JOURNAL OF MEDICAL INTERNET RESEARCH Hummel et al

Original Paper

Mental Health Among Medical Professionals During the COVID-19

Pandemic in Eight European Countries: Cross-sectional Survey
Study

Svenja Hummel1*; Neele Oetjen1*, MSc; Junfeng Du1,2, MSc; Elisabetta Posenato1, MSc; Rosa Maria Resende de
Almeida3, MSc; Raquel Losada3, MSc; Oscar Ribeiro4, PhD; Vincenza Frisardi5, MA, MD; Louise Hopper6, PhD;
Asarnusch Rashid7, PhD; Habib Nasser8, PhD; Alexandra König9, PhD; Gottfried Rudofsky10, MD; Steffi Weidt11,
Dr med, PD; Ali Zafar1, MSc, MA; Nadine Gronewold1, MSc; Gwendolyn Mayer1, Dipl-Psych; Jobst-Hendrik Schultz1,
Dr med, PD
1
Department of General Internal and Psychosomatic Medicine, Heidelberg University Hospital, Heidelberg, Germany
2
Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
3
Intras Foundation, Valladolid, Spain
4
Center for Health Technology and Services Research, Department of Education and Psychology, University of Aveiro, Aveiro, Portugal
5
Geriatric and NeuroRehabilitation Department, AUSL-IRCCS Reggio Emilia, Emilia, Italy
6
School of Psychology, Faculty of Science and Health, Dublin City University, Dublin, Ireland
7
ZTM Bad Kissingen GmbH, Bad Kissingen, Germany
8
R&D Department, RDIUP, Les Mureaux, France
9
Memory Clinic, Institut Claude Pompidou, Nice, France
10
Clinic for endocrinology and metabolic disorders, Kantonspital Olten, Olten, Switzerland
11
Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital Zurich, University of Zurich, Zurich, Switzerland
*
these authors contributed equally

Corresponding Author:
Neele Oetjen, MSc
Department of General Internal and Psychosomatic Medicine
Heidelberg University Hospital
Im Neuenheimer Feld 410
Heidelberg, 69120
Germany
Phone: 49 62215632408
Email: Neele.Oetjen@med.uni-heidelberg.de

Abstract
Background: The death toll of COVID-19 topped 170,000 in Europe by the end of May 2020. COVID-19 has caused an
immense psychological burden on the population, especially among doctors and nurses who are faced with high infection risks
and increased workload.
Objective: The aim of this study was to compare the mental health of medical professionals with nonmedical professionals in
different European countries during the COVID-19 pandemic. We hypothesized that medical professionals, particularly those
exposed to COVID-19 at work, would have higher levels of depression, anxiety, and stress. We also aimed to determine their
main stressors and most frequently used coping strategies during the crisis.
Methods: A cross-sectional online survey was conducted during peak COVID-19 months in 8 European countries. The
questionnaire included demographic data and inquired whether the participants were exposed to COVID-19 at work or not. Mental
health was assessed via the Depression Anxiety Stress Scales32 (23.53)–21 (DASS-21). A 12-item checklist on preferred coping
strategies and another 23-item questionnaire on major stressors were completed by medical professionals.
Results: The sample (N=609) consisted of 189 doctors, 165 nurses, and 255 nonmedical professionals. Participants from France
and the United Kingdom reported experiencing severe/extremely severe depression, anxiety, and stress more often compared to
those from the other countries. Nonmedical professionals had significantly higher scores for depression and anxiety. Among

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medical professionals, no significant link was reported between direct contact with patients with COVID-19 at work and anxiety,
depression, or stress. “Uncertainty about when the epidemic will be under control” caused the most amount of stress for health
care professionals while “taking protective measures” was the most frequently used coping strategy among all participants.
Conclusions: COVID-19 poses a major challenge to the mental health of working professionals as a considerable proportion
of our participants showed high values for depression, anxiety, and stress. Even though medical professionals exhibited less
mental stress than nonmedical professionals, sufficient help should be offered to all occupational groups with an emphasis on
effective coping strategies.

