Comments on “Prevalence and Predictors of Stress,Anxiety and Depression Among Health Care Workers Managing COVID-19 Pandemic in India: A Nation-Wide Observational Study”

We commend Wilson et al. for their study. ¹ Still, we would like to highlight some concerns relating to this research, which may have ramifications on its authenticity and the scope for generalization of their conclusions.

An examination of the demographics of the study population reveals that nearly half the respondents are emergency medicine physicians (EMP). This may be a reflection of the study methodology, wherein data was collected by distributing questionnaires on WhatsApp groups for professionals. Because five out of the seven authors are EMP, the circulation of the online questionnaire among colleagues might have resulted in this skewed sample. Since an overwhelming majority of the subjects surveyed belong to a single occupational class (doctors) and medical specialty (EMP), this has repercussions on the reliability of the primary data, for the following reasons:

EMP, as an occupational group, have higher levels of baseline stress when compared to other health care professionals (HCP), owing to the nature of their work. ² Therefore, the additional stress imposed by COVID-19 may not be incremental enough to facilitate a diagnosis using objective scales that assess psychological changes in the preceding month. This is, perhaps, a more feasible explanation for the low percentage of high-level stress obtained in this study, rather than the resilience or prior exposure to heavy patient loads of all Indian HCP, as postulated by the authors.

The proportion of suspected COVID-19 cases presenting to accident and emergency (A&E) services is relatively small, due to the nature of its symptoms. Even with surging cases in the month of April, only 8% of emergency room (ER) visits in the United States of America were due to suspected cases of COVID-19. ³ This figure is made more pertinent by the fact that monthly ER visits had seen a reduction of 50%–60% since March when compared to previous years. ⁴ Hence, the experiences of EMP with COVID-19 may not be representative of the vast majority of HCP dealing with the pandemic.

Therefore, we argue that it may not be prudent to generalize the findings from this study to the specified entity of “HCW managing the COVID-19 pandemic in India,” due to the risk of minimization of the psychological impact of the pandemic on HCW.

The sample comprised largely of younger physicians with fewer years of experience, as 97.5% were below 45 years of age and 90% had fewer than 10 years of experience. Although this might be attributed to self-selection bias that the authors have rightly declared as a limitation of the study, the lack of a representative sample could have implications on the interpretation of the results. Age and professional experience are notable factors contributing to stress, anxiety, and depression in frontline HCW. ⁵ Therefore, some of the inferences drawn in this study, on the role of these factors as predictors of psychological distress, may be questionable.

Table 3 outlines data under the headings of “concern about the spread of infection to family,” “satisfied with the institutional support,” and “satisfied with the availability of personal protective equipment.” The last two variables appear to be yes/no questions, but the data has been presented in the form of a quantitative scale (high/moderate/low). Further elaboration on how the data was converted from a dichotomous to a Likert scale would be pertinent.

Research indicates that the aforementioned three variables are important factors affecting the psychological well-being of HCW. ⁵ However, neither are these variables mentioned in the list of hypothesized factors/predictors that underwent statistical analysis, nor do they find a place in the accompanying table describing the results of the analysis. We infer that the analysis of this data was not undertaken and suggest that this could have added to the overall robustness of the study.

Table 5 lists one of the predictors as “perceived inability to distress.” This term lacks meaning and clarity; we assume that the authors intended to cite “perceived inability to tolerate distress.” ⁶

Our last point of contention relates to an ethical aspect. The results indicate that 3% of HCP reported symptoms of moderately severe/severe depression, which requires urgent intervention using antidepressants, psychotherapy, or a combination of both. ⁷ Severe depression that goes untreated can provoke episodes of deliberate self-harm. ⁸ Physicians already represent a vulnerable demographic for suicide, which is magnified in the current climate. ⁹ Although we recognize the desire for anonymity in conducting the survey, we propose that those respondents scoring above a certain threshold on the questionnaire should have been directed to seek professional help, by providing contact numbers of mental health services. It is not apparent from the article whether such safeguards were in place.

To conclude, we congratulate the authors on this publication that provides valuable insights on the impact of COVID-19 on frontline HCP.