology and Psychiatry, Faculty of Medicine, Ain
D
Shams University, Cairo, Egypt
The World Health Organization (WHO) declared Corona- 2
Sussex Partnership Foundation Trust, Langley Green Hospital,
virus disease 2019 as (COVID-19) pandemic in March Crawley UK
3
2020, pointing to over 110 countries and territories around Department of Community and Occupational Medicine, Faculty of
the world where coronavirus disease was present. Medicine, Ain Shams University, Cairo, Egypt
4
Department of Chest, Faculty of Medicine, Alexandria University,
Infectious disease outbreaks such as COVID-19, as well as Alexandria, Egypt
other public health events, can cause emotional distress 5
Department of Chest, Abbasiya Chest Hospital, Cairo, Egypt
and anxiety. These feelings of distress and anxiety can 6
Department of Infection control, Esna Hospital, Aswan, Egypt
7
occur even in people that are not at high risk of getting sick Department of Chest, Faculty of Medicine, Helwan University, Cairo, Egypt
8
(Montemurro, 2020; Rajkumar, 2020; Rcpsych.ac.uk, Department of Clinical Pathology, Shebin Elkoom Fever Hospital,
Menofia, Egypt
2020; WHO, 2020a). 9
Clinical Pharmacy, Maamoura Chest Hospital, Alexandria, Egypt
As COVID-19 is rapidly spreading worldwide, on May
30, 2020, there have been 5,819,962 confirmed cases Corresponding author:
Fairouz Tawfik, Okasha Institute of Psychiatry, Department of
worldwide, with 362,786 deaths. Egypt reported 22,082 Neurology and Psychiatry, Faculty of Medicine, Ain Shams University,
confirmed cases and 879 deaths have been reported in Ramsis Street, Abbassia‘ Square, Cairo 11566, Egypt.
EGYPT on 30th of May 2020 (WHO, 2020b). Email: fairouztawfik@med.asu.edu.eg
2 International Journal of Social Psychiatry 00(0)
Besides the direct impact of the pandemic, previous
studies reported how much medical staffs suffer from
vicarious traumatization. In South and Southeast Asia
countries, also in Italy, there were psychological prob-
lems in medical staff due to high workload and intermit-
tent lack of protective devices (Kang et al., 2020;
Montemurro, 2020).
The modern history of infectious diseases has witnessed
emergence of serious ones. Outbreaks of new influenza
strains such as H1N1 (swine flu) that appeared in North
America in 2009, while a novel virus of avian origin
(H7N9) emerged four years later in China. Another exam-
ple is the largest outbreak of Ebola virus disease that was
in West Africa from 2013 to 2016, but the virus was first
discovered in 1976 after an outbreak in Central Africa.
Each of these past outbreaks raised similar problems for
health services and staff in terms of the psychological
impact of increased workload, the need for personal pro-
tection, and fears of possible infection of themselves and
their families (Kisely et al., 2020).
Hence, facing the critical situation of this growing pan-
demic, healthcare workers on the frontline 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 or proper treatment, and feelings of being inade-
quately supported may all contribute to the mental burden
of these healthcare workers (Lai et al., 2020).
On the other hand, most health professionals working
in quarantine units and hospitals very often do not receive
any training for providing mental healthcare (Lima et al.,
2020). Barbisch et al. (2015) described how the confine-
ment ‘caused a sense of collective hysteria, leading the
staff to desperate measures’. Suicidal cases were reported
in India (Goyal et al., 2020) but also in other countries,
Italy included, where two infected Italian nurses commit-
ted suicide in a period of a few days probably due to fear
of spreading COVID-19 to patients (Montemurro, 2020).
The situation in Egypt is becoming more critical with the
increasing number of cases and mortality with the possibil-
ity of higher actual numbers than the reported (Hassany
et al., 2020; Tuite et al., 2020). Moreover the governmen-
tal health expenditure in Egypt is only 5.3% of gross
domestic product (GDP), such limited resources combined
with the ever increasing number of cases place a huge bur-
den on healthcare workers (The world bank, 2020). The
Egyptian Ministry of Health announced on March 31 that
two hotlines are allocated at the General Secretariat for
Mental Health in order to provide psychological support to
citizens (including healthcare providers) during the
COVID-19 pandemic (Ahramonline, 2020).
The aim of current study is to evaluate mental health
outcomes among Egyptian healthcare workers treating
patients with confirmed or suspected COVID-19 to serve
as important evidence to direct the promotion of mental
wellbeing among healthcare workers, by screening for
symptoms of depression, anxiety, insomnia, and stress and
by analyzing potential risk factors associated with these
symptoms.
Methods
Study design
This study was registered at the Faculty of Medicine Ain
Shams Research Institute (MASRI) and approved by the
Research Ethics Committee of the Faculty of Medicine,
Ain Shams University (FMASU REC). Informed consent
was included in the survey explaining in details the study
design and aim prior to respondents’ enrollment.
Participants could terminate the survey at any time they
desired. The survey was anonymous, and confidentiality
of information was assured.
The study was a cross-sectional, hospital-based survey,
conducted in April and May 2020. At the time of the study,
the total confirmed cases of COVID-19 in Egypt exceeded
7,000 (WHO, 2020c).
Healthcare workers in 20 hospitals involved in direct
care of COVID-19 patients and suspected individuals in
either fever hospitals, chest hospitals and quarantine hos-
pitals were approached in this study.
Participants
Healthcare workers involved in direct care of COVID-19
patients and suspected individuals which included doctors,
nurses, and non-specialized nurses. ‘Nurses’ refer to those
who hold a bachelor’s degree (i.e. university graduates)
while ‘non-specialized nurses’ refer to those who are grad-
uated from technical nursing schools. Healthcare workers