(J Med Internet Res 2021;23(1):e24983) doi: 10.2196/24983

KEYWORDS
mental health; COVID-19; Europe; medical professionals; stress; depression; anxiety; coping; stressors

Even 30 months after exposure to SARS, psychiatric disorders

Introduction were prevalent among SARS survivors [17].
Background COVID-19 and Medical Professionals
The death toll of COVID-19 topped 170,000 in Europe by the “Breathe. It’s what we all want these days, doctors and patients,
end of May 2020 [1]. Italy, Spain, France and the United nurses and care workers. All of us. We want air,” wrote an
Kingdom were among the worst affected countries with respect Italian frontline doctor from Milan in April during the peak of
to high infection rates and overburdened health care systems COVID-19 while sharing his routine of wearing a mask all the
[2-4]. Deaths of approximately 0.9 per 1 million inhabitants for time [18].
Spain and France, 1.45 for Italy, and 3.94 for the United
Kingdom were reported at the end of May. The death rate in Among the health care workers struggling to cope with the
Portugal was high as well with 1.32 deaths per million situation of doing their jobs while trying to protect themselves
inhabitants [5]. Nevertheless, it was not one of the most affected and their families [19], one would suspect doctors and nurses
countries [6,7]. Mortality in Germany was 0.47 deaths per 1 to be the most affected psychologically. During SARS,
million inhabitants, Austria 0.52, and Switzerland 0.3 [5]; these physicians who had direct contact with infected patients
values are lower but nevertheless alarming. As the number of expressed greater mental distress, more stigmatization, and more
cases soared, national governments introduced widespread worries about infecting their family [20]. This was confirmed
restrictions to control the virus spread such as closing down during the COVID-19 pandemic in Italy where frontline health
borders, social distancing, travel restrictions, wearing of masks, care workers reported posttraumatic stress symptoms [21].
working from home, and closure of public facilities [8,9]. The Thousands of medical professionals were sent into quarantine
impending risk of infection, increasing number of COVID-19 after contracting COVID-19 in Italy, France, and Spain [22].
cases, and the overburdening of health care systems created an The fact that they came so close to the disease put their mental
unprecedented situation, which impacted not only everyday life health at a higher risk than the general population [19]. The
but also the psychological welfare of the general population. psychological challenges of the pandemic have been described
for nurses and doctors in Europe [23,24]. Stronger effects on
COVID-19 and Mental Health the mental health of medical health workers compared to
A recent study in 41 countries showed high stress levels in the nonmedical health workers [25] and a high prevalence of mental
general population during the COVID-19 pandemic, similar to health symptoms among physicians and other medical staff have
those reported during the severe acute respiratory syndrome also been reported in China [26,27].
(SARS) epidemic in 2003 [10]. Depressive symptoms increased Coping Strategies and Major Stressors
from 8.5% before COVID-19 to 27.8% during COVID-19 in a
US study [11]. Studies have shown a similar picture for Europe. A 2012 study with nurses showed that negative coping strategies
An Italian study concluded that leaving home for work was led to higher levels of mental distress whereas positive coping
associated with increased stress, which may be due to the fear was partly negatively correlated with depression and anxiety
of getting infected [12]. In a study from Spain during the levels [28]. During SARS, physicians in Toronto were mainly
lockdown, about 34% and 21% of the participants reported concerned about disparities in the health care of non-SARS
moderate to extremely severe depression and anxiety, patients because of the special situation [20] while nurses in
respectively [13]. A study from the United Kingdom reported Taiwan experienced “endangering of colleagues” as a major
high mental distress during the lockdown [14]. The first part of stressor [29]. Getting information about the virus and sticking
a French study in March 2020 found that the prevalence of to infection control procedures seemed to be important coping
anxiety among the general population was twice as high as strategies [20,29]. During the COVID-19 pandemic, coping
reported in a study before COVID-19 [15]. In comparison, a strategies and stressors of health care workers have been
study in Hong Kong found that about one-third of SARS investigated in China, showing that health care workers worried
survivors still suffered from moderate to severe or severe anxiety a lot about possibly infecting their families and were highly
and/or depressive symptoms 4 weeks after their recovery [16]. stressed by witnessing the deaths of infected patients. Adhering
to protective measures and learning more about COVID-19
were most often used to cope [30,31].

