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The Lancet Psychiatry
Psychological effects of COVID-19 on hospital staff: a national cross-sectional survey of China mainland --Manuscript Draft--
Manuscript Number: thelancetpsych-D-20-00288
Article Type: Article (Original Research)
Keywords: COVID-19, medical staff, anxiety, depression, infectious disease outbreak, China
Corresponding Author: Yongquan Gu, M.D. Xuanwu Hospital Beijing, CHINA
First Author: Jianming Guo, M.D.
Order of Authors: Jianming Guo, M.D.
Lianming Liao, PhD
Baoguo Wang, M.D.
Xiaoqiang Li, M.D.
Lianrui Guo, M.D.
Zhu Tong, M.D.
Qinghua Guan, M.D.
Mingyue Zhou, M.D.
Yingfeng Wu, M.D.
Jian Zhang, M.D.
Yongquan Gu, M.D.
Manuscript Region of Origin: CHINA
Abstract: Objective
This study was aimed to examine the psychological impact of the COVID-2019 outbreak on medical staff in China.
Methods
In February 2020, an online survey was carried out by using a WeChat online survey tool to evaluate the effects of the outbreak on the mental health of medical staff around China.
Results
A total of 11118 medical staff responded the survey. About 4·98% of the respondents reported middle and high levels of anxiety while 13·47% of the respondents reported middle and high levels of depression since the COVID-19 outbreak. Nurses, frontline medical staff and younger medical staff were more likely to have anxiety and depression than physicians, non- frontline medical staff and older medical staff respectively.
Conclusions
Although serious psychological impact of COVID-19 is not so common in the medical staff in China, programs are needed to protect them against the negative impacts of COVID-19.
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Manuscript
Click here to access/download Necessary Additional Data
Cover Letter.doc
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Psychological effects of COVID-19 on hospital staff: a national cross-sectional survey
of China mainland
Jianming Guo M.D.1# Lianming Liao PhD,2# Baoguo Wang M.D.3 Xiaoqiang Li
M.D.4 Lianrui Guo M.D.1 Zhu Tong M.D.1 Qinghua Guan M.D.1 Mingyue Zhou
M.D.3 Yingfeng Wu M.D.1 Jian Zhang M.D.1 Yongquan Gu M.D.1*
1. Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University,
Beijing 100053, China.
2. Center of Laboratory Medicine, Union Hospital of Fujian Medical University,
Fuzhou, Fujian 350001, China.
3. Department of neurosurgery, Sanbo Brain Hospital, Capital Medical University,
Beijing 100093, China.
4. Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated
Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China.
*Correspondence: Dr. Yongquan Gu, Department of Vascular Surgery, Xuanwu
Hospital, China; Capital Medical University, Institute of Vascular Surgery, Capital
Medical University, Beijing, China.
E-mail: [email protected] Telephone: 15901598209
#Contributed equally
Manuscript
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Abstract
Objective
This study was aimed to examine the psychological impact of the COVID-2019
outbreak on medical staff in China.
Methods
In February 2020, an online survey was carried out by using a WeChat online survey
tool to evaluate the effects of the outbreak on the mental health of medical staff
around China.
Results
A total of 11118 medical staff responded the survey. About 4·98% of the respondents
reported middle and high levels of anxiety while 13·47% of the respondents reported
middle and high levels of depression since the COVID-19 outbreak. Nurses, frontline
medical staff and younger medical staff were more likely to have anxiety and
depression than physicians, non- frontline medical staff and older medical staff
respectively.
Conclusions
Although serious psychological impact of COVID-19 is not so common in the
medical staff in China, programs are needed to protect them against the negative
impacts of COVID-19.
Keywords: COVID-19, medical staff, anxiety, depression, infectious disease outbreak,
China
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Introduction
During the past two decades the world has experienced outbreaks of several
highly infectious diseases. The psychosocial impacts of the highly infectious diseases
on medical staff have been well documented.1-4
The Coronavirus Disease 2019 (COVID-19) epidemic, which rapidly spread from
Wuhan City, Hubei province to other places in China and even other countries, and
resulted in final PHEIC (Public Health Emergency of International Concern)
declaration, had caused considerable panic and anxiety around China and posed a
great threat to the health and even life of the people all over the world. Despite due
protection, health care workers had been reported to have a higher rate of infection.
