










































Age-Related Mental Health Consequences of 
COVID-19: A Global Perspective
Jean de la Rosette,1 Pilar Laguna,1 Guohua Zeng,2 Patrick Coloby,3 Adrián Momesso,4 Raed A. Azhar,5 
Piotr Chłosta,6 John Heesakkers,7 Nicolae Crisan,8 Leticia Ruiz,9,10,11 Damien Bolton,12 Reynaldo Gómez,13 
Laurence Klotz,14 Sanjay Kulkarni,15 Simon Tanguay,16 Stavros Gravas17; and on behalf of the Société 
Internationale d’Urologie (SIU) Board of Directors
1 Department of Urology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey 2 Department of Urology and Guangdong Key Laboratory of Urology,  
The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China 3 Department of Urology, Centre Hospitalier René Dubos, Pontoise, France 4 Department 
of Urology, Centro Diagnóstico Urológico, Buenos Aires, Argentina 5 Department of Urology, King Abdulaziz University, Jeddah, Saudi Arabia 6 Department of Urology, 
Jagiellonian University Medical College, Krakow, Poland 7 Unit of Functional Urology and Neurourology, Department of Urology, Radboud UMC, Nijmegen,  
The Netherlands 8 Department of Urology, Iuliu Ha ieganu University of Medicine and Pharmacy, Clinical Municipal Hospital, Cluj-Napoca, Romania 9 The Panama Clinic, 
Panama City, Panama 10 Department of Urology, Hospital Punta Pacífica, Pacífica Salud, Panama City, Panama 11 Hospital Nacional, Panama City, Panama 12        Department 
of Urology, Austin Health, Melbourne, Australia 13 Department of Urology, Universidad Andrés Bello, Hospital del Trabajador, Santiago, Chile 14 Division of Urology, 
Sunnybrook Health Sciences Centre, Toronto, Canada 15 Kulkarni Reconstructive Urology Center, Pune, India 16 Division of Urology, Department of Surgery, McGill 
University, Montreal, Canada. 17 Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece

Abstract

Purpose The Société Internationale d’Urologie (SIU) conducted a survey to determine whether the pandemic has 
harmed the mental health of practicing urologists worldwide.

Methods Members of the Executive Board of the SIU designed a self-selected survey consisting of multiple-
choice questions about the safety and mental health of urologists during the COVID-19 pandemic. The survey was 
disseminated by email to SIU members worldwide. 

Result A total of 3448 SIU members from 109 countries responded to the survey, which sought to determine the 
extent of mental health symptoms, including depression, anxiety, insomnia, and distress—experienced during 
the COVID-19 pandemic. Overall, 21% of urologists who responded reported that their mental health was very 
challenged, with 58% indicating increased stress levels, and 15% indicating greatly increased stress levels. Older 
urologists were less likely to report any of the negative mental health symptom queried (ie, delirium [rs = −0.06,  
P = 0.001], psychosis [rs = −0.04, P = 0.019], anxiety [rs = −0.09, P < 0.001], depression [rs = −0.08, P <0.001], distress  
[rs = −0.07, P < 0.001]), except insomnia (P > 0.20). Furthermore, 29% of urologists indicated they were afraid to go to 
work, while 53% reported being afraid to go home to their families after work.

Conclusions In this worldwide survey of practicing urologists, more than half of the participants reported an 
increase in insomnia, distress, and other psychological symptoms as they managed patients during the COVID-19 
pandemic, although half of respondents did not experience any mental health symptoms. Institutions should provide 
psychological coping resources to all health care staff, not only for the front-line workers during the pandemic.

Introduction

Data have begun to emerge about the ongoing pandemic’s psychological impacts on the front-line health care workers 
who have faced severe and unprecedented stressors in providing patient care[1–7]. As the novel coronavirus disease 
2019 (COVID-19) outbreak began in late 2019, leading health organizations rushed to provide resources to help front-
line health care workers cope with the psychological stress, basing their response on experiences with the 2003 severe 
acute respiratory syndrome (SARS) epidemic and the Ebola epidemic (2013–2016), among others[8–16].