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Objectives
Methods
At a time when public health systems are overburdened in the
fight against COVID-19 [2], physically and mentally healthy Study Design
professionals are essential for the provision of reliable and We used a cross-sectional, multilingual survey design to
efficient health care services. Physician burnout has been linked investigate the mental health of working professionals in 8
with medical errors [32] and further harmful effects for European countries (Germany, the United Kingdom, Spain,
coworkers, patients, and the whole health care system [33]. The France, Portugal, Austria, Italy, and Switzerland) during 3
influence of COVID-19 on mental health in individual European months of the COVID-19 crisis between April 1 and June 20,
countries and/or in individual population groups has been 2020. The focus was on medical professionals and whether they
assessed, but a clear answer to the question of an overall were exposed to COVID-19 at work. Additionally, we asked
impression of mental health in Europe during the peak months about the most stressful aspects of work and coping strategies
of the pandemic is still lacking. As global rates of infections most often used. Ethical approval for this study was granted by
rise once again and an effective vaccine remains unavailable, the Ethics Commission of the Medical Faculty of Heidelberg
this question gains further relevance for determining mental University (S-361/2020).
health care needs for working professionals in the near future.
Participants
This study aimed to explore medical and nonmedical
professionals’ mental health in different European countries The participants were recruited online via public social
during the 3-month state of emergency due to the pandemic and networking groups and via the authors’ European contacts with
whether or not it was influenced by exposure to the virus at partner organizations from international joint projects.
work. We hypothesized that medical professionals, particularly The sample (N=609) included 354 people with medical
those exposed to COVID-19 at work, would show higher scores professions, including 189 doctors and 165 nurses (including
in depression, anxiety, and stress compared to nonmedical geriatric care), and 255 people with nonmedical occupations
professionals. Moreover, we investigated which aspects of the (eg, teachers, office staff, psychologists, retired persons, social
COVID-19 pandemic worried medical professionals the most workers). Participants were aged 18-84 years (median 41 years)
while at work and which coping strategies they most frequently with 151 males and 458 females.
employed. By uncovering these stressors and coping strategies,
it might be possible to devise policies to prepare and support The percentage distribution of participants and professional
medical professionals better for future crises. groups in different European countries is summarized in Table
1.

Table 1. Distribution of professional groups within European countries.

Country Medical professionals, n (%) Nonmedical professionals, n (%) Total, n
Germany 100 (73.53) 36 (26.47) 136
Austria 6 (28.57) 15 (71.43) 21
Switzerland 33 (82.50) 7 (17.50) 40
France 15 (28.85) 37 (71.15) 52
Italy 142 (89.31) 17 (10.69) 159
Spain 28 (28.28) 71 (71.72) 99
Portugal 25 (54.35) 21 (45.65) 46
United Kingdom 5 (8.93) 51 (91.07) 56

it difficult to relax”). The responses are rated on a 4-point Likert

Measurements scale ranging from 0 (did not apply to me at all) to 3 (applied
The survey consisted of a questionnaire derived from several to me very much or most of the time) to indicate how much the
validated instruments, with added items on demographics (eg, statement applied to the participant over the past week.
gender, age, marital status, etc) and a question on whether or According to Lovibond and Lovibond [34], the authors of the
not the participants were exposed to patients with COVID-19 questionnaire, scores for the subscales are calculated by adding
at work. the answers of the 7 items for each subscale and then multiplying
Mental stress was assessed via the Depression Anxiety Stress the result by 2 to get the total score for each participant for
Scales–21 (DASS-21)—a shorter version of the DASS-42 comparison to the DASS normative data [35].
[34]—which is available in different languages. The DASS-21 To determine the most important stressors for medical staff, we
consists of 21 items, which can be divided into 3 subscales, used a questionnaire similar to the one used in a study by Lee
each containing 7 items to measure depression (eg, “I couldn't et al [29] on SARS, which contains specific items for medical
seem to experience any positive feeling at all”), anxiety (eg, “I staff. The questionnaire consisted of 23 items. On a Likert scale
was aware of dryness of my mouth”), and stress (eg, “I found from 0 (not at all) to 4 (very much), the participants indicated