Research published in early February found that of 138 patients treated at one hospital,
29% were healthcare workers. In one case, a patient admitted to a hospital in Wuhan
infected at least 10 medical workers and four other patients.5 According to Liang
Wannian, an official from the China National Health Commission, more than 3,000
frontline workers in China has tested positive for Covid-19 as of Monday (24 Feb).
From the start of COVID-19, the easy access to internet with mobile phones in China
has given rise to the so called infodemic, meaning that fake news spreads faster and
more easily than the virus.6 The level of perceived disaster-related risk will be
influenced by a person’s level of awareness and knowledge related to the disaster. Due
to its initially very high levels of unfamiliarity and uncontrollability, and the
memories of SARS’s high level of contagiousness, relatively high mortality rate and
high infection rate in medical workers (i.e., around 20% of people who got SARS
were medical workers) are still provoking anxiety and depression among medical staff,
the mental health impact of the COVID-19 outbreak was expected to be relatively
high. Shortage of supplies and medical staff as the tide of patients rose in Hubei
province and the fact that more and more batches of medical aid teams have been sent
to the epicenter of the COVID-19 infection could also have increased medical
workers’ likelihood for developing psychological stress around China. Given the
possibility of a long-time pandemic, more research is needed to understand the
psychological impacts of COVID-19 outbreak on the medical staff. To address this
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gap of knowledge, we explored levels of stress symptoms among medical workers
around China by taking advantage of the online survey tool, which can be finished in
a short time. We hoped that our findings would strengthen preparations for potential
medical aid team members and those working in high-risk locations, such as hospitals
with COVID-19 patients or for future COVID-19 patients, fever clinics, and
departments of infectious disease, emergency, pulmonary disease and computed
tomography.
Materials and methods
Online survey design
This cross-sectional survey was open to all medical staff in China mainland area.
Ethical approval was obtained from the institutional review board of the Xuanwu
Hospital Capital Medical University. Participates were invited to complete an online
psychological questionnaire through a WeChat online survey tool, which can send
online invitations through social media. The online tool contained a ‘Begin survey’
link that, if clicked, would open the online questionnaire in the respondent’s WeChat
app. At the top of the questionnaire there were words that clearly indicated that only
physician, nurse, healthcare administrators, healthcare support staff and medical
students were invited for the survey. By clicking the ‘Begin survey’ link, the
respondent indicated his/her consent to participate in the study and the informed
consent was electronically recorded. The participants’ identities were kept
confidential.
Demographic profile
Participants were required to fulfill the online questionnaire for their
demographic data (age, gender, place of residence, occupation, income, marital
status and education background) and psychological status.
Measures
For psychological distress evaluation, the internationally recognized self-rating
anxiety scale (SAS) and Self-Rating Depression Scale (SDS) were used.7,8
The SAS scale consists of 20 questions that assess how respondents feel during
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the previous week. Each question has a score of 1–4. Higher scores indicate higher
levels of anxiety. A SAS score of 50-59 points, 60-69 points, and 70 or more
indicates mild anxiety, moderate anxiety, and severe anxiety respectively.
The SDS scale is a 20-item self-report questionnaire that covers affective,
psychological and somatic symptoms associated with depression. Each item has a
score from 1 to 4. The total score ranges from 20 to 80. Higher scores indicate higher
levels of depression: 50-59 for mild depression, 60-69 for moderate depression, and
70 or more for severe depression.
Data collection and statistical methods
Responses were downloaded from the online survey tool as a spreadsheet and
anonymized. Given the exploratory nature of the study, the statistical analysis was
largely descriptive. Data were processed by SPSS (20.0) software package. SAS and
SDS score were expressed as mean and standard deviation. Mann-Whitney U test was
used to compare the difference in SDS and SDS scores between the groups.
Comparison of continuous variables was performed using t-test for
independent-samples. For the data that did not conform to the normal distribution,
rank sum test was performed. P-values <0·05 were considered statistically significant.
Results
Demographic profile
The survey started from February 18th 19:26 and finished at February 20th 19:26.
The respondents’ demographic profile is presented in Table 1. Altogether, 11,118
health care workers completed the survey. Among them, 2802 (25·2%) were male and
3245 (29·19%) were aged 40 years or older. There were 7,940 (71·42%) participants
who had married. Almost all of them (96·37%) had a bachelor's degree or above.
