Investigation of the status of depression and anxiety among leaders and staff in pharmacy intravenous admixture services in China

We aimed to investigate the status of depression and anxiety among leaders and staff in pharmacy intravenous admixture services (PIVAS) and analyze influencing factors to provide a reference for improving their mental health status. This study involved a multi-center cross-sectional survey. PIVAS leaders and staff from across China were invited to participate. The Generalized Anxiety Disorder-7 and 9-item Patient Health Questionnaire were used to measure the status of anxiety and depression. A multiple linear regression model was used to analyze influencing factors. In total, 137 PIVAS leaders and 501 staff were included in this study. The results showed that 43.8% (60/137) of the leaders had anxiety and 38.7% (53/137) had depression. Among staff, 47.3% (237/501) had anxiety and 46.5% (233/501) had depression. Multiple linear regression showed that for PIVAS leaders, the degree of recognition by doctors was associated with anxiety scores, whereas PIVAS charge standard, PIVAS profit and loss situation, and the degree of recognition by doctors were associated with depression scores. For PIVAS staff, satisfaction with working in PIVAS was associated with anxiety scores, and job title, working hours per day, and satisfaction with working in PIVAS were associated with depression scores. Depression and anxiety are common among PIVAS leaders and staff working in hospitals in China. Hospitals should implement measures to improve the mental health of PIVAS leaders and staff.


Introduction
Pharmacy intravenous admixture services (PIVAS) refer to hospital based comprehensive and technical pharmaceutical departments that integrate clinical pharmacy and scientific research according to international standards and good manufacturing practice standards.3] The rapid growth of intravenous infusion therapy in recent years means the workload associated with centralized admixture of intravenous drugs in PIVAS has increased.Because this work is important and specialized, the requirements for PIVAS staff and leaders are relatively high.[6] The busy daily work and pressure burden mean that staff may be prone to anxiety and depression, which affects their quality of life and work, and reduces their daily work efficiency and accuracy of medication dispensing, which poses a serious threat to medical safety in hospitals.
It is necessary to understand the mental health status of PIVAS staff to guarantee medical safety and quality.However, few studies have focused on this topic.In 2019, Chao et al [7] investigated 239 nurses working in PIVAS in 3 cities in Shaanxi Province in China and analyzed their current status and factors influencing anxiety.They found a high rate of anxiety among This study was funded by Sichuan Preventive Medicine Association.The sponsor had no role in the study.The sponsor had no role in the study design, writing of the manuscript, or decision to submit this or future manuscripts for publication.
nurses working in PIVAS.However, that study only included participants from 1 province, focused on anxiety status, and did not consider depression status, meaning the research results are not representative.In 2015, Jin et al [8] analyzed the mental health status of 40 nurses working in PIVAS, but that sample size was small, and they did not analyze factors influencing mental health status.
Therefore, we conducted a multi-center cross-sectional survey in China to investigate the status of depression and anxiety among PIVAS leaders and staff, and analyze the factors influencing depression and anxiety to provide a reference for improving their mental health status.

Study design
This was a multi-center cross-sectional survey.We used a self-designed questionnaire to investigate the status of depression and anxiety among leaders and staff working in PIVAS in China.We distributed the questionnaire via the WeChat group for the Intravenous Dispensing Management and Application Branch of the China Medical Education Association, there are 324 members in the group.We also ask the PIVAS leaders to invite their colleagues to attend this survey via a face-to-face invitation.

Participants
All leaders and staff working in PIVAS across China were invited to participate in this survey.The inclusion criteria were as follows: leaders and staff were working in PIVAS across China; the job titles of participants were junior or above; participants were willing to attend this survey.The exclusion criteria were as follows: participants refused to participate in the survey; participant was an intern or a trainee; and participants have no job titles.

Information collected
This study used a self-designed questionnaire to collect data to investigate the status of anxiety and depression of PIVAS leaders and staff.The questionnaire collected basic information

Outcome measurement
The Generalized Anxiety Disorder-7 (GAD-7) was used measure the status of anxiety. [9]Each item describes 1 typical generalized anxiety disorder symptom and is evaluated by the frequency with which that symptom was reported over the last 2 weeks.Each item is scored from 0 (not at all) to 3 (nearly every day).Item scores are summed to give a total GAD-7 score ranging from 0 to 21.A score of 0-4 is defined as no anxiety, 5-9 as mild anxiety, 10-13 as moderate anxiety, 14-18 as moderate to severe anxiety, and 19-21 as severe anxiety.The 9-item Patient Health Questionnaire (PHQ-9) was used to measure participants' depression status. [10]The PHQ-9 focuses on the frequency of occurrence over the past 2 weeks of 9 depressive symptoms derived from the Diagnostic and Statistical manual of Mental Disorders, Fourth Edition diagnostic criteria.Each item is scored from 0 (not at all) to 3 (nearly every day), with the total score ranging from 0 to 27.A PHQ-9 score of 0-4 is defined as no depression, 5-9 points as mild depression, 10-14 points as moderate depression, and 20-27 as severe depression.We used the Chinese version of GAD-7 and PHQ-9 to conduct the outcome measurement.

Quality control
Before the formal investigation, we improved the contents of the questionnaire by conducting pre-investigation.During the investigation, we strictly followed the inclusion and exclusion criteria, selected the participants, and checked the rationality of the questionnaire in time.After the investigation, we checked the completeness and authenticity of the results of investigation.