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how often they thought about or were concerned about the severe, and extremely severe [34]. These subscales were then
individual stressors in their everyday life or at work. Given the grouped as normal/mild, moderate, and severe/very severe.
focus of the study, this questionnaire was completed only by
We created two groups: medical professionals consisting of
the medical staff participants.
doctors and nurses; and nonmedical professionals, which
Also based on Lee et al [29], we derived a questionnaire on included other jobs in health care, volunteers, nonmedical staff,
coping strategies where participants could respond to 12 items and community health care workers.
using a scale from 0 (almost never) to 3 (almost always).
Descriptive analysis (including means, SDs, and frequencies)
Although all participants completed the coping strategies
and inference statistics (multivariate analysis of variance
questionnaires, only results from the medical staff participants
[MANOVA]) were calculated using SPSS, version 24 (IBM
are presented here considering the aims and objectives of the
Corp) [37].
study.
Procedure Results
All questionnaires were translated from English by native
Distress Levels Across Surveyed European Countries
speakers or professional translators for use in the respective
countries. The survey was made available online via the Across all surveyed countries, 65% (n=396) of the participants
Soscisurvey.de [36] platform. Consent to participate was reported a normal/mild level of depression, followed by 18%
obtained online. The English and German questionnaires were (n=108) with moderate and 17% (n=105) with severe/extremely
distributed at the beginning of April 2020, followed shortly severe depression. Regarding anxiety, 63% (n=386) reported a
after by the Italian version. The surveys in Spain and Portugal normal/mild level of anxiety, 15% (n=91) a moderate level, and
were launched in mid-April and in France in mid-May. 22% (n=132) a severe/extremely severe level. In terms of stress,
59% (n=356) reported a normal/mild level, 14% (n=87) a
Data Analysis moderate level, and 27% (n=166) a severe/extremely severe
Using the Lovibond and Lovibond [34] method, the depression, level. Tables 2-4 shows the mean scores for depression, anxiety,
anxiety, and stress subscales on DASS-21 were, according to and stress for each of the 8 European countries as well as the
individual sum scores, categorized as normal, mild, moderate, percentage of participants assigned to the groups normal/mild,
moderate, and severe/extremely severe.

Table 2. Depression levels in different European countries assessed using the Depression Anxiety Stress Scales–21.
Country Mean (SD)a Normal/mild, n (%) Moderate, n (%) Severe/very severe, n (%)

Germany 11.49 (8.91) 87 (63.97) 28 (20.59) 21 (15.44)

Austria 7.33 (8.23) 17 (80.95) 3 (14.29) 1 (4.76)
Switzerland 7.45 (8.68) 31 (77.50) 6 (15.00) 3 (7.50)
France 17.42 (11.63) 22 (42.31) 11 (21.15) 19 (36.54)
Italy 10.03 (9.30) 119 (74.84) 19 (11.95) 21 (13.21)
Spain 8.51 (8.98) 75 (75.76) 14 (14.14) 10 (10.10)
Portugal 12.26 (8.46) 24 (52.17) 14 (30.44) 8 (17.39)
United Kingdom 17.64 (11.04) 21 (37.50) 13 (23.21) 22 (39.29)
Total 11.34 (9.90) 396 (65.02) 108 (17.73) 105 (17.24)

Table 3. Anxiety levels in different European countries assessed using the Depression Anxiety Stress Scales–21.
Country Mean (SD) Normal/mild, n (%) Moderate, n (%) Severe/very severe, n (%)
Germany 8.44 (7.94) 85 (62.50) 19 (13.97) 32 (23.53)
Austria 4.86 (5.68) 15 (71.43) 5 (23.81) 1 (4.76)
Switzerland 4.10 (6.13) 34 (85.00) 3 (7.50) 3 (7.50)
France 11.39 (10.53) 27 (51.92) 10 (19.23) 15 (28.85)
Italy 7.64 (8.39) 110 (69.18) 25 (15.72) 24 (15.09)
Spain 10.04 (10.54) 60 (60.61) 12 (12.12) 27 (27.27)
Portugal 9.83 (8.59) 23 (50.00) 11 (23.91) 12 (26.09)
United Kingdom 10.36 (9.69) 32 (57.14) 6 (10.71) 18 (32.14)
Total 8.61 (9.00) 386 (63.38) 91 (14.94) 132 (21.67)