with history of any psychiatric disorder were excluded.
The sample consisted of 30 to 50 healthcare workers from
each hospital. The target sample size of participants was
calculated using PASS program version 15, setting the
type-1 error (α) at 0.05 and margin of error 5%. Result
from previous study6 showed that 50.4% of healthcare
workers dealing with COVID-19 cases had psychological
co- morbidities (depression). Calculation according to
these values produced a sample size of 500 cases, taking in
account 20% dropout rate, and using the formula; N = Zα2P
(1 − P)/d2, in which α = 0.05 and Zα = 1.96, and d = 5%.
Sampling method
A multistage probability sample of clusters of hospitals in
geographically defined areas was prepared. In the first
stage, Egypt was divided geographically into four regions:
Delta region, Upper Egypt, Suez Canal region, and Greater
Cairo. In the second stage of the sampling plan, one or two
Elkholy et al. 3
hospitals (clusters) were randomly selected from each
selected governorate and all healthcare workers in each
hospital were invited to participate in the study.
Study tools
Sociodemographic data of the participants including age,
sex, educational level (doctorate degree, master’s degree,
bachelor’s degree or technical school degree), marital sta-
tus, and place of work were collected.
We focused on symptoms of depression, anxiety,
insomnia, and distress for all participants, using the fol-
lowing tools:
−− Patient Health Questionnaire (PHQ) (Spitzer et al.,
1999), Arabic version was used after permission of
the author (Sawaya et al., 2016). Scores of 0 to 4 are
considered normal, 5 to 9 indicate mild depression,
scores of 10 to 14 indicates moderate depression,
and scores of 15 to 21 indicates severe depression.
−− The 7-item Generalized Anxiety Disorder (GAD-7)
(Spitzer et al., 2006), Arabic version was used (with
authors’ permission) to identify patients with prob-
able GAD (Sawaya et al., 2016). The scale scores
range from 0 to 21; with scores of 0 to 4 considered
normal, scores of 5 to 9 indicate mild anxiety, scores
of 10 to 14 indicates moderate anxiety, and scores
of 15 to 21 indicate severe anxiety.
−− The 7-item Insomnia Severity Index (ISI) (Morin,
1993), Arabic version was used after permission of
the author (Suleiman & Yates, 2011). Scale scores
ranges from 0 to 28; with scores of 0 to 7 considered
normal, scores of 8 to 14 indicate subthreshold
insomnia, scores of 15 to 21 indicate moderate
insomnia while scores of 22 to 28 indicate severe
insomnia.
−− The Perceived Stress Scale (PSS) (Cohen et al.,
1983) is one of the most popular tools for measur-
ing psychological stress and evaluating the degree
to which individuals believe their life has been
unpredictable, uncontrollable, and overloaded dur-
ing the previous month. In our study we have used
the Arabic version after permission of the author
(Chaaya et al., 2010). The scale scores of 0 to 8
were considered normal, scores of 9 to 25 indicate
mild distress, scores of 26 to 43 indicate moderate
distress while scores of 44 to 88 indicate severe
distress.
Data management and analysis
Data were revised, coded, entered on a computer and ana-
lyzed using SPSS package version number 22. Quantitative
data were tested for normality with Shapiro-Wilk test and
described as mean, standard deviation (SD) or median/
interquartile range according to data distribution. Mann-
Whitney U test and Kruskal-Wallis test were used to com-
pare the severity of each symptom between two or more
groups. Qualitative data were expressed as frequencies (n)
and percentage (%). Chi-square test was used to test the
association between qualitative variables. Multivariate
logistic regression analysis was performed for detecting
risk factors for symptoms of Anxiety, insomnia, depres-
sion, and stress in participants, after adjustment for con-
founders, including age, sex, marital status, job, educational
level, type, and site of hospital. p-value ⩽.05 was consid-
ered significant.
Results
Descriptive data
Socio-demographic characteristics.  In the study, 502 health-
care workers were included; 301 (60.0%) were physicians,
81 (16.1%) were specialized nurses, 120 (23.9%) were
non-specialized nurses. One hundred seventy-seven
(35.3%) worked in chest hospitals, 88 (17.5%) worked in
fever hospital, and 237 (47.2%) worked quarantine hospi-
tals. Male to female ratio was 1:1. Sixty-nine participant
(13.7%) aged from 18 to 25, 163 (32.5%) from 26 to
30 years, 223 (44.4%) from 31 to 40 years, and 47 (9.45%)
were above 40 years old. As regards marital status; 184
(36.7%) were single, 301 (60%) were married, and 17
(3.4%) were divorced/widowed. Among physicians, 126
(41.9%) were working as chest specialists, 38 (12.6%)
were ICU specialists, 87 (28.9%) were internal medicine/
pediatric specialists, 40 (13.3%) were laboratory/radiol-
ogy specialists and 10 (3.3%) were surgery specialists.
According to the educational level, 163 (32.5%) had a
bachelor’s degree, 198 (39.4%) had master’s degree, 21
(4.2%) had doctorate degree, and 120 (23.9%) had techni-
cal institute degree. A 145 participants (28.9%) were dis-
tributed in Greater Cairo hospitals, 230 (45.8%) in Delta
areas, 94 (18.7%) in Upper Egypt, and 33 (6.6%) in Suez
Canal. All the 502 participants were frontline healthcare
workers directly engaged in diagnosing, treating, or caring
for patients with or suspected to have COVID-19.
The clinical characteristics of the study sample
The total number of participants was 502, however for
each of the tools the number of whom completed the tools
differed; GAD-7 questionnaire was answered by 484 par-
ticipants, ISI questionnaire by 473 participants, PHQ by
457, and PSS by 444 participants.
A considerable proportion of healthcare workers had
symptoms of anxiety as 370 of the participants (76.4%)
were showing abnormal scores on the GAD-7 scale; 175
(36.2%) were mild, 118 (24.4%) were moderate, and 77
(15.9%) were severe. According to the insomnia severity
scale 320 (67.7%) showed positive results; 195 (41.2%)
4 International Journal of Social Psychiatry 00(0)

