Acute psychological effects of Coronavirus Disease 2019 outbreak among healthcare workers in China: a cross-sectional study

The COVID-19 outbreak that began in Wuhan, China in December 2019 rapidly escalated into a public health emergency, generating widespread psychological stress. Healthcare workers (HCWs), who are essential to outbreak control, face heightened risks of infection and death, as seen previously in SARS, MERS, and Ebola, and consequently may experience acute psychological effects such as depression, anxiety, and PTSD. Additional stressors during the early outbreak phase included uncertainty about the epidemic’s trajectory, heavy clinical workload, and shortages of protective resources. Despite the launch of psychological intervention programs in China, baseline data and risk factors for HCWs’ psychological well-being were limited, and prior research emphasized long-term comorbidities rather than acute effects. This study aimed to assess the acute psychological effects (depression, anxiety, and PTSD) among HCWs in the early stage of the COVID-19 outbreak in China and to identify associated socioeconomic and occupational risk factors to inform targeted interventions.

Design: Cross-sectional, survey-based study conducted in China from January 20 to February 7, 2020. Participants and recruitment: Targeted doctors and nurses working in hospitals with fever clinics or COVID-19 wards. Recruitment emphasized Wuhan (epicenter), with additional participants from other areas of Hubei Province and other Chinese provinces. Data were collected via the anonymous online platform Yunxiang (www.yjx.cn). Sample size estimation used N = Z^2 p (1 − p) / d^2 with α = 0.05 (Z=1.96), p=0.20, and d=0.10, yielding a minimum of ~1600. Ethics and consent: Approved by the Clinical Research Ethics Committee of Renmin Hospital of Wuhan University (WDY2020K1004). Electronic informed consent obtained; only respondents selecting “yes” proceeded to the questionnaire. The anonymous questionnaire had 74 required items and took ~10 minutes; respondents could terminate at any time. Measures: - Depression: Patient Health Questionnaire-9 (PHQ-9); validated in Chinese populations, Cronbach’s α=0.89. Total score 0–27; depression defined as ≥10. - Anxiety: Generalized Anxiety Disorder-7 (GAD-7); Cronbach’s α=0.89. Total score 0–21; anxiety defined as >6. - PTSD: Impact of Event Scale–Revised (IES-R); 22 items with intrusion, avoidance, and hyperarousal subscales. Total IES-R score is the mean across items; subscales are means of their items. PTSD indicated by total score ≥33. Subscale reliabilities: 0.87 (Intrusion), 0.85 (Avoidance), 0.83 (Hyperarousal). Covariates: - Occupational: occupation (doctor/nurse), technical title (junior/intermediate/senior), hospital type (secondary/tertiary), frontline status (directly engaged in fever/COVID-19 care: yes/no), sufficient training for protection (yes/no), sufficient protective resources (yes/no), confidence in protection measures (yes/no), worry about infection (yes/no). - Socioeconomic: gender, age, marital status (unmarried/married/widowed or divorced), education (undergraduate or less vs postgraduate or higher), location (Wuhan; Hubei except Wuhan; other provinces). Data processing and analysis: 2367 questionnaires were initially completed (response rate 73.6%). Exclusions: 346 with completion time <5 min (300 s) or >20 min (1200 s), and 124 from provinces contributing <20 participants, leaving 1897 for analysis. Categorical variables summarized as n (%). Group comparisons used Chi-square tests. Associations between covariates and outcomes (depression, anxiety, PTSD) assessed via logistic regression; binary logistic models estimated odds ratios (ORs) with 95% confidence intervals (CIs). Analyses conducted in SPSS 20.0; α=0.05.

Sample characteristics (N=1897): 17.5% male, 82.5% female; 61.7% aged 25–40; 67.5% married; 84.8% with undergraduate or less education. Location: 49.5% Wuhan, 26.6% Hubei (except Wuhan), 23.9% other provinces. Occupation: 29.7% doctors, 70.3% nurses. Hospital type: 76.3% tertiary. Frontline: 39.1%. Protection-related: 71.0% reported sufficient training; 78.8% sufficient resources; 68.4% confidence in protection measures; 82.8% worried about infection. Prevalence of acute psychological effects: depression 15.0%; anxiety 27.1%; PTSD 9.8%. Risk and protective factors (multivariable logistic regression): - Depression and/or anxiety: Associated with intermediate technical title, frontline work, insufficient training for protection, lack of confidence in protection measures; worry about infection increased risk for all three outcomes; HCWs in Hubei (except Wuhan) had lower anxiety risk vs Wuhan. - PTSD: Higher risk among nurses (vs doctors), those with intermediate technical title, frontline workers, and those lacking confidence in protection measures; worry about infection also increased risk. - Protective: Not working at the frontline was protective against depression, anxiety, and PTSD.

The study addressed the acute psychological impact of the early COVID-19 outbreak on HCWs and identified modifiable occupational risk factors. Elevated rates of depression, anxiety, and PTSD among HCWs—especially those working on the frontline—underscore the psychological burden of rapid outbreak response, infection risk, and resource constraints. Findings that insufficient training and low confidence in protective measures are associated with worse psychological outcomes suggest that strengthening infection-prevention training, ensuring adequate protective resources, and improving communication about protection efficacy may mitigate distress. The higher risk among nurses and those with intermediate technical titles highlights the need for targeted mental health support for these groups. Regional differences (lower anxiety outside Wuhan within Hubei) reflect varying exposure intensity, reinforcing the contextual nature of risk. Overall, the results inform the design and prioritization of psychological interventions during infectious disease outbreaks to protect HCWs’ mental health and sustain healthcare system capacity.

This cross-sectional survey of Chinese HCWs during the initial COVID-19 outbreak documented substantial acute psychological effects, with depression (15.0%), anxiety (27.1%), and PTSD (9.8%) prevalent. Frontline work, intermediate technical title, inadequate protection training, lack of confidence in protective measures, and worry about infection were key risk factors; nurses were particularly vulnerable to PTSD. The findings support immediate implementation of psychological interventions, along with comprehensive training and reliable protective resources to bolster HCWs’ confidence and safety before and during frontline deployment. Future research should use longitudinal designs to track long-term mental health trajectories, evaluate intervention effectiveness, and delineate causal pathways between occupational exposures, protective factors, and psychological outcomes across diverse healthcare settings.