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Table 4. Stress levels in different European countries assessed using the Depression Anxiety Stress Scales–21.
Country Mean (SD) Normal/mild, n (%) Moderate, n (%) Severe/very severe, n (%)
Germany 17.13 (9.94) 76 (55.88) 27 (19.85) 33 (24.27)
Austria 14.10 (7.96) 17 (80.95) 1 (4.76) 3 (14.29)
Switzerland 11.40 (11.29) 32 (80.00) 2 (5.00) 6 (15.00)
France 21.77 (12.24) 25 (48.08) 4 (7.69) 23 (44.23)
Italy 17.25 (10.46) 91 (57.23) 27 (16.98) 41 (25.79)
Spain 16.42 (10.45) 62 (62.63) 13 (13.13) 24 (24.24)
Portugal 20.78 (10.95) 24 (52.17) 3 (6.52) 19 (41.30)
United Kingdom 18.86 (10.13) 29 (51.79) 10 (17.86) 17 (30.36)
Total 17.40 (10.71) 356 (58.46) 87 (14.29) 166 (27.26)

(mean 9.65, SD 9.66). No statistically significant differences

Comparison of Medical With Nonmedical Professionals were found between medical professionals who had or had no
A one-way MANOVA showed a significant main effect for exposure to COVID-19 at work (F3,350=0.525, P=.67, Wilk’s
profession (F3,605=5.019, P=.002, Wilk’s Λ=0.976). The effects Λ=0.996).
were significant for depression (F1,607=7.929, P=.005) and
Table 5 shows the 3 subscales of the DASS-21 and the
anxiety (F1,607=5.87, P=.02], which indicated that medical
percentage of medical and nonmedical professionals categorized
professionals were less depressed (mean 10.39, SD 9.12) as normal/mild, moderate, severe/extremely severe for each of
compared to nonmedical staff (mean 12.67, SD 10.77), as well these subscales.
as less anxious (mean 7.90, SD 8.36) than nonmedical staff

Table 5. Overview of depression, anxiety, and stress levels for medical (n=345) and nonmedical professionals (n=255) assessed using the Depression
Anxiety Stress Scales–21.
Participants Mean (SD) Normal/mild, n (%) Moderate, n (%) Severe/very severe, n (%)
Depression
Medical professionals 10.39 (9.12) 246 (69.49) 60 (16.95) 48 (13.56)
Nonmedical professionals 12.67 (10.77) 150 (58.82) 48 (18.82) 57 (22.35)
Total 11.34 (9.90) 396 (65.03) 108 (17.73) 105 (17.24)
Anxiety
Medical professionals 7.90 (8.36) 240 (67.80) 49 (13.84) 65 (18.36)
Nonmedical professionals 9.65 (9.66) 146 (57.26) 42 (16.47) 67 (26.28)
Total 8.61 (9.00) 386 (63.38) 91 (14.94) 132 (21.68)
Stress
Medical professionals 17.10 (10.51) 208 (58.76) 55 (15.54) 91 (25.71)
Nonmedical professionals 17.80 (10.98) 148 (58.04) 32 (12.55) 75 (29.41)
Total 17.40 (10.71) 356 (58.46) 87 (14.29) 166 (27.26)

2.02, SD 0.89). Participants were least concerned about

Stress Factors for Medical Professionals themselves (mean 1.12, SD 1.04) or coworkers (mean 1.25, SD
The highest rated stressors were “uncertainty about when the 0.97) showing COVID-19–like symptoms, conflicts at work as
epidemic will be under control” (mean 2.27, SD 0.85), “worry the equivocal definition of responsibility between doctors and
about inflicting COVID-19 on family” (mean 2.25, SD 0.99), nurses (mean 1.19, SD 1.04), and blame from their commanding
“worry about nosocomial spread” (mean 2.02, SD 0.92) and a officers (mean 0.70, SD 0.95). An overview of all stressors in
“frequent modification of infection control procedures” (mean the order of reported severity can be found in Table 6.

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Table 6. Stressors for doctors and nurses during COVID-19.