Table 1.  Description and comparison of severity categories of depression, anxiety, insomnia, and stress measurements according
to age groups.

Age group p* Sig

  18–25 26–30 31–40 >40

  N % N % N % N %
GAD-7 Normal 17 25.8 38 24.1 45 21.1 14 29.8 .739 NS
Mild 27 40.9 55 34.8 79 37.1 14 29.8
Moderate 15 22.7 43 27.2 49 23.0 11 23.4
Severe 7 10.6 22 13.9 40 18.8 8 17.0
ISI None 22 33.8 44 28.9 70 33.2 17 37.8 .508 NS
Subthreshold 27 41.5 67 44.1 79 37.4 22 48.9
Moderate 11 16.9 33 21.7 52 24.6 5 11.1
Severe 5 7.7 8 5.3 10 4.7 1 2.2
PHQ No 26 41.3 25 17.2 41 20.0 12 27.3 .007 HS
Mild 16 25.4 48 33.1 76 37.1 20 45.5
Moderate 14 22.2 42 29.0 47 22.9 6 13.6
Severe 7 11.1 30 20.7 41 20.0 6 13.6
PSS Low 7 11.5 26 18.3 35 17.7 17 39.5 .003 HS
Moderate 47 77.0 84 59.2 131 66.2 22 51.2
High 7 11.5 32 22.5 32 16.2 4 9.3

Note. NS = non-significant; HS = highly significant; p = p-value; Sig = significance; GAD- 7 = 7-item generalized anxiety disorder; ISI = insomnia severity
index; PHQ = patient health questionnaire; PSS = perceived stress scale.
*Chi-square tests.

were sub-threshold, 101 (21.4%) were moderate and 24
(5.1%) were severe while, 353 (77.2%) had depressive
symptoms; 160 (35.0%) were mild, were 109 (23.9%)
moderate, and 84 (18.4%) were severe. As regard the per-
ceived stress scale; 359 (80.9%) showed abnormal results,
284 (64.0%) were showing moderate stress levels, and 75
(16.9%) were with high results.
Severity of measurements and associated
factors
Through the study non statistical significance was found on
comparing the site of the hospital, marital status, educa-
tional degree, specialty of the physicians, and the job cate-
gory of the study participants with the four questionnaires.
On the other hand, when comparing HCW according to
age groups as regard the four studied measurement; no sta-
tistically significance difference was found regarding
GAD 7 and ISI. However, a highly significant difference
was found as regard PHQ and PSS, as 41.3% of workers in
the youngest age group (18–25) had no depression com-
pared to only 17%, 20%, and 27% of workers in 26 to 30,
31 to 40, and >40 years groups, respectively. Nevertheless,
only 11.7% of workers in the youngest age group (18–25)
had low grade stress compared to 18.3%, 17.7%, and
39.5% of workers in 26 to 30, 31 to 40, and >40 years
groups, respectively (Table 1).
Moreover, on comparing sex groups regarding GAD7,
ISI, PHQ, and PSS; statistical significance difference was
found between males and females as regard GAD7, PHQ,
and PSS with higher proportions of females expressing
severe forms of anxiety, depression, and stress compared
to males (20% vs 11.9%, 25.1% vs 11.7%, and 22.8% vs
11.1%, respectively).
On comparing between HCW according to type of hos-
pital regarding our study measurements, no significant dif-
ference was found regarding ISI and PSS, while a statistical
significant difference was found between HCW in differ-
ent types of hospital as regard GAD7 and PHQ, as 29.7%
of quarantine hospitals HCW were normal in GAD7 com-
pared to 19.7% and 14.6% of chest and fever hospital
workers respectively. Similarly, 28.2% of quarantine hos-
pitals HCW had no depression using PHQ scale compared
to 19.0% and 15.4% of chest and fever hospital workers,
respectively (Table 2).
Associated Factors to different symptomatology
Participants in the age group of 26-30 years had signifi-
cantly higher scores in PHQ and PSS. Female participants
showed significantly higher scores in all 4 scales compared
with males. Fever hospital workers had significantly higher
scores in GAD, PHQ and PSS compared to other hospitals
workers. As regard occupation; physicians had significantly
higher scores in PHQ scale compared to nurses (specialized
and non-specialized) while no differences were detected in
other tools. Among physicians, Intensive care units (ICU)
doctors had significantly higher scores in GAD, PHQ and
Elkholy et al. 5

Table 2.  Description and comparison of severity categories of depression, anxiety, insomnia, and stress measurements according
to type of hospital of study participants.

