23 APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v6.i1.2019.23-29 ISSN 2412 - 3188 Original Article Prevalence of depression, anxiety and stress among healthcare professionals at tertiary care hospitals, Karachi – Pakistan Yameema Ayub, Raheel Anjum, Shabana Margrat, Azeem Ashraf & Saira Qayyum St. James Institute of Nursing and Health Science Abstract Background: The prevalence and severity of mental health issues among the healthcare professionals (HPs) has escalated during the past few years. Depression, anxiety and stress are common complaints among the HP’s, having a profound impact on their personal and professional life. The purpose of this study was to assess the severity level of depression, anxiety and stress among HPs at tertiary care hospitals of Karachi. Methodology: A cross-sectional study was conducted from May to July 2019 at three tertiary care teaching hospitals of Karachi including Jinnah Post Graduate Medical Centre (JPMC), National Institute of Child Health (NICH) and National Institute of Cardiovascular Diseases (NICVD). Total 260 HPs (doctors, nurses, physiotherapist, pharmacist, laboratory technician and nursing technicians) were selected through convenience sampling method. In addition to the demographic details, the prevalence and severity score of depression, anxiety and stress was assessed using depression, anxiety and stress scale 42 (DASS 42). The collected data was analyzed using SPSS version 23. Results: Among 260 HP’s, 48.5% were males and 51.5% were females, moderate depression was found in 33(12.7%) HP’s, 28(10.8%) had severe depression while 6(2.3%) were suffering from extremely severe depression. Anxiety levels were moderate in 67(25.8%), 32(12.3%) and 21(8.1%) reported severe and very severe anxiety respectively. Moreover, stress levels were moderate among 45(17.3%) HP’s, while severe and very severe levels were observed among 13(5%) and 7(2.7%) responders respectively. There was no association in between the sociodemographic characteristics and depression, anxiety and stress (p>0.05). Conclusion: It was observed that most of the HP’s were suffering from mild to moderate depression, anxiety and stress. Further research is required to explore the possible contributing factors and methods for eradication of this health issue. Keywords Depression, Anxiety, Stress, DASS 42, Healthcare Professionals. Citation: Ayub Y, Anjum R, Margrat S, Emmanual A, Ashraf A, Qayyum S. Prevalence of depression, anxiety and stress among healthcare professionals at tertiary care hospital, Karachi – Pakistan. APP. 2019; 6(1):23-29 Corresponding Author Email: ymmy_ayub@yahoo.com DOI: 10.29052/2412-3188.v6.i1.2019.23-29 Received 11/08/2019 Accepted 03/10/2019 Published 12/10/2019 Copyright © The Author(s). 2019 This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The author(s) received no specific funding for this work. Conflicts of Interests: The authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v6.i1.2019. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 24 ISSN 2412 - 3188 APP| Published By AEIRC| Volume 6 Issue 1 Introduction Highly prevailing mental health condition of the era, depression along with anxiety and stress have become the major public health concern. Major etiological factors include unemployment, low socioeconomic status, long work hours, isolation, lack of socializing and substance abuse, etc1. These complaints are more frequent among females as compared to males which may be due to the pressure associated with their social roles in everyday life or it may also be linked to the hormonal imbalances associated with menstruation, childbirth, and menopause1. Depression, anxiety and stress significantly affects the individual’s personal, social and as well as professional life. It is evident that regardless of age, gender or professional seniority, the HP’s are frequently exposed to stressful conditions especially in their work setting2-4. Modulating the work life, depression and stress associated mood disorders greatly affect the HP’s concentration at work and also compromises the quality of healthcare services they provide5,6,7. Based on the systemic review conducted in 2015 including 15 countries, the estimated prevalence of depressive symptoms among the physicians of four Asian, seven European and four Middle Eastern countries was 28.8%, it was suggested that the prevalence ranges in between 20.9% to 43.2% and excel each year8. The incidence rate varies among the different occupational categories i.e. nurses are more affected by depression, the increasing stress is mainly due to the overburdened work routine. A study reported high depression rate (18%) among nurses as compared to other HP’s (9.4%)9. According to a local study including physiotherapists employed in major cities of Pakistan, 70.1% were suffering from depression, 53.17% from anxiety and 60.05% were in stress10. However, it is apparent that depression, anxiety