Anxiety, depression, and suicide risk among health workers during the COVID-19 pandemic

Objective: To evaluate the relationship between symptoms of anxiety, depression and risk of suicide in hospital health workers during the COVID-19 pandemic. Methods: This is a quantitative, cross-sectional, web survey-type study carried out with 270 health workers from a university hospital in September 2022, using an electronic form, in which the Hospital Anxiety and Depression Scale and questions of the Self-Reporting Questionnaire were used. Data were analyzed using SPSS Software, version 26. Described and inferential statistics were performed. The study was approved by the Research Ethics Committee, through Opinion number 5,625,667. Results: There was a prevalence of 40% for anxiety symptoms and 33% for

English | Rev. enferm.UFPI.2024;13:e4207| DOI: 10.26694/reufpi.v13i1.42077) This study is justified by the potential that such investigations have to generate knowledge that subsidizes the development of prevention and intervention strategies in the face of processes that trigger the mental illness of health workers in a pandemic scenario.Thus, the objective of this research is to evaluate the relationship between symptoms of anxiety, depression and risk of suicide among hospital health workers during the COVID-19 pandemic.

METHODS
This is a cross-sectional study, which integrates a macro research project entitled: "Epidemiology, subjectivities and technologies: Brazilian perspective in times of the COVID-19 pandemic".The research was developed in the municipality of Teresina-PI and the data were collected at the University Hospital of the Federal University of Piauí (HU-UFPI).
The population of this study consisted of health workers (physicians, nurses, nursing technicians, physical therapists, occupational therapists, psychologists, social workers, pharmacists, speech therapists, nutritionists, biologists, dentists, laboratory technicians, necropsy technicians and pharmacy technicians) who are part of the staff of this institution.
The inclusion criteria were: health workers of the HU-UFPI, of both sexes.Health professionals who were away from their work activities at the HU-UFPI during the COVID-19 pandemic for a period greater than or equal to 180 days were excluded from the study.
Data collection took place in September 2022, when the third dose of the vaccine was already available, with the forwarding of an electronic survey form, prepared by the authors themselves, through social media (WhatsApp® and Instagram®), to the target audience of the research.
It is noteworthy that the form was composed of three sessions, as follows: I. sociodemographic profile, health profile and professional profile; II.Analysis of anxiety and depression, in which the Hospital Anxiety and Depression Scale -HADS, authored by Zigmond and Snaith (8)  (1983), and validation in Brazil by Botega et al. (9) (1995) was used.The scale consists of 14 items and its measurement receives values from 0 (zero) to 3 (three), using as cutoff points, for both anxiety and depression, from 0 (zero) to 8 (eight) -without anxiety or depression; and, greater than or equal to 9 (nine) -with anxiety or depression.The score values are the result of the sum of the values of all items of the scale per participant, obtaining a total score.III.For the analysis of the variable "suicide risk", the 4 questions of the "depressive thoughts" domain of the SRQ-20 were used, which question the participant Are you unable to play a useful role in your life?", "Have you lost interest in things?",Do you feel like a useless person who is good for nothing?"Have you had any ideas about ending your life?"The Self-Reporting Questionnaire -SRQ-20, an instrument created by Harding et al, in 1980, and validated in Brazil by Williams in 1986, is a selfadministered instrument, composed of 20 questions and allows a screening of mental illness, suggesting suspicion, without, however, attributing a specific diagnosis. (7)The sensitivity and specificity coefficients obtained in the validation for the SRQ-20 are 77% and 74%, respectively. (10)The SRQ-20 cutoff point for this study was set at 7/8, according to the study by Mari (11)  (1987).In addition, it is noteworthy that all instruments used in this study are recommended by the World Health Organization (WHO), Ministry of Health and are in the public domain.
Data were organized and tabulated in a Microsoft Office Excel 2016® spreadsheet.To perform the descriptive and inferential statistical analysis, the database was processed in the statistical software (SPSS), version 26.For data analysis, exploratory descriptive statistics was initially applied, organizing the data in the form of tables.For qualitative variables, absolute and relative frequency were applied.
In the inferential analysis, Fisher's exact test was applied to measure the association between sociodemographic variables, health profile, professional and the risk of suicide with the classification anxiety/Depression (HADS) of health professionals at the University Hospital (HU-UFPI).For the variables that presented association, the odds ratio was applied, through binary logistic regression.For all analyses, a significance level < 5% was considered.
Regarding the health profile, it was found that the majority did physical activity (66.3%), had no comorbidities (72.2%), had never been diagnosed with mental illness (72.2%) and said they had not sought Psychologist or Psychiatrist during the COVID-19 pandemic (67.0%).As for the professional profile, most had a graduate degree at the specialization level (73.6%), as for the working day, 59.3% referred to a workload of 36 hours per week at the institution, however, (58.1%) had other labor ties making a total weekly workload of 50 hours on mean (Standard deviation = 15).It was also found that most of these workers worked in the institution's wards (45.9%) and work or had worked on the front line of COVID-19 (53.2%).
It was found that there is an association between anxiety symptoms with sex (p-value=0.008) and religion (p-value=0.038),demonstrating that being female increases the chances of having anxiety symptoms by 2.415 times when compared to males.In addition, being a spiritist increases by 5.345 times and being an evangelical increases by 1.659 times the chances of having anxiety symptoms, when compared to Catholics (Table 1).
It was also observed that having been, at some point in life, diagnosed with mental illness, increases the chances of both anxiety symptoms by 2.840 times and depressive symptoms by 2.057 times.In addition, having sought a psychologist or psychiatrist during the COVID-19 pandemic also increased the odds of having anxiety symptoms and depressive symptoms by 2.593 and 2.078, respectively (Table 1).Source: authors, 2023.
In Table 2, regarding the association between depression/anxiety and the professional profile of the workers, it is verified that in both groups there was no association between the variables studied.However, it is worth noting that in the analysis of the descriptive data, it was evident both in the group with anxiety symptoms and in the group with depressive symptoms, that most had specialization, had a workload of more than 36 hours per week, worked in wards, had other employment ties and worked on the front line of COVID-19.Source: authors, 2023.
In Table 3, when evaluating the risk of suicide and the depression/anxiety classification (HADS) of healthcare personnel, a statistical association was evident between all the variables analyzed.However, it was observed that people who lost interest in things increased their chances of developing anxiety symptoms by 6.584 and depressive symptoms by 19.362, while people with ideas of ending their lives increased their chances of developing anxiety symptoms by 17.620; and in 12.362 symptoms of depression.In turn, the other variables did not have a difference in chances of occurrence, as can be seen in the analysis of the confidence interval.