Place of work p* Sig

  Chest Fever Quarantine

  N % N % N %
GAD7 Normal 34 19.7 12 14.6 68 29.7 .032 S
Mild 62 35.8 29 35.4 84 36.7
Moderate 44 25.4 24 29.3 50 21.8
Severe 33 19.1 17 20.7 27 11.8
Insomnia None 55 32.7 23 28.0 75 33.6 .62 NS
severity index Subthreshold 69 41.1 41 50.0 85 38.1
Moderate 36 21.4 13 15.9 52 23.3
Severe 8 4.8 5 6.1 11 4.9
PHQ No 31 19.0 12 15.4 61 28.2 .002 HS
Mild 58 35.6 28 35.9 74 34.3
Moderate 37 22.7 15 19.2 57 26.4
Severe 37 22.7 23 29.5 24 11.1
Perceived Low 24 15.1 13 16.9 48 23.1 .08 NS
stress scale Moderate 100 62.9 50 64.9 134 64.4
High 35 22.0 14 18.2 26 12.5

Note. N = number; NS = non-significant; HS = highly significant; p = p-value; Sig = significance. GAD- 7 = 7-item generalized anxiety disorder;
PHQ = patient health questionnaire.
*Chi-square tests.

PSS. Also, participants with bachelor’s degree had signifi-
cantly higher score in PHQ scale. (Table 3)
Risk factors of mental health outcomes
After adjustment of confounders using multivariable logis-
tic regression, it was shown that females were at higher
risk of experiencing symptoms of severe anxiety (odds
ratio [OR], 1.85; 95% CI, 1.12–3.05; p = .016), severe
depression (OR, 2.013; 95% CI, 1.17–3.4; p = .011), and
severe stress (OR, 2.68; 95% CI, 1.5–4.6; p < .001) com-
pared to males. Participants with age group (31–40) were
at higher risk of severe insomnia compared to those with
>40 years old participants (OR, 2.79; 95% CI, 1.02–7.66;
p = .01), Participants with age group (26–30) were at higher
risk of severe stress compared to those with >40 years old
(OR, 3.19; 95% CI, 1.05–9.7; p = .01). Fever hospital
workers were at higher risk of severe depression (OR,
1.52; 95% CI, 1.11–2.09; p < .01), compared to Quarantine
hospital workers (Table 4).
Discussion
To our knowledge this is one of the earliest studies to
address the issue of mental health of frontline healthcare
workers during COVID-19 in the middle east and Africa,
which may add value to the preexisting literature which
mostly was done in Asian countries (Lai et al., 2020;
Zhang et al., 2020a, 2020b).
The psychological response of healthcare workers to an
epidemic of infectious diseases is complex and might be
related to different factors. Sources of distress among
healthcare workers may include feelings of vulnerability or
loss of control and concerns about one’s health and possibil-
ity being, infection of colleagues, spread of virus to others,
health of family, and others especially children and old aged
group. Other work related factors to consider are employ-
ment uncertainty, financial worries, lack of getting rest,
exposure to critical life events such as death, and being iso-
lated for long periods. Moreover, Predictable shortages of
supplies and an increasing influx of suspected and actual
cases of COVID-19 contribute to the pressures and concerns
of healthcare workers (SINAnews, 2020; WHO, 2020d).
Furthermore, showing a high rate of transmission and
uncertainties about mode of transmission of COVID-19
adds to the worries of this group. It is commonly recog-
nized that droplet transmission is the main route. However,
COVID-19 was also found on the surfaces like doors, toi-
lets, personal items as cell phones, and etc. Thereby,
healthcare workers are extra vigilant about their behavior
and staying safe (e.g. not to touch their faces after contact-
ing with cases or their belongings) which also heightens
their anxiety levels (Han et al., 2020).
As there is also no available treatment, nor a definite
protective vaccine, it is expected that frontline workers
feel worried all the time. There is not even enough evi-
dence that those who survived the infection have devel-
oped immunity against the virus (WHO, 2020e). Moreover,
 6

Table 3.  Description and comparison of scores of depression, anxiety, insomnia, and stress measurements among participants’ subgroups.

GAD total p ISI total p PHQ total P PSS total p

  Med IQR Med IQR Med IQR Med IQR

Age group 18–25 7 4 11 .515* 10 6 14 .131* 6 3 12 .004* 19 16 23 .026*
26–30 8 5 12 12 7 15 9 6 13 20 16 26
31–40 8 5 13 10 6 15 9 6 13 19 15 25
>40 8 4 12 9 5 12 7 4 11 17 11 22
Sex Male 7 4 11 <.001** 9 5 14 .03** 7 4 11 <.001** 18 13 23 <.001**
Female 9 7 14 11 7 15 10 6 15 21 17 26
Marital status Unmarried 7 4 12 .15** 10 6 14 .68** 8 5 13 .84** 19.5 16 24 .30**
Married 8 5 13 10 6 15 8 5 13 19 15 24
Place of work Chest 8 6 13 .001* 10 6 15 .91* 9 6 14 .001* 20 16 25 .015*
Fever 10 6 14 10 7 14 9 7 15 21 17 25
Quarantine 7 4 11 10 6 15 8 4 11.5 19 14 23
Site of hospital Greater Cairo Greater Cairo 8 5 13 .051* 10 6 14 .219* 8 5 12 .201* 19 15 24 .65*
Delta Delta 9 6 13 11 6 15 9 6 14 20 16 25
Upper Egypt Upper Egypt 7 3 12 9 5 14 8 3 13 19 14 24
Suez Canal Suez Canal 7 5 9 9 7 15 8 5 10 19 16 21
Job Physician 8 5 13 .37* 11 6 15 .56* 9 6 13 .014* 20 15 25 .40*
Sp. Nurse 8 4 12 9 6 15 8 5 13 19 15 22
Non-sp. Nurse 7 5 12 10 6 14 7 4 11 19 16 23
Degree Institute 7 5 12 .63* 10 6 14 .77* 7 3 12 .02* 19 15 23 .81*
Bachelor 8 5 12 11 7 15 9 6 13 19 16 23.5
MSc 8 5 13 10 6 14 8 6 13 20 15 25
MD 9 4 12 9 6 14 8 5 11 19 14 22
Specialty Chest 9 6 14 .016* 11 6 15 .33* 9 7 14 .04* 20 15 25 .017*
ICU 10 6 14 13 9 17 10 7 15 23 19 27
Int med/ped 8 4 12 11 6 15 8 5 12 19 14 24
Lab/radio 8 5 12 9 6 14 9 5 15 18 13 25
Surgery 4 2 6 8 4 17 5 3 7 14 8 18