Itemsa Responses, n Mean (SD)

Uncertainty about when the epidemic will be under control 350 2.27 (0.85)
Worry about inflicting COVID-19 on family 351 2.25 (0.99)
Worry about nosocomial spread 348 2.02 (0.92)
Frequent modification of infection control procedures 350 2.02 (0.89)
Protective gears cause physical discomfort 349 1.75 (1.02)
Deterioration of patients’ condition 347 1.70 (1.00)
Worry about lack of proper knowledge and equipment 349 1.67 (1.04)
Worry about being negligent and endangering patients 350 1.66 (1.07)
Worry about getting infected 349 1.62 (1.03)
Patients’ emotional reaction 348 1.57 (0.96)
Worry about lack of manpower 348 1.56 (1.05)
Unclear documentation and reporting procedures 347 1.54 (1.01)
Patient families’ emotional reaction 346 1.52 (1.01)
Coworkers being emotionally unstable 348 1.52 (0.97)
Being without a properly fitted environment 348 1.51 (1.08)
Conflict between duty and safety 348 1.49 (1.07)
Worry about being negligent and endangering coworkers 351 1.48 (1.03)
Be infected by colleagues 349 1.31 (1.02)
Protective gear being a hindrance to providing quality care 349 1.28 (1.05)
Coworkers displaying COVID-19–like symptoms 347 1.25 (0.97)
Equivocal definition of the responsibility between doctors and nurses 346 1.19 (1.04)
Yourself displaying COVID-19–like symptoms 347 1.12 (1.04)
Blame from commanding officers 345 0.70 (0.95)

a
Responses to the question: “When you think about COVID-19 in your life and work, how often did you think or worry about the following things?”
(0=not at all, 3=very much).

knowledge about COVID-19” (mean 2.34, SD 0.80). Alcohol

Coping Strategies of Medical Professionals and drugs were the least used strategy (mean 0.32, SD 0.60).
The most frequently used strategies were “taking protective Table 7 summarizes these results.
measures” (mean 2.70, SD 0.57) and “actively acquiring more

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Table 7. Doctors’ and nurses’ coping strategies during COVID-19 (n=354).

Itemsa Mean (SD)

Taking protective measures (washing hands, wearing a mask, taking own temperature, etc) 2.7 (0.57)
Actively acquiring more knowledge about COVID-19 (symptoms, transmission pathway, etc) 2.34 (0.80)
Video-chatting with family and friends by phone to share concerns and support 1.84 (0.87)
Engaging in recreational activities (online shopping, social media, internet surfing, etc) 1.62 (0.94)
Engaging in health-promoting behaviors (more rest, exercise, balanced diet, etc) 1.55 (0.99)
Switching thoughts and facing the situations with a positive attitude 1.54 (0.89)
Limiting oneself from watching too much news about COVID-19 1.37 (0.96)
Distracting oneself from thinking about COVID-19 issues by suppression or keeping busy 1.30 (0.92)
Acquiring mental health knowledge and information 1.01 (0.95)
Venting emotions by crying, screaming, smashing things, etc 0.50 (0.81)
Practicing relaxation methods (meditation, yoga, tai chi, etc) 0.46 (0.82)
Using alcohol or drugs 0.32 (0.60)

a
Responses to the question: “When you think about COVID-19 in your life and work, how often did you use or try to use the following methods to
handle the situation?” (1=almost never, 4=almost always).