DISCUSSION
This study demonstrated, in relation to biological factors, that women have presented considerably more symptoms that point to anxiety and depression (prevalence of 82.4% and 77.5%, respectively) than men.The literature provides evidence that reinforces the relationship between mental disorders and sex, since female workers presented significantly more depressive symptoms, with a 62% higher prevalence in relation to males. (2)In the same sense, a study by Lai et al. (12) (2020) indicates that women from the nursing category who worked in Wuhan, China, the epicenter of the COVID-19 pandemic, presented more severe symptoms of mental illness when compared to other health workers, another finding similar to this study for evidencing a predominance of anxious and depressive symptoms among nurses and nursing technicians.In this sense, it is worth noting that the nursing category is predominantly composed of women, which may be related to historical and cultural issues associated with the act of caring. (13,14) e influence of religion was also verified, although in the present study religiosity did not constitute a lower risk for anxious and depressive symptoms.However, it is noted that among Catholics, the predominant religion, most did not present symptoms of anxiety or depression (71.0% and 68.0%, respectively).Still in the sociodemographic aspect, in this study there was no influence of cohabitation, however, it was observed that workers who have children mostly reported symptoms of anxiety and depression.On the other hand, Santos (17) (2021) argues that the performance in coping with COVID-19 is marked by the female presence, many of them mothers, who had to leave their children after the work period to avoid the spread of the coronavirus in the family environment, contributing to the worsening of psychic vulnerability in these women who often do not have a family support network.
This study also evaluated the health profile of these workers, and in this regard, it was demonstrated a predominance of symptoms of anxiety and depression (38.9 and 39.3%, in this order) among workers who reported comorbidities.This finding was similar to that found in the study by Vedovato et al. (18) (2021), which is part of the project entitled "Work, health and emotions: health workers in the face of COVID-19", which showed that those workers who worked in the direct care of patients with COVID-19 and who had a history of other diseases, expressed greater concern about contamination, as they recognized themselves as more vulnerable and prone to the most severe forms of the disease, increasing the risks of death among this group.
There was also an association among those who reported a diagnosis of mental illness prior to the pandemic, of whom (46.3%) had anxious symptoms and (43.8%) symptoms of depression.According to Duarte et al. (5) (2020), having a diagnosis of previous mental illness makes the individual more vulnerable to the stressors of the pandemic and, when added to the restrictions in the provision of health care during the period of social isolation, may have contributed to the worsening of the health condition of this group.
Similarly, there was a prevalence of symptoms of anxiety (52.8%) and depression (50.6%) among health workers who sought psychological or psychiatric support during the COVID-19 pandemic.It is presumable that amid so many adjustments and challenges in their routines, these individuals have recognized the need to ask for professional help.As a mechanism to deal with the mental suffering of health English | Rev. enferm.UFPI.2024;13:e4207| DOI: 10.26694/reufpi.v13i1.4207workers, several channels of psychosocial intervention emerged in the midst of the crisis and, with the help of the internet, enabled effective and early monitoring, breaking the barriers of isolation. (19)egarding the professional profile of these workers, no statistical significance was found for any of the variables studied.It can be inferred that anxiety/depression are independent of factors related to the characterization of the bond of this population (stable, salaries above the market average), as well as having a high educational level (specialization, master's and PhD), although such factors may have contributed to the clarification, care, protection against COVID and, consequently, attenuated negative factors of the crisis.Thus, also, Rosa et al. (20) (2021), in their qualitative and quantitative study with nursing professionals, found that despite the report of many participants about the fear of losing their job or income during the pandemic, most (60.9%)denied having this fear.It is also worth considering that in the period there was a greater demand for health workers.In this sense, the present study also revealed that among the participants, most workloads equal to or greater than 36 hours per week and that, of these, 82.4% presented anxious symptoms and 83.2% presented depressive symptoms and, in addition, there is a predominance of workers with more than one employment bond (58.1%).This finding converges with the most reported scenario during the beginning of the pandemic, in which the care teams were exhausted by having to endure the increase in care and the work overload imposed by the pandemic. (21)nother high point of this study is the analysis of suicide risk indicators among these health workers, so it was found that the variables: "Are you unable to play a useful role in your life?" Have you lost interest in things?Do you feel like a useless person who is good for nothing?And "Have you been thinking about ending your life?" were associated and statistically important (p-value < 0.05), regarding the classification of HADS, both for anxiety and depression.Thus, there was a greater chance (19.362) of manifestation of depressive symptoms for the variable "Have you lost interest in things?"and, regarding the variable "Have you had ideas about ending your life?", which refers, more directly, to a tendency to suicide, there were 17.620 times more chances of manifesting anxiety symptoms and 12.362 times more chances for symptoms of depression.The results highlight the importance of implementing measures to support and care for the mental health of these workers during public health emergencies, such as the COVID-19 pandemic.Protecting the mental health of health workers is essential not only for the well-being of these professionals, but also for patient safety and the quality of services provided.
This study has limitations because it is cross-sectional in nature, therefore, its results cannot attribute causality.In addition, a possible selection bias can be considered, since the research was outlined in its method as web survey, which, despite the advantage of speed and reach through virtual means, may eventually present the effect of "self-selection", which may lead to an increase in the prevalence of the outcome in the population.

