Prevalence of Depression, Anxiety, Post-Traumatic Stress, and Insomnia Symptoms Among Frontline Healthcare Workers in a COVID-19 Hospital in Northeast Mexico

The COVID-19 pandemic, declared by WHO on March 11, 2020, has been associated with elevated psychological burden across populations, including frontline healthcare workers (FHCWs). Prior outbreaks and early pandemic studies reported increased depression, anxiety, sleep disturbances, and post-traumatic stress among FHCWs. In Mexico, first cases were confirmed on February 28, 2020, and the country subsequently ranked among the highest in COVID-19 deaths, with Mexican FHCWs experiencing significant psychological distress and the highest mortality among HCWs globally. Contributing contextual factors included workforce shortages, supply shortages, intense workload, shifting schedules, and social stigma/violence toward HCWs. Prior Mexican studies identified higher risk of mental health symptoms among women, younger workers (≤39–40 years), FHCW status, and those with positive COVID-19 status; nurses and residents may be at higher risk than attending physicians. This study aimed to determine the prevalence of depression, anxiety, post-traumatic stress, and insomnia symptoms, and associated factors (gender, age, working position, marital status, drug use, transportation, and work hours) among FHCWs in a third-level COVID-19 hospital in northeast Mexico.

International and Mexican studies early in the pandemic reported elevated mental health symptoms among FHCWs, with variability by wave and context. Lai et al. (China) found lower depression, anxiety, and insomnia but higher post-traumatic stress in early 2020 compared to this study’s later timeframe. Repeated cross-sectional studies suggest depression increased from first to subsequent waves, while anxiety, insomnia, and post-traumatic stress varied. Meta-analyses and systematic reviews report higher burden among women and nurses compared to men and physicians. Mexican multicenter studies (Robles et al.) during early phases found high depression, anxiety, and PTSD; residents and general practitioners often exhibited higher burden than nurses and attending physicians. Reasons for heightened risk in nurses include heavy workload, role-specific stressors (e.g., patient death, conflict, limited support), and maladaptive coping; supportive cultures and coping strategies can mitigate risk. Residents face mistreatment, long hours, workload as punishment, and low pay in Mexico, potentially increasing distress. Being female, single, and young are repeatedly associated with higher risk of depression, anxiety, and stress in pandemics.

Design: Observational, cross-sectional, descriptive study at Centro Medico Zambrano-Hellion (CMZH), a third-level care hospital attending COVID-19 patients in northeast Mexico. Participants and recruitment: Invitation emails were sent to all medical staff (nurses, attending physicians, residents/fellows) aged ≥18 years providing direct care to hospitalized COVID-19 patients. Recruitment occurred August 28 to November 30, 2020 (approximately six months after first Mexican cases). Participants provided electronic informed consent and registered with institutional email; duplicate responses were prevented. Participants reported any prior/current psychiatric diagnosis and treatment; all could complete the survey, but those with prior/current psychiatric diagnosis under treatment, those without consent, and those with missing survey data were excluded from final analyses. Data were anonymized. Participants above cut-off on any scale were referred to mental health specialists. Ethics: Approved by institutional Ethics (P000392-SaludMental_COVID19-CEIC-CR003; CONBIOETICA 19 CEI 011-2016-10-17) and Research (P000392-SaludMental_COVID19-CI-CR003; COFEPRIS 20 CI 19 039 002) committees, in accordance with the Declaration of Helsinki. Measures: Survey captured gender, age, marital status, transportation mode, nonmedical drug use, occupation (attending physician, resident/fellow, nurse), and daily working hours. Mental health measures included: - PHQ-9 for depression; 9 items scored 0–3; total 0–27; cut-off ≥10 (sensitivity/specificity ~88%); Spanish-validated in Mexico (α≈0.89). - GAD-7 for anxiety; 7 items scored 0–3; total 0–21; Spanish cut-off ≥10 (sensitivity 86.8%, specificity 93.4%; α≈0.936). - IES-R for post-traumatic stress related to COVID-19; cut-off ≥33 (sensitivity 91%, specificity 82%); Spanish-validated (α≈0.98). - ISI for insomnia; 7 items scored 0–4; total 0–28; cut-off ≥10 (sensitivity 86.1%, specificity 87.7%); Spanish-validated (α≈0.82). Statistical analysis: Data entry in Excel; analysis in SPSS v23. Normality by Shapiro–Wilk. Descriptives: mean±SD or median (IQR) for continuous; frequencies and percentages for categorical. Group comparisons (symptom above vs. below cut-off) by chi-squared tests for variables of interest (gender, age, position, marital status, transport, drug use, work hours). Binary logistic regression estimated unadjusted and adjusted odds ratios (ORs) with 95% CIs for risk factors for each outcome; model fit assessed with Hosmer–Lemeshow. Significance set at P<0.05.