Statistical methods
Normally distributed data were expressed as mean ± standard deviation, and t-tests or analysis of variance was used for the analysis.A rank sum test was used when the data were not normally distributed.Categorical variables were analyzed with chi-square tests.Following a univariate analysis, factors with a P value ≤ .2 were included in the multiple linear regression model.P values ≤ .05were considered statistically significant.We used SPSS version 21.0 (IBM Corp., Armonk, NY) for the data analyses.1).

Discussion
This multi-center cross-sectional survey investigated the status of depression and anxiety among PIVAS leaders and staff, and analyzed factors influencing anxiety and depression.
At present, more than 2000 medical institutions in China have established PIVAS, [11] so 6.85% PIVAS in China participated in our study.The results showed that anxiety and depression were relatively common in PIVAS leaders and staff in China.The prevalence of anxiety among staff in this study was similar to that reported by Chao et al. [7] Multiple linear regression showed that the degree of recognition by doctors, PIVAS charge standard, and PIVAS profit and loss situation were associated with mental health among PIVAS leaders.Satisfaction with working in PIVAS, job title, and working hours per day were associated with depression scores among PIVAS staff.
In terms of influencing factors, PIVAS leaders in situations with no charge standard, a low degree recognition by doctors, and without profit were likely to report symptoms of anxiety and depression.There are 2 possible reasons for these findings.
First, in China, most PIVAS have no charge standard, and are therefore in a state of loss and need to be financially subsidized by the hospital [3,12] ; this means these services operate under high pressure.Second, the service objects of PIVAS include patients, clinicians, and nurses.PIVAS must communicate with doctors frequently, especially when encountering unreasonable orders for interventions.This requires PIVAS staff to have solid professional knowledge and good communication skills, and means PIVAS leaders need to pay close attention to the development of ability among staff, which may create additional pressure for PIVAS leaders. [13]Therefore, leaders are concerned about doctors' recognition of PIVAS, which was therefore a factor influencing their mental health.
Staff that were not satisfied with working in PIVAS, had lower job titles, and who worked longer hours per day were more likely to report symptoms of anxiety and depression than other staff.This may be because PIVAS is responsible for the centralized configuration of intravenous medication for the whole hospital, and the configuration time is concentrated, meaning the workload is heavy and high-paced. [6,8,13]Therefore, the longer hour staff work in PIVAS, the more likely they are to feel tired and less satisfied with work, which can affect their mental health.In addition, all staff in hospitals needs to publish research papers to promote their professional title, [4] but the high workload in PIVAS leaves little time to write scientific research papers.As the individual's professional title affects their income, employees with low professional titles are more likely to report symptoms of anxiety and depression.
The anxiety and depression status of PIVAS staff and leaders merits more attention from hospitals and society, and hospitals should implement measures to improve the mental health of PIVAS employees, such as strengthening vocational training, improving the sense of job acquisition and income level, and enriching the lives of staff to help them adjust to the work pressure. [14]In addition, PIVAS could introduce automation and artificial intelligence equipment, which could improve work efficiency and reduce errors and work intensity, which may in turn reduce the incidence of depression and anxiety. [6]ur study had several limitations that should be addressed in further studies.First, as we did not have a full list of PIVAS leaders and staff, we could not use random sampling to select participants.However, the sample size of this study was relatively large and the survey respondents were from different regions of China, which gave good representation.Second, the cross-sectional study design means we could not make causal inferences.Third, although GAD-7 and PHQ-9 have been used to detect symptoms of anxiety and depression disorders in various settings and across diverse populations in China, [15][16][17][18] and which were with good reliability and validity, but anxiety and depression were measured by self-assessment, which might have resulted in an exaggerated incidence of mental health problems.Fourth, we only use the WeChat group to recruit participants, it would be better to utilize multiple methods to enhance generalizability.Further larger-scale studies with long follow-up periods are needed to continuously investigate the mental health status of PIVAS leaders and staff more comprehensively.
In conclusion, depression and anxiety are common among PIVAS leaders and staff in hospitals in China, and hospitals should implement measures to improve the mental health of PIVAS leaders and staff.
CY and DL contributed equally to this work.

Table 1
Univariate linear regression analysis of factors influencing anxiety and depressionof PIVAS leaders.leaders (gender, region, hospital level, job title) and staff (gender, region, hospital level, job title, education background, working years, working hours per day, whether PIVAS training was sufficient, importance PIVAS attached to personnel training, satisfaction with PIVAS training, satisfaction with working in PIVAS, whether they had mastered scientific research methodology, need for scientific research, interest in scientific research, and the ability to do scientific research).The questionnaire also collected basic information about PIVAS, including daily average infusion volume, PIVAS charge standard, PIVAS profit and loss situation, degree of recognition by doctors, degree of recognition by nurses, need for scientific research among staff, interest in scientific research among staff, whether staff had mastered scientific research methodology, and staff scientific research ability.

Table 2
Multiple linear regression analysis of factors influencing anxiety and depression of PIVAS leaders.
3.3.Factors affecting anxiety and depression3.3.1.PIVAS leaders.In the univariate analysis, statistical test of 4 variables showed that P value was less than 0.2: PIVAS profit and loss situation (P = .111),degree of recognition by doctors (P = .14),interest in scientific research among staff

Table 3
Univariate linear regression analysis of factors influencing anxiety and depression of PIVAS staff.

Table 4
Multiple linear regression analysis of factors influencing anxiety and depression of PIVAS staff.