There were respondents from all provinces and metropolis of China mainland (Table
2), and the top five regions were Jiangsu (3874, 34·84%), Hebei (945, 8·50%), Henan
(853, 6·95%), Beijing (730, 6·57%) and Heilongjiang (647, 5·82%).
Among them, 3351 (30·14%) were physicians, 5,900 (53·07%) were nurses, 757
(6·81%) were medical students, 464 (4·17%) were clinical medical assistants, and 450
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(4·05%) were clinical administration staff. There were 3,351 (30·14%) first-line
medical workers who were directly involved in the care for patients infected with
COVID-19 (Table 1).
Presentation of psychological stress
Among all of the participants, 6348 (57·10%) reported they often felt anxious or
panic, and 1541 (13·86%) reported they had never experienced anxiety. About
three-quarters of them (6932, 65·48%) thought they had no suitable methods to solve
their psychological stress and had to endure or addressed them by themselves. Most of
the participants (9,274, 83·41%) thought that psychological interventions were
necessary. Over one-half of the participants (6711, 60·36%) believed that
psychological interventions should be available to medical staff soon after the
outbreak to alleviate psychological stress (Table 3).
About 4·98% and 13·47% of the medical staff reported they had high levels of
anxiety symptoms (that is, a SAS score of 60 or more) and depression symptoms
respectively (that is, a SDS score of 60 or more) following the outbreak of COVID-19
(Table 4).We compared stress between frontline medical staff and non-frontline
medical staff (Table 5). The median SDS score for the first-line medical staff was 44,
while that for the non-first-line medical staff was 41. The SDS scores of the first-line
medical staff were significantly higher than those of the non-first-line medical staff
(U=1·200E7, Z=-6·539, P<0·0005). The median SAS score of the first-line medical
staff was 41, and that of the non-first-line medical staff was 39. The SAS scores of the
first-line medical staff were significantly higher than those of the non-first-line
medical staff (U=1·131E7, Z=-10·988, P<0·0005).
We then compared the SDS scores between physicians and nurses (Table 6). The
median SDS score of the physicians was 41, and that of the nurses was 43. The nurses
had significantly higher SDS scores that the physicians did (U=9111898·5, Z=-6·631,
P<0·0005). The median SAS score of the physicians was 39, and that of the nurses
was 40. Again, the nurses had significantly higher SAS scores than the physicians did
(U=9165186, Z=-6·204, P<0·0005).
Finally, we compared SDS score and SAS score between participants aged 40
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years and under and those over 40 years of age (Table 7). The median SDS score in
the staff aged 40 years and under was 43, and that of the staff over 40 years was 40.
The former had significant higher SDS scores than the later (U=1·184E7, Z=-6·050,
P<0·0005). Similar trend was observed for the SAS scale.
Discussion
In the present report we present our most recent online survey on the
psychological impact of the COVID-19 outbreak on the hospital staff in China around
the peak of the epidemic. Among all of the participants, 6348 (57·10%) reported they
often felt anxious or panic, and 1541 (13·86%) reported they had never experienced
anxiety. About 4·98% of the respondents reported middle and high levels of anxiety
while 13·47% of the respondents reported middle and high levels of depression.
Improving our understanding of medical staff’s stress and the factors associated with
those stress should be helpful.
The level of perceived disaster-related risk will be influenced by a person’s level
of awareness and knowledge related to the disaster. Programs aimed at raising such
knowledge and awareness influence peoples’ perceptions, and may help a society to
become better prepared, and be more in control of a disaster situation; however, such
programs are unavailable at the outbreak of COVID-19. More efforts are needed to
quickly establish such program as knowledge on the virus increase to alleviate their
anxiety and improve their general mental health.
There are several notable findings in the present survey. First, we found that more
than one-half of participants (57·10%) reported they often felt anxious or panic even
they are presently not dealing with COVID-19 patients. We think the underlying
reason may be due to the fact that all of the medical staff in China is ready to
participate the medical aid teams for Hubei province under the leadership of the
central government. Although the National Health Commission of China released the
notification of basic principles for emergency psychological crisis interventions for
the 2019-nCoV pneumonia on Jan 26, 20209, this notification only emphasizes that
mental health care should be provided for medical workers caring for infected patients
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and does to mention any suggestions for the mental health problems of the
non-frontline medical workers, which are also have high-level stress as indicated by
our survey. A study of the early experience of a university teaching hospital in
responding to the psychological and occupational impact of the SARS outbreak upon
hospital workers indicated they were adversely affected by fear of contagion and of
infecting family, friends and colleagues immediately after outbreak.10 According to
our survey, the psychological impact may appear in the medical staff before
experience of caring infected patients.