accordance with our results, in a study from Singapore,

Discussion nonmedical health care professionals had a higher prevalence
Overview of anxiety than medical health care professionals during
COVID-19. The authors believed that nonmedical health care
This study focused on doctors and nurses who were and are professionals might have had less access to psychological
facing exceptional physical and mental challenges during the support, less direct information about the situation and received
COVID-19 pandemic. In order to gain a deeper understanding less training on personal protective equipment and infection
of their situation, we investigated the perceived burden of control measures [42]. In addition, previous European studies
different stressors on medical professionals as well as their show that there is also an increased psychological burden during
coping strategies. Additionally, a general overview of the COVID-19 in the general population. For example, female
experienced stress, anxiety, and depression in various European gender and younger age were identified as risk factors [43,44],
countries during peak months of the pandemic was presented. which were represented in large numbers in our study
Mental Health of Medical Professionals population. It has therefore already been recommended to take
care of the mental health of the general population as well as
The majority of doctors and nurses reported a normal to mild
special population groups [44].
level of psychological strain, but about one-third expressed a
moderate to extremely severe level of distress. Mental distress Interestingly, we did not find any significant association between
is associated with patient safety and a higher probability of direct contact with COVID-19–infected patients at work and
medical errors [32,33]. Considering that long-term effects such scores for anxiety, depression, or stress among medical
as posttraumatic stress disorders are not uncommon among this professionals despite a previous study with health workers
professional group [38] and that the COVID-19 infection rate during the pandemic reporting more psychological distress when
may increase again, our results should be taken seriously. there was direct exposure to infected patients [21]. Not only in
medical departments specializing in COVID-19 but in all
However, surprisingly, the mean scores for depression and
medical units, protective measures such as permanent wearing
anxiety among health care professionals were significantly lower
of face masks, bans on visits to hospitals and nursing homes,
than among nonmedical professionals. Regarding the level of
and stricter hygiene regulations were made obligatory for
stress, there was no significant difference between the two
medical personnel in the surveyed countries. In addition, because
groups. These results are encouraging in the sense that the
of the considerable number of deaths of doctors and nurses [45],
medical professionals—although confronted with difficult
COVID-19 would have been perceived by medical professionals
challenges and risks [19,39,40]—seemed to be mentally well
as a kind of ever-present threat and not only when in direct
prepared to handle the pandemic situation. A possible
contact with infected patients.
explanation could be, however, that their medical background
helped them to better understand and classify COVID-19–related Major Stressors and Coping Strategies
information when compared to their nonmedical counterparts. “Uncertainty about when the epidemic will be under control”
When they could feel self-sufficient, the situation appeared and “worry about inflicting COVID-19 on family” were at the
more manageable for them. A study with SARS survivors top of the list when medical professionals were asked about the
concluded that a better sense of self-care and self-efficacy led most stressful things in their everyday life or at work during
to better psychological adjustment to the situation [41]. In the pandemic. Possible infection of family is a major concern