Key Words Competing Interests Article Information

Mental health, urologists, coronavirus 
COVID-19, pandemic, global health, 
psychological symptoms

None declared. Received on September 23, 2020 
Accepted on November 21, 2020

Soc Int Urol J. 2021;2(1):25–31 

25SIUJ.ORG SIUJ  •  Volume 2, Number 1  •  January 2021

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http://www.siuj.org


COVID-19 has altered the way in which health care 
workers currently practice medicine and deliver care, 
regardless of specialty or discipline. From the curtail-
ment of routine and elective care to the intensification of 
protective protocols to the redeployment of non-specialist 
physicians to assist with direct care of COVID-19 
patients, the practice of medicine in the first months of 
2020 differs substantially from late 2019 norms.

Urologists (one of the affected groups of medical 
specialists) typically divide their time between patient 
consultations and surgery. They are not on the front line 
as emergency responders. However, because of increased 
staffing needs during the pandemic, some urologists and 
physicians in other second-line specialties have been 
redeployed to the emergency departments or COVID-19 
tents to assist with triage of presumed COVID-19 
patients, as well as to COVID-19 in-patient units and to 
intensive care units to manage critically ill patients.

As the clinical demands faced by health care 
practitioners have changed, so have the challenges 
of maintaining mental health equilibrium during an 
uncertain time. Thus, the mental health of all medical 
workers, including those outside the emergency 
medicine and critica l care disciplines, warrants 
evaluation during the pandemic. In this survey, the 
Société Internationale d’Urologie (SIU) aimed to capture 
the mental health challenges urologists are facing and to 
determine if these challenges vary by region, gender, or 
age groups.

Methods
Members of the Executive Board of the SIU designed 
the survey on safety and mental health. This was a self-
selected survey comprising multiple-choice questions 
about respondents’ demographics, as well as concerns 
related to contracting COVID-19 and the provision 
by health care institutions of personal protective 
equipment (PPE); information about how to protect 
staff and patients from COVID-19; and tools/support 
for managing increased stress. The full survey has been 
published, and issues related to PPE have been addressed 
separately[17]. This analysis deals with participants’ 
reports of concerns and stresses related to COVID-19, 
and the support they received from their institutions.

The survey was opened on April 16, 2020, and closed 
on May 1, 2020. It was administered online using the 
Aventri platform (Connecticut, US). Distribution of the 
survey took place via email, using names on the SIU 
eNews mailing distribution list (15 252 contacts). The 
survey included the reasons why it was being conducted 
and the importance of participation. No compensation 
was offered for its completion. All responses were 
anonymous.

To facilitate analysis of the impact of COVID-19 
on health care settings as it spread from East to 
West, respondents were grouped into the following 
regions: East/Southeast Asia and nearby regions, 
West/Southwest Asia and nearby regions, Europe, 
Africa, North America, and South America. The list of 
countries included in each region has been published 
elsewhere[17]. Information about age and gender 
was also analyzed to determine the impact of these 
parameters on mental health.

Statistical Analysis Strategy
Continuous variables were analyzed using omnibus 
one-way ANOVAs, with follow-up pairwise tests that 
were Bonferroni-corrected for multiple comparisons. 
Categorical questions were analyzed using omnibus 
Pearson chi-square tests, with a follow-up examination 
of the adjusted standardized residuals, which were also 
Bonferroni-corrected for multiple comparisons.

Data were analyzed by respondent age (selected from 
the following 4 categories: <40, 40–50, 51–60, >60), 
gender, and geographical region. Age was analyzed 
using Spearman rank-order correlations (rs).

Results
The SIU has a Central Office located in Montreal, 
Canada, and is governed by an international Board of 
Directors, with representatives in all continents. The SIU 
currently has 10 018 members in 131 countries. A total of 
3488 participants took the survey and the background 
demographics have been published elsewhere[17].

Overall, 21% of urologists reported that their mental 
health and that of their colleagues was very challenged 
during this pandemic, with 58% indicating that their 
stress levels increased, and 15% indicating their stress 
levels greatly increased (Figure 1). While urologists 
reported feeling appreciated as doctors involved in 
treating patients during the COVID-19 pandemic 
(median score, 7; range, 0–10), they reported that their 
mental health has been challenged significantly during 
the pandemic (median score, 6; range, 0–10).

In total, 29% of urologists reported that they were 
afraid to go to work and 53% reported that they were 
afraid to go home to their families after work. Urologists’ 
greatest reported fear relating to their work was infecting 
their families (57%), with 17% reporting fear that they 
might infect themselves (Figure 2). In addition, 14% of 
urologists reported that their biggest fear was that their 
ability to provide patient care would be compromised, 
and 10% reported that their biggest fear was that their 
institutions would not be able to handle the patient load.