CONCLUSION
The present research showed, in relation to the sociodemographic, health and professional profiles of the health workers evaluated, that the manifestations of anxiety and depression were preponderant in women, from the nursing category, and pointed to a significant index of indications of suicide risk among this population.
Regarding anxiety, female workers were more likely to develop anxiety than males, and this result may have been a reflection of the greater presence of women in the sample.The chances were lower when the professional was of the Catholic religion, compared to the other religions in the sample.It was also evidenced that the existence of a history of mental illness, the search for professional help, as well as the presence of comorbidities increased the chances of developing anxiety/depression.
As for the risk of suicide, it was found that among individuals who had anxiety or depression, the chance of suicide is higher among those who have lost interest in things and those who think about ending their lives.
Thus, it was revealed, through the analyses carried out, that there is a relationship between the stressors of the COVID-19 pandemic and the triggering or exacerbation of symptoms of anxiety, depression and behaviors that signal the risk of suicide among health workers.These findings are in addition to those English | Rev. enferm.UFPI.2024;13:e4207| DOI: 10.26694/reufpi.v13i1.4207already in the literature that warn of the need to invest in strategies to welcome and protect the health of these workers.However, more studies are needed to deepen this theme so that, added to those already existing, they can reach more robust conclusions, especially regarding the factors that trigger these disorders and lead to aspects that can be adjusted.
Although this study was carried out in a single health service, its results can guide the planning of actions with more precise objectives, aimed at promoting health, preventing diseases and constituting a health protection network for these workers, in their work environment, through strategies to improve the organizational climate, based on good people management practices.

CONTRIBUITIONS
Contributed to the conception or design of the study/research: Cruz RL, Júnior FJGS.Contributed to data collection: Cruz RL.Contributed to the analysis and/or interpretation of data: Cruz RL, Júnior FJGS.Contributed to article writing or critical review: Cruz RL, Júnior FJGS, Gonçalves AMS, Sales JCS, madeira MZA.Final approval of the version to be published: Júnior FJGS, Gonçalves AMS, Sales JCS, madeira MZA.

Table 2 .
Analysis of the association between the classification of anxiety/depression (HADS) and the professional profile of health personnel.Teresina, Piauí, Brazil, 2023.N= 270