Note. p = p-value; Med = median; IQR = interquartile range; GAD-7 = 7-item generalized anxiety disorder; ISI: insomnia severity index; PHQ = patient health questionnaire; PSS = perceived stress scale;
Sp.Nurse = specialized nurse; Non-sp. Nurse = non- specialized nurse; MSc = master degree; MD = medical doctor degree; ICU = intensive care unit; Int med = internal medicine; ped = pediatrics;
Lab = laboratory; radio: radiology.
*Kruskal-Wallis test.
**Mann Whitney test.
International Journal of Social Psychiatry 00(0)
Elkholy et al. 7

Table 4.  Multivariable logistic regression analysis of risk factors for mental health outcomes among studied participants.

  No. of severe Adjusted OR p-value**

cases/no. of total (95% CI)*
cases (%) Category Overall

GAD 7, severe anxiety

Sex
 Male 29/244 (11.9%) 1 [Reference] NA .016
 Female 48/240 (20%) 1.85 (1.12–3.05) .016
Severe insomnia
Age group
  >40 5/45 (11.1%) 1 [Reference] NA .019
 18–25 7/56 (10.8%) 0.73 (0.2–2.63) .635
 26–30 29/152 (19.1%) 1.69 (0.59–4.8) .323
 31–40 49/211 (23.2%) 2.79 (1.02–7.66) .045
Severe depression
Sex
 Male 27/230 (11.7%) 1 [Reference] NA .011
 Female 57/227 (25.1%) 2.013 (1.17–3.4) .011
Type of hospital
 Quarantine 24/216 (11.1%) 1 [Reference] NA .011
 Chest 37/163 (22.7%) 1.78 (0.97–3.2) .059
 Fever 23/78 (29.5%) 2.7 (1.4–5.3) .003
High stress
Age group
  >40 4/43 (9.3%) 1 [Reference] NA .032
 18–25 7/61 (11.6%) 1.164 (0.3–4.3) .820
 26–30 32/142 (22.5%) 3.19 (1.05–9.7) .042
 31–40 32/198 (16.2%) 1.74 (0.57–5.2) .326
Sex
 Male 25/225 (11.1%) 1 [Reference] NA .0001
 Female 50/219 (22.8%) 2.68 (1.5–4.6) 0.001

Note. No = number; OR = odds ratio; CI = confidence interval; GAD 7 = 7-item generalized anxiety disorder; NA = not applicable.
*Adjusted for Age, sex, marital status, job, educational level, type and site of hospital.
**Category refers to the p value for each category vs the reference, while overall refers to the results of the logistic regression.