and stress are primarily caused by workload while other secondary causes are financial status, job stress and dissatisfaction etc10. Nurses all around the world face it and it is linked to their long work hours, frequent night shifts and violence at work-place11 and sometimes it even leads to intentions to quit job12. It not only alters the mental and physical health, also reported to increase the substance use, abuse and suicide risk among the HP’s7,13. The aim of the present study was to estimate the prevalence of depression, anxiety and stress among the HP’s at tertiary care hospitals of Karachi. Methodology This cross-sectional multicenter study was conducted at three tertiary care hospitals of Karachi including JPMC, NICH and NICVD from May to July 2019. A sample of 260 was calculated using open epi software version 2.3.1, including six different categories of HPs (doctors, nurses, physiotherapists, pharmacist, laboratory technicians and nursing technicians). The targeted population for this study was HP’s involved in preventive, curative and rehabilitative healthcare services at the study setting. The HP’s demographic details including age, gender, marital status, education and profession etc. were taken after attaining the written informed consent. Depression, anxiety and stress was assessed using DASS 4214. The sum of scores was obtained from the 14 items in each scale and the scale severity was interpreted as per the details shown in the table below. Table 1: Cut-off score for severity ratings of DASS 42 severity scale Grades Depression Anxiety Stress Normal 0 – 9 0 – 7 0 – 14 Mild 10 – 13 8 – 9 15 – 18 Moderate 14 – 20 10 – 14 19 – 25 Severe 21 – 27 15 – 19 26 – 33 Extreme severe 28 + 20 + 34 + *Depression, Anxiety & Stress subscales of DASS42 25 ISSN 2412 - 3188 APP| Published By AEIRC| Volume 6 Issue 1 Ethical approval was obtained from St. James institute of nursing and health sciences. The collected data was analyzed using SPSS Version 23, where frequency and percentages were used to present the qualitative variables of the study like gender, marital status and socioeconomic status, etc. Result During the study period, 260 HP’s from diverse professions and specialties were included in the study, majority were nurses i.e. 58.1% followed 18.1% were doctors and 9.6% were nursing technicians with female predominance 134 vs 126 males. 94.6% had a work experience of <15 years. Table 1: Socio-demographic characteristics of study participants Variables Sub-categories (n=260) Gender Male 126(48.5) Female 134(51.5) Age Group <35 years 224(86.15) >35 years 36(13.84) Marital status Married 169(65) Single/widow/separated 91(35) Education Undergraduate 56(21.5) Postgraduate 43(16.5) Others 161(61.9) Socioeconomic status PKR 150,000 10(3.8) Professional Categories Nurse 151(58.1) Nursing technician 25(9.6) Laboratory technician 7(2.7) Pharmacist 6(2.3) Doctor 47(18.1) Physiotherapist 24(9.2) Affiliation JPMC 73(28.1) NICVD 95(36.5) NICH 92(35.4) Work Experience <15 years 246(94.6) >15 years 14(5.38) *JPMC-Jinnah Post-Graduate Medical Centre; NICVD-National Institute of Cardiovascular Diseases; NICH-National Institute of Child Health The mean DASS scores for the prevalence of depression, anxiety and stress are given in table 2. Out of the total sample, 51.5% HP’s scored normal on depression subscale while 22.7% fell into the mild category followed by moderate 12.7% and 2.3% showed extreme scores. For Anxiety subscale, 39.6% HP’s had normal scores and 25.8% had moderate scores for anxiety while 8.1% were having extremes severity scores. DASS42 Stress subscale displayed normal 26 ISSN 2412 - 3188 APP| Published By AEIRC| Volume 6 Issue 1 scores among 58.1% HP’s, 17.3% moderate scores, 16.9% mild scores and 2.7% extreme scores. Table 2: Prevalence of depression, anxiety and stress in study participants Score Severity Ratings Depression Anxiety Stress Normal 134(51.5) 103(39.6) 151(58.1) Mild 59(22.7) 37(14.2) 44(16.9) Moderate 33(12.7) 67(25.8) 45(17.3) Severe 28(10.8) 32(12.3) 13(5) Extreme 6(2.3) 21(8.1) 7(2.7) * Depression, Anxiety & Stress subscales of DASS42 *Values are given as n(%) The association of depression, anxiety and stress with various sociodemographic characteristics is given in table 3. No significant relationship observed between the observed variables and the prevalence of depression, anxiety and stress. Table 3: Stratification of sociodemographic factors with depression, anxiety and stress. Associated Factors Depression p- value Anxiety p- value Stress p-value Gender Male 63 0.630 76 0.983 49 0.279 Female 63 81 61 Age Groups <35 years 111 0.707 136 0.525 98 0.250 >35 years 15 88 126 Marital status Single/widow/separated 46 0.621 52 0.433 40 0.693 Married 80 105 70 Socioecono mic status PKR 150,000 4 4 3 Professiona l categories Nurse 74 0.436 95 0.063 64 0.08 Nursing technician 15 14 6 Laboratory technician 3 5 2 Pharmacist 1 0 1 Doctor 20 23 