26 SIUJ  •  Volume 2, Number 1  •  January 2021 SIUJ.ORG

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Many urologists reported that the challenge to 
their mental health may have resulted in symptoms of 
insomnia (21%), distress (17%), physical exhaustion 
(14%), severe anxiety (11%), depression (11%), psychosis 
(1.6%), posttraumatic stress disorder (PTSD) (1%), or 
delirium (1%). More than half (53%) the respondents 
reported experiencing no symptoms due to stress 
from COVD-19 (Figure 3). Overall, 84% of urologists 
reported that they know how to protect themselves, and 
74.5% said they were getting enough time off work to be 
healthy and recharge.

In total, only 27% of urologists reported receiving 
psychological or emotional coping tools or suggestions 
from their institutions (Figure 4). Among urologists 
who reported receiving these tools, 61% indicated they 
were provided with the option of meeting with mental 
health professionals, 33% reported receiving handouts 
on mental health, and 25% reported having access to 
workshops. In addition, 10% reported being required 
to meet with a mental health professional. Also, among 
urologists who reported receiving psychological or 
emotional coping tools, 53% received only one such tool, 
while 24% received 2 and 22% received 3 or more.

Only 22% of respondents indicated there was a 
team member, such as a nurse, psychosocial worker, or 
community social worker, trained to provide support 
to the health care team (Figure 4). Among the 78% who 

reported not receiving such support, 53% thought it 
would be helpful to have it.

Analyses were performed by gender, region, and age. 
The analysis of gender and geographical region did not 
yield clinically relevant results.

Age differences
Older urologists reported feeling more appreciated 
than younger urologists as doctors involved in treating 
patients during COVID-19 (rs = 0.11, P < 0.001). They 
were less likely than younger urologists to report that 
their own mental health and that of their colleagues was 
challenged during this pandemic (rs = −0.08, P < 0.001).
Older urologists were also less likely than younger 
urologists to report fear of going to work (rs = −0.04,  
P  = 0.025) or going home after work (rs = −0.16,  
P < 0.001). They also reported experiencing less 
avoidance by their family or community (rs = −0.10, 
P < 0.001), were more likely than younger urologists 
to report being most afraid that they would become 
infected (rs = 0.11, P < 0.001), and less likely to report 
being most afraid that members of their family would 
become infected (rs = −0.15, P < 0.001). 

Every negative mental health symptom queried 
(except insomnia [P > 0.20]) was less common in older 
urologists: delirium (rs = −0.06, P = 0.001), psychosis 
(rs = −0.04, P = 0.019), anxiety (rs = −0.09, P < 0.001), 

FIGURE 1. 

Impact of COVID-19 on stress level, by age (Survey question 22)
FIG 1 A79x                       
Figure 1. Impact of COVID-19 on Stress Level, by Age (Survey Question 22)

55.52 58.60 58.29
61.59

57.88

0

10

20

30

40

50

60

70

80

90

100

Greatly increased Increased Same Decreased

Pr
op

or
tio

n 
of

 re
sp

on
de

nt
s 

%

Degree of change in stress

16.89
13.48 14.27 12.60 14.71

22.82 23.80 25.27 23.74 23.58

4.78 4.11 2.17 2.24 3.76

<40 40–50 51–60 >60 Total

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FIGURE 3. 

Experience of symptoms due to COVID-19 (Survey question 24)

FIGURE 2. 

Biggest fears about COVID-19, by age (Survey question 23)

FIG 3 A79                       
Figure 3. Q24: Experience of Symptoms Due to COVID-19

10.9

21.3

Delirium Psychosis Severe anxiety Depression Insomnia

Symptom

Distress Physical
exhaustion

PTSD None

Abbreviation: PTSD, posttraumatic stress disorder

11.4

0.8 1.6

16.5

1.1

14.0

53.4 

0

10

20

30

40

50

60

70

80

90

100

Pr
op

or
tio

n 
of

 re
sp

on
de

nt
s 

%

FIG 1 A79x                       
Figure 1. Impact of COVID-19 on Stress Level, by Age (Survey Question 22)

64.09
59.27

49.59
42.48

56.54

Becoming infected Member of family becoming infected Fear of going to work Fear of going home