there is no consensus on the best management of infected
individuals and limited numbers of Intensive Care beds,
which healthcare workers are aware of and understand the
grievousness of the situation.
Unfortunately, the media impact has not been very help-
ful, especially social media. Spreading of faulty information
and sharing unconfirmed data about the numbers of cases
played a role in increasing the mass concerns, even among
professionals. Sometimes, governments’ messages were so
clear and intimidating to urge people to follow the guidance,
which also triggered panic among different categories
including healthcare workers. Important aspect needed to be
highlighted is the role of social media and technology in
such issue, WHO has identified that the ‘COVID-19 out-
break and response have been accompanied by a massive
“infodemic” – an over-abundance of information – some
accurate and some not – that makes it hard for people to find
trustworthy sources and reliable guidance’ (WHO, 2020f),
studies indicated social media exposure during pandemics
may be associated with higher risk of mental health issues.
A recent Chinese study showed that a higher prevalence of
mental health problems mainly anxiety and depression was
positively associated with frequently social media exposure
during the COVID-19 outbreak.(Gao et al., 2020), which
was also reported previously in a study which showed that
social media exposure may positively related to forming
risk perceptions during the Middle East respiratory syn-
drome (MERS) outbreak in South Korea (Choi et al., 2017).
Moreover, many healthcare workers used social media to
share their own experiences, complaints about lack of pro-
tective equipment and obituaries of their lost colleagues and
families (Glenza, 2020).
This cross-sectional survey enrolled 502 participants
and revealed a high prevalence of mental health symptoms
among healthcare workers treating patients with COVID-
19 in Egypt. Overall, 77.3%, 69.5%, 79.3%, and 83.1% of
all participants reported symptoms of, anxiety, Insomnia,
depression, and stress, respectively. These results are higher
than ones reported in different studies by Lai et al.s’ (2020)
study, Zhang et al. (2020a), and Zhang et al. (2020b), which
8 International Journal of Social Psychiatry 00(0)
may reflect the difficult situation facing Egyptian frontline
healthcare workers. It could be related to limited number of
Egyptian physicians and nurses as reported by the world
bank to be 0.5 per 1,000 person for doctors and 1.9 per
1,000 for nurses, which is lower than most of European and
Asian countries including china. Adding to that the pres-
ence of low number of hospital beds available (1.6 per
1,000 people) (The world bank, 2020). Placing a huge
responsibility on physicians to choose the appropriate cases
who which will be most benefited from admission.
This study also supports the existing literature that has
examined mental health of healthcare workers during pre-
vious outbreaks such as H1N1 influenza and Severe Acute
Respiratory Syndrome (SARS) (Lee et al., 2018). For
example, during the SARS outbreak in 2003, 18% to 57%
of health professionals experienced serious emotional
problems and psychiatric symptoms during and after the
event in one study conducted by Lee et al. (2018). Another
study conducted by Chua et al. (2004) showed that 89% of
healthcare workers who were in high-risk situations
reported psychological symptoms during the acute SARS
outbreak.
On the other hand, females was associated with higher
risk of experiencing severe depression, anxiety, insomnia
and stress which may be due to the already reported gender
difference for anxious and depressive symptoms (Albert,
2015). This finding is consistent with previous studies as
Lai et al.s’ (2020) study and Zhang et al. (2020a, 2020b).
On contrary to Lai et al.s’ (2020) study in which nurses
reported more severe symptoms on all measurements, this
study found that physicians and higher rates educational
levels were more prone to depression, this could be related
to the higher number of nurses participation when compared
with physicians in their study and being females as well.
Ages from 26 to 30 were at higher rates of experiencing
insomnia and severe depression. A possible explanation is
those age groups usually occupy the junior to intermediate
level jobs which require longer working hours and more
duties. Our findings are consistent with Lai et al.s’ (2020)
study which shows that junior positions are associated
with greater risk of psychological problems.
Turning to the ICU workers, they showed higher scores
on GAD-7, PHQ, and PSS which could be related to their
close, frequent contact with patients. This is consistent
with Embriaco et al. (2012) findings that showed that one
of every four French ICU workers had symptoms of
depression.
A comparison between three different types of hospi-
tals which form the main bulk of hospitals involved in
diagnosis and management of COVID-19 patients was
done. Fever and Chest hospitals are responsible for diag-
nosis while Quarantine hospitals responsible for treatment
of confirmed cases. This study reported that working in
Fever hospitals was associated with higher rates of severe
depression than Quarantine hospitals. This may be due to
the stress of the triaging and facing higher numbers of
patients in emergency rooms than in Quarantine hospitals.
Also, the uncertainty surrounding the diagnosis of each
examined patient compared to Quarantine hospitals which
receive referrals for isolation of confirmed cases without
direct contact with suspected cases from general popula-
tion may also play a role.
Limitations
The cross-sectional nature for this study does not allow
follow up of either progression of the symptomatology or
improvement of healthcare providers. Also, it might be
expected that the pandemic situation may have long term
outcome that will only appear in later stages which this
study design cannot detect. The lack of baseline statistics
of the abovementioned symptomatology prior to the pan-
demic situation may raise the debate of how to assess the
exact impact of the situation. Moreover, the survey nature
of the study allows for respondents’ bias.
Strengths
One of the few studies providing a missing aspect, a new
approach to support healthcare workers in Egypt and form
future plans for the health care sector.