20 Physiotherapist 13 20 17 *Values are given as frequency Discussion The prevalence of depression, anxiety and stress was high among the HP’s enrolled in the current study i.e. 48.46%, 60.38% and 41.92% respectively which is consistent with the findings of Alkhazrajy et al.15 (70.25%) and Liezel16(55%). While in contrast studies conducted in Japan, China and Germany showed decreased prevalence of depressive symptoms among HP’s i.e. 11.3%, 8.8%, 31.7%, and 17%, respectively17-19. Moreover, a local study in Pakistan also showed similar results to the mentioned studies i.e. 25.8% prevalence only20. The high prevalence of depression among the study population may be due to the increasing workload, lack of working staff, limited number of HP’s and low income. 27 ISSN 2412 - 3188 APP| Published By AEIRC| Volume 6 Issue 1 Stratification of sociodemographic characteristics of the study population with depression, anxiety and stress showed insignificant results i.e. no significant association was observed between age and depression levels (p=0.707) which is also supported by other studies concluding age as a nonsignificant contributing factor for depressive symptoms in medical profession21,22. Moreover, working hours are the significant contributing factors for depression, anxiety and stress as indicated by a number of studies5,21. The physicians who were working for more than 60 hours/week and in double shifts were more likely to experience depressive symptoms as compared to counterparts22. A study indicated that low income was also a common factor among the HP’s with depressive symptoms23 which is contradictory to other studies indicating no significant relationship between the two variables. Also supported by our results I indicating contradictory results (p=0.957) to the study conducted by El-Hamrawya23. The current study indicated a higher rate of depression among males as compared to females i.e. 63/126 vs 63/134. While globally it is an evident fact that the prevalence of depressive symptoms is higher among females irrespective of professions, also showed by several studies where females were more depressed than males24-26. Furthermore, the marital status also plays a significant role in the prevalence of depression, anxiety and stress. It was reported by a study that married doctors are more likely to develop depression as compared to unmarried23. No significant associations observed in the current study which is also supported by Gu et al.27, Alkhazrajy et al.15, Becker et al.21 and Fahrenkopf et al.5, concluding that no significant association exist between gender, marital status and prevalence of depressive symptoms. There are several studies conducted both at national and international level determining the prevalence of depression, anxiety and stress among single category of HP’s but our study is unique in the way that it brought various categories of HP’s under one umbrella, like nurses, doctors, laboratory technicians, physiotherapist and pharmacist were all included in this study. Moreover, DASS 42 is valid tool for depression analysis and three major hospitals of Karachi were included for the study but sample size is very limited due to shortage of time and answers of some behaviour questions might be doubtful because participants might have lied about it. Therefore, our results do not provide a generalized view. It is recommended that hospitals should be aware of the increasing prevalence of depression, anxiety and stress among HP’s, and assessments should be carried out periodically. Moreover, firm policies and campaigns must be designed and implemented to eradicate this health issue so that continuous and balanced services could be provided to the patients. It is also suggested that further studies with more participants from both government and private sectors should be conducted so the results can be properly estimated at whole community level. Conclusion The HP’s enrolled in the study were mostly affected by moderate to severe level of depression, anxiety and stress. Periodic, monthly or bimonthly assessment of these measures are recommended to control this health concern among the HP’s. As their physical and mental health status plays a very significant role in their practicing environment and also affects the quality of services they are providing. Programs and campaigns must be driven in order to increase the knowledge of these concerns among the HP’s and in order to improve the mental health of the employees the 28 ISSN 2412 - 3188 APP| Published By AEIRC| Volume 6 Issue 1 healthcare sectors must take effective measures focusing on better health and healthy working environment. Acknowledgement St. James Institute of Nursing & Health Science. References 1. Salk RH, Petersen JL, Abramson LY, Hyde JS. The contemporary face of gender differences and similarities in depression throughout adolescence: development and chronicity. J Affect Disord 2016; 205:28–35. 2. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med 2003;114(6):513–519. 3. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, Sen S, Mata DA. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. Jama. 2016;316(21):2214- 2236. 4. Joules N, Williams DM, Thompson AW. Depression in resident physicians: a systematic review. Open J. Depress. 2014;3(03):89-100. 5. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, Edwards S, Wiedermann BL, Landrigan CP. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336(7642):488-491. 6. Tsai YC, Liu CH. Factors and symptoms associated with work stress and health- promoting lifestyles among hospital staff: a pilot study in Taiwan. BMC health services research. 2012;12(1): Article 199. 7. de Oliveira Jr GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, McCarthy RJ. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesth Analg 2013;117(1):182–193. 8. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, Sen S. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. Jama. 2015;314(22):2373-2383. 9. Letvak S, Ruhm CJ, McCoy T. Depression in hospital-employed nurses. Clin Nurse Spec. 2012;26(3):177–182. 10. Babur MN, Liaqat M. Prevalence and Factors effecting Depression, Stress and Anxiety among Physiotherapists of Pakistan. Isra Med J. 2017;9(6):427–430. 11. Gong Y, Han T, Yin X, Yang G, Zhuang R, Chen Y, Lu Z. Prevalence of depressive symptoms and work-related risk factors among nurses in public hospitals in southern China: A cross-sectional study. Sci Rep. 2015;4:1–5. 12. Chiang Y-M, Chang Y. Stress, depression, and intention to leave among nurses in different medical units: implications for healthcare management/nursing practice. Health Policy. 2012;108(2–3):149–157. 13. Lebensohn P, Dodds S, Benn R, Brooks AJ, Birch M. Resident wellness behaviors: relationship to stress, depression, and burnout. Fam Med. 2013;45(8):541–549 14. Depression, Anxiety and Stress (DASS). [updated July 26, 2018] [Cited June, 21 2019]. Available at: http://www2.psy.unsw.edu.au/dass/ 15. Alkhazrajy, Lujain Anwar; Sabah, Sadik; Abed, SM Hassan. Prevalence of depressive symptoms among primary health care providers in Baghdad. Int J Health Psychol Res 2014; 2(2):1-20. 16. Liezel R. The prevalence of burnout and depression among medical doctors working in the Cape Town metropole community health care clinics and district hospitals of the provincial government of the Western Cape: a cross-sectional study [PhD thesis]. Stellenbosch: Stellenbosch University; 2011. 29 ISSN 2412 - 3188 APP| Published By AEIRC| Volume 6 Issue 1 17. Wada K, Yoshikawa T, Goto T, Hirai A, Matsushima E, Nakashima Y, Akaho R, Kido M, Hosaka T. Association of depression and suicidal ideation with unreasonable patient demands and complaints among Japanese physicians: a national cross-sectional survey. Int J Behav Med. 2011; 18(4):384–390. 18. Shen LL, Lao LM, Jiang SF, Yang H, Ren LM, Ying DG, Zhu SZ. A survey of anxiety and depression symptoms among primary-care physicians in China. Int J Psychiatry Med. 2012; 44(3):257–270. 19. Bernburg M, Vitzthum K, Groneberg DA, Mache S. Physicians' occupational stress, depressive symptoms and work ability in relation to their working environment: a cross-sectional study of differences among medical residents with various specialties working in German hospitals. BMJ Open 2016; 6(6):e011369. 20. Atif K, Khan HU, Ullah MZ, Shah FS, Latif A. Prevalence of anxiety and depression among doctors; the unscreened and undiagnosed clientele in Lahore, Pakistan. Pak J Med. Sci 2016; 32(2):294–298 21. Becker JL, Milad MP, Klock SC. Burnout, depression, and career satisfaction: cross- sectional study of obstetrics and gynecology residents. Am J Obstet Gynecol. 2006; 195(5):1444–1449. 22. Gong Y, Han T, Chen W, Dib HH, Yang G, Zhuang R, Chen Y, Tong X, Yin X, Lu Z. Prevalence of anxiety and depressive symptoms and related risk factors among physicians in China: a cross-sectional study. PLoS One 2014; 9(7):e103242. 23. El-Hamrawya LG, Hegazy NN, El- Halawany SM. Prevalence of depressive symptoms among healthcare providers in Shibin El-Kom city in Menoufia governorate. Menoufia Med. J. 2018;31(2):708. 24. Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, et al. Depressive symptoms in medical students and residents: a multischool study. Acad Med 2009; 84(2):236–241. 25. Sen S, Kranzler HR, Krystal JH, Speller H, Chan G, Gelernter J, Guille C. A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry 2010; 67(6):557–565. 26. Erdur B, Ergin A, Turkcuer I, Parlak I, Ergin N, Boz B. A study of depression and anxiety among doctors working in emergency units in Denizli, Turkey. Emerg Med J 2006; 23(10):759–763. 27. Gu A, Onyeama GM, Bakare MO, Igwe MN. Prevalence of depression among resident doctors in a teaching hospital, South East Nigeria. Int J Clin Psychiatry 2015; 3(1):1–5. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v6.i1.2019.23-29