Degree of change in stress

13.34 14.82
18.07

27.24

16.74

31.71 29.70
25.78

29.49 29.09

62.59

52.72

43.73 43.49

52.98

<40 40–50 51–60 >60 Total

0

10

20

30

40

50

60

70

80

90

100

Pr
op

or
tio

n 
of

 re
sp

on
de

nt
s 

%

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depression (rs = −0.08, P < 0.001), distress (rs = −0.07, 
P < 0.001), PTSD (rs = −0.04, P = 0.025), and physical 
exhaustion (rs = −0.10, P < 0.001). Older urologists were 
less likely to report such outcomes overall (rs = −0.14,  
P < 0.001), but they were more likely to report having no 
symptoms (rs = 0.12, P < 0.001). 

Older urologists were more likely than younger 
urologists to report feeling that they knew how to 
protect themselves at work from becoming infected with 
COVID-19 (rs = 0.08, P < 0.001), and were more likely 
to report getting enough time off work to recover and 
recharge (rs = 0.09, P < 0.001). Older urologists were 
also less likely to report sleeping at their institutions  
(rs  = −0.24, P < 0.001).

Older urologists were not more likely than younger 
urologists to report that their institutions provided 
them with psychological or emotional coping tools  
(P > 0.25) or to report that there was someone on their 
team trained to provide psychosocial support (rs = 0.03, 
P = 0.065). Among urologists who said that there was 
no such person on their team, older urologists were less 
likely than younger urologists to say that such a person 
would be helpful (rs = −0.10, P < 0.001).

Discussion
Recent evidence suggests that COVID-19 has taken its 
toll on the mental and physical health of physicians and 

related health professionals, as well as on the general 
population[1-7].

This survey addressed the impact of the COVID-19 
pandemic on the mental well-being of urologists, 
who typically do not work with infected patients. 
Nonetheless, physical or mental symptoms due to 
COVID-19 were reported by nearly half of urologists. 
Despite their lack of front-line exposure to COVID-19 
patients, urologists reported overall high rates of 
negative mental health and well-being outcomes. 
Almost one-third reported that they were afraid to go 
to work, while more than half reported that they were 
afraid to go home to their families after work. These 
findings may be explained by the fact that health care 
workers are fighting an invisible and virulent enemy in 
high-risk settings. A continuous and seemingly endless 
number of COVID-19 patients have been treated by 
urologists during the past months, which has relentlessly 
challenged the boundaries of their own mental and 
physical limits.

With limited short-term perspective on the one 
hand, and lack of PPE and mental health support on 
the other, it comes as no surprise that the challenges 
we are facing are similar to those encountered during 
earlier pandemics such as SARS; however, the impact 
of the COVID-19 pandemic is novel. During the past 
decade(s), health care systems have evolved, with the 

FIGURE 4. 

Ability/support received to address fears about COVID-19, by age (survey question 25)
FIG 1 A79x                       
Figure 4. Ability/Support Received to Address Fears About COVID-19, by Age (Survey Question 25)

71.83
78.30 79.16

83.55
76.95

0

10

20

30

40

50

60

70

80

90

100

Know how to protect oneself  Getting enough time off work Hospital provides coping tools Hospital provides psychosocial support

Pr
op

or
tio

n 
of

 re
sp

on
de

nt
s 

%

Knowledge/support to address COVID-19 fears

82.88
86.82 88.90 86.33

25.97 26.25 28.35 26.77 27.55
20.73 22.70

23.74 24.24 22.43

<40 40–50 51–60 >60 Total

89.94

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training of physicians occurring under strict working 
directives and hours-of-service limits. An increasing 
number of physicians are working fewer hours per week 
and giving greater importance to their quality of life 
rather than making work their priority.

While we did not observe any striking differences in 
mental health impact by region or gender, we observed 
significant differences in various mental health domains 
among age groups. Older urologists reported that their 
mental health and that of their colleagues was less 
challenged during this pandemic than the mental health 
of younger urologists, and they were less likely than 
younger urologists to be afraid to go to work or afraid 
they would infect their family when they returned home. 
On the other hand, older urologists were more likely 
to be concerned about becoming infected themselves. 
Given that their age makes them more vulnerable, this is 
a reasonable reaction.

Although we did not observe high proportions of 
reports of severe negative mental health outcomes, such 
as delirium, psychosis, or PTSD, there were relatively 
high rates of reported anxiety, depression, insomnia, and 
distress. All symptoms except insomnia were more likely 
to be reported by younger urologists. Older urologists 
were also more likely than their younger counterparts to 
report having no mental health symptoms at all.