Secondly, we found that nurses have higher levels of stress compared to
physicians. This may be due to the facts that nurses are relatively young and mostly
female. A study of a hospital outbreak of vancomycin-resistant enterococci (VRE)
describes a severe burden on nursing staff.11 In addition, nurses are responsible for the
collection of sputum for virus detection, which is the most dangerous work. Secondly,
younger staff has higher levels of stress compared to older staff. The most recent
outbreak of highly infectious disease in China was SARS, which occurred in
mid-November 2002 in Guangdong Province and killed 349 patients in mainland
China by the end of the epidemic. As 18 years had passed since the outbreak of SARS,
medical staff older than 40 years have experienced SARS epidemic and are thus more
ready for COVID-19 mentally than their younger colleagues. We speculate that the
younger staff’s level of fear and worry related to an infectious disease outbreak may
be greater because they live with their children and may have greater family
responsibilities.
Although one of the strengths of this study is the examination of stress symptom
levels in a relatively large population comprised of various types of hospital staff, this
study is limited by its relatively few participates from Hubei province, which has the
most serious situation and has the most of the first-line medical staff. As COVID-19 is
highly contagious, the frontline medical workers are exposed to more viral particles
than the non- frontline medical workers. What is more, long work hours could make
their immune systems more vulnerable than normal. These may greatly increase their
stress levels. However, the findings do provide valuable information for policy
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makers and mental health professionals worldwide regarding the psychological
impact of an infectious disease outbreak, which may assist them in making
preparations psychologically for possible outbreaks in regions outside China.
When we were prepared our manuscript, two comments were published
regarding potential COVID-19-related mental health of the hospital workers in China.
Kang et al pointed out that presently mental health care for the patients and health
professionals directly affected by the 2019-nCoV epidemic has been under-addressed,
although psychological intervention teams have been set up in a few hospital and the
several psychological assistance hotline teams providing telephone guidance to help
deal with mental health problems are also available.12 Nevertheless hundreds of
medical workers are receiving these interventions with good response.13 Our survey
found 65·48% of medical staff could not find a suitable solution to their psychological
distress and could only endure or digest on their own. Therefore, psychological
intervention was necessary. Indeed, 60·36% medical staff believed that psychological
intervention should be implemented at the very beginning of an epidemic outbreak to
alleviate psychological distress.
Conclusions
During COVID-19 epidemic, Chinese medical staff was under great
psychological pressure and with high risk of psychological distress. In addition to
quickly establish programs that provide knowledge on the virus, timely psychological
support and intervention should be provided to the medical staff to alleviate their
anxiety and improve their general mental health.
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Funding
This work is supported by The National Key R&D Program of China
(2017YFC1104100, 2018YFC2000704). Beijing municipal administration of
hospitals climbing talent training program (DFL20150801), Beijing Municipal
Administration of Hospitals Incubating Program (PX2018035), and Beijing Municipal
Administration of Hospitals’ Youth Program (QML20180804).
Conflict of Interest
No
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Reference
1. Wu P, Liu X, Fang Y, et al. Alcohol abuse/dependence symptoms among hospital
employees exposed to a SARS outbreak. Alcohol Alcohol. 2008 Nov-Dec;43:706-12.
2. Chan AO, Huak CY. Psychological impact of the 2003 severe acute respiratory
syndrome outbreak on health care workers in a medium size regional general hospital
in Singapore. Occup Med (Lond). 2004 May;54:190-6.
3. Tang L, Pan L, Yuan L, et al. Prevalence and related factors of post-traumatic stress
disorder among medical staff members exposed to H7N9 patients. Int J Nurs Sci.
2016 Dec 11;4:63-67
4. Paladino L, Sharpe RP, Galwankar SC, et al. American College of Academic
International Medicine (ACAIM). Reflections on the Ebola Public Health Emergency
of International Concern, Part 2: The Unseen Epidemic of Posttraumatic Stress among
Health-care Personnel and Survivors of the 2014-2016 Ebola Outbreak. J Glob Infect
Dis. 2017 Apr-Jun;9:45-50.
5. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients
With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA.
Published online February 07, 2020. doi:10.1001/jama.2020.1585.
6. https://www.who.int/dg/speeches/detail/munich-security-conference.
7. Zung WW. A rating instrument for anxiety disorders. Psychosomatics.
1971;12:371–379.
8. Zung WW. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63–70.
9. National Health Commission of China Principles for emergency psychological
crisis intervention for the new coronavirus pneumonia (in Chinese). http: // www. nhc.
gov.cn/jkj/s3577/202001/6adc08b966594253b2b791be5c3b9467.shtml.
10. 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
May 13;168:1245-51.
11. Mitchell A, Cummins T, Spearing N, et al. Nurses' experience with
vancomycin-resistant enterococci (VRE). J Clin Nurs 2002;11:126-33.
12. Kang L, Li Y, Hu S, et al. The mental health of medical workers in Wuhan, China
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dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020; (published online
Feb 5.) https://doi.org/10.1016/S2215-0366(20)30047-X.
13. Chen Q, Liang M, Li Y, et al. Mental health care for medical staff in China
during the COVID-19 outbreak, The Lancet Psychiatry, 2020, ISSN 2215-0366,
https://doi.org/10.1016/S2215-0366(20)30078-X.(http://www.sciencedirect.com/scien
ce/article/pii/S221503662030078X)
Table 1. The respondents’ demographic profile
Parameters No. %
Total 11118
Gender
Male 2802 25·20
Female 8316 74·80
Age
below 20yrs 188 1·69
20-30yrs 3991 35·90
30-40yrs 3694 33·23
40-50yrs 2174 19·55
50-60yrs 997 8·97
Above 60yrs 74 0·67
Marital status
Married 7940 71·42
Unmarried 2954 26·57
Divorced 202 1·82
Widowed 22 0·20
Education background
Primary school and below 8 0·07
Junior high school 34 0·31
Senior high school 362 3·26
Undergraduate 8721 78·44
Postgraduate and above 1993 17·93
Occupation
Nurses 5900 53·07
Doctors 3367 30·28
Medical students 757 6·81
Clinical assistant departments'
staffs 464 4·17
Clinical administration 450 4·05
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departments' staffs
Logistic staffs 128 1·15
Family members of medical
workers 52 0·47
Household income
2000 and below 790 7·11
2000-5999 3596 32·34
6000-8999 3064 27·56
9000 and above 3668 32·99
Residence
Hubei 362 3·25
Outside Hubei 10756 96·75
Table 2. Residence distribution
Parameters No. %
Total 11118
Location
Jiangsu 3874 34·84
Hebei 945 8·50
Henan 853 7·67
Beijing 730 6·57
Heilongjiang 647 5·82
Shandong 587 5·28
Chongqing 540 4·86
Anhui 367 3·30
Hubei 362 3·26
Shanghai 256 2·30
Guangdong 238 2·14
Jiangxi 191 1·72
Yunnan 184 1·65
Sichuan 145 1·30
Inner Mongolia 133 1·20
Shanxi 132 1·19
Liaoning 130 1·17
Fujian 111 1·00
Tianjin 104 0·94
Guangxi 98 0·88
Hunan 91 0·82
Zhejiang 77 0·69
Shaanxi 70 0·63
Jilin 70 0·63
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Xinjiang 68 0·61
Guizhou 46 0·41
Hainan 25 0·22
Gansu 22 0·20
Ningxia 13 0·12
Qinghai 6 0·05
Overseas 2 0·02
Xizang 1 0·01
Table 3. Partial of questionnaire survey results
Parameters No. %
Total 11118
Frequency of psychological distress
Sometimes 5139 46·22
Seldom 3329 29·94
Never 1541 13·86
Often 969 8·72
Always 240 2·16
How to deal psychological distress
Endure or solve on its own 6932 65·48
Talk to friends or family 6011 56·78
Use online information for help 2056 19·42
Professional counseling 1451 13·71
Other 46 0·43
Is it necessary to intervene
Necessary 9274 83·41
Unnecessary 1844 16·59