Conclusion
Physicians, female gender and working in Fever hospitals
dealing with suspected patients with COVID-19, were
associated with high rates of symptoms of depression, anx-
iety, insomnia, and distress. Protecting healthcare workers
is an important component of public health measures for
addressing the COVID-19 epidemic. Special interventions
need to be immediately implemented, to promote mental
well-being in healthcare workers exposed to COVID-19
and to mitigate the effects of the pandemic on their current
mental health.
This may include enhancing awareness to the early
symptoms of depression, anxiety, and stress. Individual
coping strategies, such as acceptance, behavioral activa-
tion, and mindfulness, are effective during crises; fostering
resilience and recovery by increasing tolerance to distress,
enhancing feelings of connectedness and encouraging
actions that are goal-directed and value-driven. Adding on
to peer-support programs that could help the HCW in
changing their psychological reactions toward the stressful
situations that they are facing (Polizzi et al., 2020).
Acknowledgement
The authors would like to thank all healthcare workers that took
time to fill in the survey and helped.
Elkholy et al. 9
Author contributions
H.E.: conceptualized the study, drafted the first version, revised it
critically for important intellectual content, and approved the ver-
sion to be published. F.T.: conceptualized the study, drafted the
first version, revised it critically for important intellectual content,
and approved the version to be published. I.I.: conceptualized the
study, collected the data, drafted the first version, revised it criti-
cally for important intellectual content, and approved the version
to be published. W.S. E.: conceptualized the study, analyzed the
data, drafted the first version, revised it critically for important
intellectual content, and approved the version to be published.
M.S.: collected the data, revised it critically for important intel-
lectual content, and approved the version to be published. S.M.:
collected the data, revised it critically for important intellectual
content, and approved the version to be published. M.H.: col-
lected the data, revised it critically for important intellectual con-
tent, and approved the version to be published. M.A.: collected the
data, revised it critically for important intellectual content, and
approved the version to be published. A.Z.F.: collected the data,
revised it critically for important intellectual content, and
approved the version to be published. R.A.: collected the data,
revised it critically for important intellectual content, and
approved the version to be published. M.S.: conceptualized the
study, Methodology, Supervision, Writing – Review & Editing,
revised it critically for important intellectual content, and
approved the version to be published. A.N.O.: conceptualized the
study, Methodology, Supervision, Writing – Review & Editing,
revised it critically for important intellectual content and approved
the version to be published. All authors reviewed, provided criti-
cal feedback, helped in shaping the research, and approved the
final version.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Fairouz Tawfik https://orcid.org/0000-0003-0210-0147
References
Ahramonline. (2020). Egypt sets up hotlines for psychological
support during coronavirus shutdown - Politics - Egypt
[Internet]. Retrieved June 2, 2020, from http://english.
ahram.org.eg/NewsContent/1/64/366341/Egypt/Politics-/
Egypt-sets-up-hotlines-for-psychological-support-d.aspx
Albert, P.R. (2015). Why is depression more prevalent in
women? Journal of Psychiatry & Neuroscience, 40(4),
219–221. https://doi.org/10.1503/jpn.150205
Barbisch, D., Koenig, K. L., & Shih, F. Y. (2015). Is there a case
for quarantine? Perspectives from SARS to Ebola. Disaster
Medicine and Public Health Preparedness, 9(5), 547–553.
https://doi.org/10.1017/dmp.2015.38.
Chaaya, M., Osman, H., Naassan, G., & Mahfoud, Z. (2010).
Validation of the Arabic version of the Cohen Perceived Stress
Scale (PSS-10) among pregnant and postpartum women.
BMC Psychiatry, 10, 111. https://doi.org/10.1186/1471-
244X-10-111
Choi, D-H., Yoo, W., Noh, G-Y., & Park, K. (2017). The impact
of social media on risk perceptions during the MERS out-
break in South Korea. Computers in Human Behavior, 72,
422–431.
Chua, S. E., Cheung, V., Cheung, C., McAlonan, G. M., Wong,
J. W. S., Cheung, E. P. T., Chan, M. T. Y., Wong, M. M.
C., Tang, S. W., Choy, K. M., Wong, M. K., Chu, C. M., &
Tsang, K. W. T. (2004). Psychological effects of the SARS
outbreak in Hong Kong on high-risk health care work-
ers. The Canadian Journal of Psychiatry, 49(6), 391-393.
https://doi.org/10.1177/070674370404900609
Cohen, S., Kamarch, T., & Mermelstein, R. (1983). A global
measure of perceived stress. Journal of Health and Social
Behavior, 24(4), 385-396. https://doi.org/10.2307/2136404
Embriaco, N., Hraiech, S., Azoulay, E., Baumstarck-Barrau,
K., Forel, J-M., Kentish-Barnes, N., Pochard, F., Loundou,
A., Roch, A., & Papazian, L. (2012). Symptoms of depres-
sion in ICU physicians. Annals of Intensive Care, 2(1), 34.
https://doi.org/10.1186/2110-5820-2-34
Gao, J., Zheng, P, Jia, Y., Chen, H., Mao, Y., Chen, S., Wang, Y.,
Fu, H., & Dai, J. (2020). Mental health problems and social
media exposure during COVID-19 outbreak. PLoS One, 15(4),
e0231924. https://doi.org/10.1371/journal.pone.0231924
Glenza, J. (2020). Medical staff beg for masks on social media
amid coronavirus crisis. [online] The Guardian. Retrieved
August 23, 2020, from https://www.theguardian.com/
world/2020/mar/24/coronavrirus-medical-staff-beg-for-
masks-social-media
Goyal, K., Chauhan, P., Chhikara, K., Gupta, P., & Singh, M.
P. (2020). Fear of COVID 2019: First suicidal case in
India! Asian Journal of Psychiatry, 49, 101989. https://doi.
org/10.1016/j.ajp.2020.101989
Han, Q., Lin, Q., Ni, Z., & You, L. (2020) Uncertainties about the
transmission routes of 2019 novel coronavirus. Influenza
and Other Respiratory Viruses, 14(4), 470–471. https://doi.
org/10.1111/irv.12735
Hassany, M., Abdel-Razek, W., Asem, N., AbdAllah, M., &
Zaid, H. (2020). Estimation of COVID-19 burden in Egypt.
The Lancet Infectious Diseases, 20(8), 896–897 https://doi.
org/10.1016/S1473-3099(20)30319-4
Kang, L., Li, Y., Hu, S., Chen, M., Yang, C., Yang, B. X., Wang,