This analysis offers the prospect of constructing a 
profile of the most psychologically vulnerable. This 
would be difficult within the present dataset. While 
the initial analysis suggested that single urologists 
showed several worse mental health outcomes than 
those with partners, after controlling for age, the 
social environment factor no longer emerged as an 
independent predictor. Only age was predictive.

Older urologists reported feeling more appreciated 
than younger urologists, and they were less likely than 
younger urologists to indicate that their mental health 
and that of colleagues was challenged during this 
pandemic.

Despite the challenges that urologists face in terms of 
their mental health and well-being, they reported that 
they were not receiving adequate coping tools from their 
institutions. Only 22% had a team member trained to 
provide psychosocial support and 53% of those who did 
not have such support reported that it would be helpful.

Both patients and health care professionals have 
been affected by the psychosocial consequences of the 
COVID-19 crisis[1-7]. Several groups have been working 
on specific guidelines for mental health services for 
the COVID-19 outbreak, but their efforts may not 
have reached non-front-line health care professionals. 

The greater impact on the psychological functioning 
of younger doctors warrants further exploration. The 
effectiveness of this approach has been demonstrated 
among health care workers in China, where early 
intervention decreased the prevalence of insomnia in 
front-line professions within a short time period [18]. 
In addition, during the previous SARS outbreak, health 
care workers with higher levels of trust in equipment 
or infection-control initiatives showed lower levels of 
emotional exhaustion and mental problems[19].

The present survey provides a global snapshot of 
a group of medical specialists who are partly involved 
in handling and treating COVID-19-infected patients. 
Adverse psychological effects were common, and 
adequate support was rare. We propose that large-scale 
epidemiological surveys be conducted to help examine 
the prevalence of mental health problems associated 
with the COVID-19 pandemic in different sub-
populations, including health care workers. We hope 
that these findings may be shared with our colleagues 
in psychology/psychiatry to benefit further research and 
address the growing problem in mental health issues 
during the pandemic.

These are extraordinary times demanding extraordi-
nary actions. We believe that health care workers need 
and are entitled to adequate work-related psychosocial 
supports from their institutions. We conclude by 
quoting Greenberg et al.: “There is a pressing need to 
ensure that the tasks ahead do not cause long-lasting 
damage to health care staff. They will be the heroes of 
the day, but we will need them for tomorrow”[7].

There are several limitations to this survey. First, 
the questionnaire itself was not validated, as we aimed 
to capture the data rapidly during the initial stages 
of the pandemic. This survey is limited by its self-
selected nature. The survey was restricted to urologists, 
because of the composition of SIU membership. The 
participation by region of urologists in Africa and South 
America was low, as was the participation of women 
(11.4%). Unfortunately, the subdivision of regions was 
decided at the time of the survey preparation and did not 
directly correspond to the WHO regional classification, 
so it was not possible to compare the pandemic load 
by region with the WHO data[8]. In addition, we did 
not find any significant differences in outcome by 
region. The survey’s strength is that it provides a global 
snapshot of the mental health conditions in a significant 
sample size (3488 participants). It seems apparent from 
the survey that there is a worldwide need for further 
resources to address the adverse mental health effects 
of the pandemic on urologists and other health care 
workers.

30 SIUJ  •  Volume 2, Number 1  •  January 2021 SIUJ.ORG

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Conclusions

Urologists face substantial struggles with respect to their 
mental health and well-being during the COVID-19 
pandemic, and many are not offered adequate coping 
tools or support from their institutions. Older urologists 
reported better mental health and well-being outcomes 
than younger urologists.

Acknowledgments

The authors would like to acknowledge support from 
the SIU Central Office, including Merveille de Souza, 
Carrie Thompson, Melissa St-Onge, Susie Petrusa, 
and Christine Albino, for editorial support; and the 
contributions of Darcy Lewis and Alison Palkhivala 
for medical writing support, and Michael Barlev for 
statistical support.

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31SIUJ.ORG SIUJ  •  Volume 2, Number 1  •  January 2021

Age-Related Mental Health Consequences of COVID-19: A Global Perspective

 https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_10
 https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_10
 https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_10
 https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_10. Accessed May 26, 2020
 https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_10. Accessed May 26, 2020
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