When to intervene
Immediately 6711 60·36
During outbreak 2466 22·18
Wait until the outbreak stabilizes 1031 9·27
No need to intervene 584 5·25
Wait until outbreak was controlled
completely 326 2·93
Table 4. SDS&SAS score distribution
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Parameters No. %
Total 11118
SDS score distribution
No depression (SDS<50) 7621 68·55%
Mild depression (50≤SDS≤59) 1999 17·98%
Moderate depression (60≤SDS≤69) 1390 12·50%
Severe depression (SDS≥70) 108 0·97%
SAS score distribution
No anxiety (SAS<50) 9178 82·55%
Mild anxiety (50≤SAS≤59) 1386 12·47%
Moderate anxiety (60≤SAS≤69) 416 3·74%
Severe anxiety (SAS≥70) 138 1·24%
Table 5. Frontline medical personnel versus non-frontline medical
personnel SDS&SAS score distribution
Parameters No. %
Total 11118
Frontline medical personnel 3351
SDS score distribution
No depression (SDS<50) 2151 64·18%
Mild depression (50≤SDS≤59) 567 16·92%
Moderate depression
(60≤SDS≤69) 550 16·41%
Severe depression (SDS≥70) 83 2·47%
SAS score distribution
No anxiety (SAS<50) 2600 77·58%
Mild anxiety (50≤SAS≤59) 496 14·80%
Moderate anxiety (60≤SAS≤69) 182 5·43%
Severe anxiety (SAS≥70) 73 2·17%
Non-frontline medical personnel 7767
SDS score distribution
No depression (SDS<50) 5470 70·42%
Mild depression (50≤SDS≤59) 1085 13·96%
Moderate depression
(60≤SDS≤69) 1119 14·40%
Severe depression (SDS≥70) 93 1·19%
SAS score distribution
No anxiety (SAS<50) 6578 84·69%
Mild anxiety (50≤SAS≤59) 890 11·46%
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Moderate anxiety (60≤SAS≤69) 234 3·01%
Severe anxiety (SAS≥70) 65 0·83%
Table 6. Physician and nurses SDS&SAS score distribution
Parameters No. %
Total 9319
Physician 3367
SDS score distribution
No depression (SDS<50) 2417 71·78%
Mild depression (50≤SDS≤59) 470 13·96%
Moderate depression
(60≤SDS≤69) 421 12·50%
Severe depression (SDS≥70) 59 1·76%
SAS score distribution
No anxiety (SAS<50) 2801 83·19%
Mild anxiety (50≤SAS≤59) 379 11·26%
Moderate anxiety (60≤SAS≤69) 137 4·07%
Severe anxiety (SAS≥70) 50 1·48%
Nurses 5900
SDS score distribution
No depression (SDS<50) 3894 66·00%
Mild depression (50≤SDS≤59) 935 15·85%
Moderate depression
(60≤SDS≤69) 978 16·58%
Severe depression (SDS≥70) 93 1·57%
SAS score distribution
No anxiety (SAS<50) 4800 84·21%
Mild anxiety (50≤SAS≤59) 804 13·63%
Moderate anxiety (60≤SAS≤69) 235 3·98%
Severe anxiety (SAS≥70) 61 1·03%
Table 7. participants under 40 and over 40 SDS&SAS score distribution
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Parameters No. %
Total 11118
Participants under 40 years old 7873
SDS score distribution
No depression (SDS<50) 5283 67·10%
Mild depression (50≤SDS≤59) 1198 15·22%
Moderate depression
(60≤SDS≤69) 1269 16·12%
Severe depression（SDS≥70） 123 1·56%
SAS score distribution
No anxiety (SAS<50) 6440 81·80%
Mild anxiety (50≤SAS≤59) 1044 13·26%
Moderate anxiety (60≤SAS≤69) 301 3·82%
Severe anxiety (SAS≥70) 88 1·12%
Participants over 40 years old 3245
SDS score distribution
No depression (SDS<50) 2338 72·05%
Mild depression (50≤SDS≤59) 454 13·99%
Moderate depression
(60≤SDS≤69) 400 12·33%
Severe depression (SDS≥70) 53 1·63%
SAS score distribution
No anxiety (SAS<50) 2738 84·38%
Mild anxiety (50≤SAS≤59) 342 10·54%
Moderate anxiety (60≤SAS≤69) 115 3·54%
Severe anxiety (SAS≥70) 50 1·54%
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Manuscript
Click here to access/download Necessary Additional Data
icmje-coi-form.pdf
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