Participants: Of 325 eligible FHCWs, 131 were included after exclusions (129 did not consent/participate, 41 reported personal psychiatric history, 24 had missing data). Sample: 63% women (83/131), mean age 33.9±8.2 years (21–71), 43% attending physicians (57), 20% residents/fellows (26), 37% nurses (48). Work hours: 66% had ≥12-hour shifts. Number of symptoms above cut-offs: 56% had 0 symptoms; 18% had 3–4 symptoms. Prevalence: Depression (PHQ-9 ≥10) 35.9% (47/131); Anxiety (GAD-7 ≥10) 20.6% (27/131); Post-traumatic stress (IES-R ≥33) 22.9% (30/131); Insomnia (ISI ≥10) 24.4% (32/131). Group differences (chi-squared): - Women vs men: higher depression (79% vs 21% of cases; P=0.006) and higher post-traumatic stress (83% vs 17%; P=0.010); anxiety and insomnia not significantly different by gender. - Age: depression more prevalent in ≤40 vs >40 years (92% vs 8% of cases; P=0.021); other outcomes not significantly different by age. - Position: residents/fellows and nurses had higher depression and insomnia than attendings; e.g., depression P<0.001 across positions; insomnia P=0.035. - Marital status: depression higher in single vs married (P<0.001). Among single FHCWs, most were women (72%; P=0.029) and ≤40 years (93%; P<0.001). Unadjusted ORs (selected): - Female sex associated with higher odds of depression (OR 3.06, 95% CI 1.35–6.94, P=0.008) and post-traumatic stress (OR 3.71, 95% CI 1.31–10.47, P=0.013). - Position vs attending: residents/fellows had higher odds of depression (OR 8.53, 95% CI 2.95–24.72, P<0.001) and insomnia (OR 3.83, 95% CI 1.29–11.36, P=0.016); nurses had higher odds of depression (OR 4.51, 95% CI 1.82–11.22, P=0.001) and a trend for PTSD (OR 2.42, 95% CI 0.95–6.19, P=0.064) and insomnia (OR 2.52, 95% CI 0.95–6.67, P=0.062). - Married status protective for depression (OR 0.26, 95% CI 0.12–0.56, P=0.001). - Age >40 protective for depression (OR 0.28, 95% CI 0.09–0.87, P=0.028). Adjusted model for depression (PHQ-9): - Female vs male: aOR 3.05 (95% CI 1.03–8.97), P=0.043. - Residents/fellows vs attending: aOR 7.64 (95% CI 2.30–25.35), P=0.001. - Nurses vs attending: aOR 2.93 (95% CI 1.09–7.87), P=0.033. - Married vs single: aOR 0.38 (95% CI 0.16–0.90), P=0.028. Model fit: Hosmer–Lemeshow χ2=4.546, df=7, P=0.715. Sub-analysis (residents/fellows vs nurses): Not statistically significant; nurses showed non-significant lower odds for depression (OR 0.53), anxiety (OR 0.59), insomnia (OR 0.66), and higher odds for PTSD (OR 1.52) relative to residents/fellows.

The study documents substantial mental health symptom burden among Mexican FHCWs during August–November 2020. Compared to early Chinese data (Lai et al.), depression and insomnia were higher while PTSD was lower, potentially reflecting timing differences (later wave), evolving stressors (e.g., prolonged workload, bereavement), and context (converted COVID-19 hospital with adequate PPE possibly reducing PTSD). Consistent with meta-analyses and Western reviews, women and nurses showed greater vulnerability; residents/fellows also exhibited elevated risk, aligning with Mexican data indicating residents may be particularly affected. Possible mechanisms include role-specific stressors for nurses (workload, conflict, exposure to death, limited support) and structural issues in Mexican residency (mistreatment, excessive hours, low pay), compounded by elevated perceived infection risk and societal stigma during the pandemic. Female sex, single status, and younger age were associated with higher depression, consistent with literature suggesting hormonal, social, and caregiving burdens and greater pandemic-related domestic responsibilities among women. Findings underscore the need for targeted psychological and organizational support, including interventions promoting adaptive coping, team support, workload management, and policies addressing the specific needs of women, nurses, and trainees.

Among FHCWs in a private COVID-19 hospital in northeast Mexico, symptoms of depression (36%), anxiety (21%), post-traumatic stress (23%), and insomnia (24%) were prevalent. Residents/fellows and nurses experienced higher depression and insomnia than attending physicians, while being married was protective for depression; men had less post-traumatic stress in unadjusted analyses. Health authorities and institutions should prioritize timely detection and management of psychiatric symptoms, with targeted support for residents/fellows and nurses, to mitigate long-term mental health consequences.

Cross-sectional design precludes causal inference; sample size was modest with no control group. Conducted in a private hospital with adequate supplies/PPE, limiting generalizability to public institutions. No sub-analyses by specialty or unit (e.g., ICU) due to staffing rotations; frequent changes between day/night shifts precluded shift-based comparisons. Recruitment and exclusion criteria (excluding those with prior/current psychiatric diagnosis under treatment) may affect prevalence estimates.