Y., Hu, J., Lai, J., Ma, X., Chen, J., Guan, L., Wang, G., Ma,
H., & Liu, Z. (2020). The mental health of medical workers
in Wuhan, China dealing with the 2019 novel coronavirus.
The Lancet Psychiatry, 7(3), e14. https://doi.org/10.1016/
S2215-0366(20)30047-X
Kisely, S., Warren, N., McMahon, L., Dalais, C., Henry, I., &
Siskind, D. (2020). Occurrence, prevention, and management
of the psychological effects of emerging virus outbreaks on
healthcare workers: Rapid review and meta-analysis. BMJ,
369, m1642. https://doi.org/10.1136/bmj.m1642
Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., Wu, J., Du,
H., Chen, T., Li, R., Tan, H., Kang, L., Yao, L., Huang,
M., Wang, H., Wang, G., Liu, Z., & Hu, S. (2020). Factors
associated with mental health outcomes among health
careworkers exposed to coronavirus disease 2019. JAMA
Network Open, 3(3), e203976. https://doi.org/10.1001/
jamanetworkopen.3976
Lee, S. M., Kang, W.S., Cho, A. R., Kim, T., & Park, J. K.
(2018). Psychological impact of the 2015 MERS outbreak
10 International Journal of Social Psychiatry 00(0)
on hospital workers and quarantined hemodialysis patients.
Comprehensive Psychiatry, 87, 123-127. https://doi.org/10.
1016/j.comppsych.2018.10.003
Lima, C. K. T., Carvalho, P. M. M., Lima, I. A. A. S., Nunes, J. V.
A. O., Saraiva, J. S., de Souza, R. I., da Silva, C. G. L., & Neto,
M. L. R. (2020). The emotional impact of Coronavirus 2019-
nCoV (new Coronavirus disease). Psychiatry Research, 287,
112915. https://doi.org/10.1016/j.psychres.2020.112915
Montemurro, N. (2020).The emotional impact of COVID-19: From
medical staff to common people. Brain Behavior and Immunity,
87, 23–24. https://doi.org/10.1016/j.bbi.2020.03.032
Morin, C. M. (1993). Insomnia: Psychological assessment and
management. Guilford Press.
Polizzi, C., Lynn, S. J., & Perry, A. (2020). Stress and coping in
the time of COVID-19: Pathways to resilience and recovery.
Clinical Neuropsychiatry, 17(2), 59–62.
Rajkumar, R. P. (2020). COVID-19 and mental health: A review
of the existing literature. Asian Journal of Psychiatry, 52,
102066. https://doi.org/10.1016/j.ajp.2020.102066
Rcpsych.ac.uk. [Internet]. (2020). Retrieved June 2, 2020, from
https://www.rcpsych.ac.uk/docs/default-source/about-us/
covid-19/the-roles-and-work-of-psychiatrists-during-the-
pandemic-statement.pdf?sfvrsn=211f6941_2
Sawaya, H., Atoui, M., Hamadeh, A., Zeinoun, P., & Nahas, Z.
(2016). Adaptation and initial validation of the patient health
questionnaire - 9 (PHQ-9) and the generalized anxiety disor-
der - 7 questionnaire (GAD-7) in an arabic speaking lebanese
psychiatric outpatient sample. Psychiatry Research, 239,
245–252. https://doi.org/10.1016/j.psychres.2016.03.030
SINAnews [Internet]. (2020). Beijing: In January, Hubei had
more than 3,000 medical infections, and the Wuhan Health
and Medical Committee reported ‘None’ for half a month.
Retrieved March 6, 2020, from https://news.sina.com.
cn/o/2020-03-06/dociimxyqvz8395569.shtml. Chinese
Spitzer, R. L., Kroenke, K., & Williams, J. B. (1999). Validation and
utility of a self-report version of PRIME-MD: The PHQ pri-
mary care study. Primary care evaluation of mental disorders.
Patient Health Questionnaire JAMA, 282(18), 1737–1744.
https://doi.org/10.1001/jama.282.18.1737.PMID:10568646
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B.
(2006). A brief measure for assessing generalized anxiety
disorder. Archieves of Internal Medicine, 166(10), 1092–
1097. https://doi.org/10.1001/archinte.166.10.1092
Suleiman, K. H., & Yates, B. C. (2011). Translating the
insomnia severity index into Arabic. Journal of Nursing
Scholarship, 43(1), 49–53. https://doi.org/10.1111/j.1547-
5069.2010.01374.x
The World Bank. Open Data | Data [Internet]. Data.worldbank.
org. (2020). Retrieved June 4, 2020, from https://data.
worldbank.org/
Tuite, A. R., Ng, V., Rees, E., Fisman, D., Wilder-Smith,
A., Khan, K., & Bogoch, I. I. (2020). Estimation of the
COVID-19 burden in Egypt through exported case detec-
tion. The Lancet Infectious Diseases, 20(8), 894. https://doi.
org/10.1016/S1473-3099(20)30233-4
World Health Organization [Internet]. (2020a). WHO charac-
terizes COVID-19 as a pandemic. Retrieved March 11,
2020, from https://www.who.int/emergencies/diseases/
novel-coronavirus-2019/events-as-they-happen
World Health Organization [Internet]. (2020b). Coronavirus
disease 2019 (COVID-19) situation report 131. World
Health Organization. Retrived May 30, 2020, from
https://www.who.int/docs/default-source/coronavi-
ruse/situation-reports/20200530-covid-19-sitrep-131.
pdf?sfvrsn=d31ba4b3_2
World Health Organization [Internet]. (2020c). Coronavirus
disease 2019 (COVID-19) situation report 107. World
Health Organization. Retrived May 30, 2020, from
https://www.who.int/docs/default-source/coronavi-
ruse/situation-reports/20200506covid-19-sitrep-107.
pdf?sfvrsn=159c3dc_2
World Health Organization [Internet]. (2020d). Geneva:
Shortage of personal protective equipment endangering
health workers worldwide. Retrieved March 3, 2020, from
https://www.who.int/news-room/detail/03-03-2020-short-
age-of-personal-protectiveequipment-endangering-health-
workersworldwide
World Health Organization [Internet]. (2020e). ‘Immunity pass-
ports’ in the context of COVID-19. Retrieved August 21,
2020, from https://www.who.int/news-room/commentaries/
detail/immunity-passports-in-the-context-of-covid-19
World Health Organization. (2020f). Novel coronavirus (2019-
nCoV): Situation report-13. Retrieved March 16, 2020,
from https://www.who.int/docs/default-source/coronavi-
ruse/situation-reports/20200202-sitrep-13-ncov-v3.pdf
Zhang, W-R., Wang, K., Yin, L., Zhao, W-F., Xue, Q., Peng,
M., Min, B-Q., Tian, Q., Leng, H-X., Du, J-L., Chang, H.,
Yang, Y., Li, W., Shangguan, F-F., Yan, T-Y., Dong, H-Q.,
Han, Y., Wang, Y-P., Cosci, F., & Wang, H-X. (2020a).
Mental health and psychosocial problems of medical
health workers during the COVID-19 epidemic in China.
Psychotherapy and Psychosomatics, 89(4), 242–250.
https://doi.org/10.1159/000507639
Zhang, C., Yang, L., Liu, S., Ma, S., Wang, Y., Cai, Z., Du, H.,
Li, R., Kang, L., Su, M., Zhang, J., Liu, Z., & Zhang, B.
(2020b). Survey of insomnia and related social psychologi-
cal factors among medical staff involved in the 2019 novel
coronavirus disease outbreak. Frontiers in Psychiatry,
11, 306. Published 2020 Apr. 14. https://doi.org/10.3389/
fpsyt.2020.00306