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that has been reported several times before, for example, in the Kingdom found elevated scores for depression and anxiety
United Kingdom [38] or formerly among Taiwanese nurses during COVID-19 [51], and a study from France presented a
during the SARS outbreak [29] and Chinese health care workers considerable prevalence of anxiety 1 week after the start of the
during COVID-19 [30]. Our results confirm the dilemma already lockdown [15]. In Italy and Spain, even though the situation
mentioned by Perrin et al [19] during SARS: health care workers was worse, the participants in our study showed lower scores
do their job by helping others but at the same time feel anxious of psychological strain compared to France and the United
about getting infected or infecting their families. Our participants Kingdom. One reason for their lower scores of depression,
were less worried about getting infected themselves than anxiety, and stress could be the high proportion of medical
infecting their families with COVID-19. professionals in the Italian sample, whose overall mental health
was significantly better than that of the nonmedical
The strategies most frequently used by medical professionals
professionals. Another reason could be that the surveys started
to deal with this unusual situation were “taking protective
at different points of time in these countries and the peak of the
measures (washing hands, wearing a mask, taking own
pandemic was different for each country.
temperature)” and “actively acquiring more knowledge about
COVID-19 (symptoms, transmission pathway, etc).” Effective The lower levels of psychological distress among participants
protective measures were also the most common coping strategy in Austria and Switzerland could be attributed to the countries’
among Taiwanese nurses during SARS [29] and Chinese health relatively lower number of cases per 1 million people [5]. In
care workers during COVID-19 [30]. Another important strategy Germany, which had a higher number of cases [5] but less
was “video-chatting with family and friends to share concerns psychological strain, the health care system seemed to be better
and support,” which apparently had a higher priority for the prepared as this is the country with the highest number of critical
participants in our study when compared to the nurses in Taiwan care beds in Europe [2,52].
(“chatting with family and friends by phone to share concerns
and support”) during SARS [29]. However, nowadays there are
Limitations
more possibilities, especially via social media, to be in touch Although our findings support previous studies on the
digitally with friends and family compared to during the SARS psychological burden of COVID-19, a few limitations should
outbreak. This has the advantage to get in touch directly with be considered. Links to the online survey were distributed via
people experiencing mental burden, with the help of so-called social media and via the personal and professional networks of
e-mental health applications. The increasing role of these the authors. Since the contact networks in the individual
web-based interventions during the pandemic has already been European countries were not equally strong and online
observed [46]. While the acceptance of this development, distribution of a link was difficult to control, the number of
especially among medical professionals, is high [47], different participants for each country was different, leading to uneven
generations follow their own patterns of usage. However, all distribution of professional groups per country.
generations seek to stay related to their family members [48]. Moreover, the surveys did not start simultaneously in all
COVID-19 and Mental Health in Europe European countries and data could not be acquired when the
COVID-19 outbreak peaked in each country. In addition,
Our results show that although the majority of respondents
translating questionnaires into different languages always carries
reported normal to mild levels of depression, anxiety, and stress,
the risk that the individual translations are not completely
the mean overall level of mental strain experienced was up to
identical. Since we also partially adapted the already translated
2x higher compared to the normative data means of the
versions of DASS-21 to our online format, this could have led
DASS-21 [49]. However, according to DASS guidelines, it
to an additional language bias. Finally, the category “nonmedical
should be noted here that there is no DASS-21 cut-off for
professionals” was heterogeneous. Persons who worked in
clinical diagnostics [35].
nonmedical sectors of the health care system were included in
Our results concur with earlier studies about COVID-19 that this category and might have been exposed to COVID-19.
have reported elevated levels of psychological distress during
the pandemic [12-15,50,51]. However, these studies report only
Implications
about a particular European country, which makes it clear that The COVID-19 pandemic has caused fundamental changes in
COVID-19 has a negative effect on the psyche but neglects that the health care and non–health care sectors and has put
there can be differences across countries. The descriptive considerable strain not only on medical but also on nonmedical
cross-sectional overview of our study shows that there are professionals. A sizeable part of participants expressed moderate
differences among countries in the numbers of people belonging to extremely severe symptoms of depression, anxiety, and/or
to the severe/extremely severe category for depression, anxiety, stress while nonmedical professionals seemed to be more
and stress. burdened than their medical counterparts. Targeted and
personalized mental health services are needed not only for
Participants from the United Kingdom and France showed, on medical professionals but also for other professional groups
a descriptive level, the highest scores for depression, anxiety, during pandemics. When developing these services, specific
and stress when compared to other countries. This may be needs and fears should be taken into account. One approach
because England and France were among the countries most could be to examine the reasons why the medical staff are better
affected by COVID-19 [2] with a case fatality rate of 19.2% for at handling the pandemic situation and using these results to
France and 14.7% for the United Kingdom by the end of May develop or optimize mental health services for future pandemics.
[5]. Similar to our study, a previous study in the United
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By providing the opportunity for medical professionals to carry COVID-19 by using valid diagnostic tools and other research
out their own protective measures and by providing sufficient designs like longitudinal surveys or qualitative studies. In-depth
information about the virus, they might be able to better interviews could provide additional valuable information on
overcome such situations. Further research is needed to analyze major stressors and coping strategies.
the long-term consequences of the psychological strain of

Acknowledgments
This study would not have been possible without the support of European health care institutions that helped us distribute the
survey link. We thank our Spanish supporters Fundación INTRAS; the Regional Authority of Social Affairs (Castilla y León);
the nursing homes ACALERTE and LARES; Hospital San Pedro en Logroño, La Rioja; the Fundación Rey Ardid (Aragón
region); and the care organizations Pronisa, AFAVITAE, and ACyLNP. In France, we would like to thank the Marseille Public
University Hospital System. In Austria, we thank the Sozialdienste Wolfurt for their support.

Conflicts of Interest
None declared.

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Abbreviations
DASS-21: Depression Anxiety Stress Scales–21
MANOVA: multivariate analysis of variance
SARS: severe acute respiratory syndrome

Edited by G Eysenbach; submitted 13.10.20; peer-reviewed by A Bregenzer; comments to author 03.11.20; revised version received
20.11.20; accepted 03.12.20; published 18.01.21
Please cite as:
Hummel S, Oetjen N, Du J, Posenato E, Resende de Almeida RM, Losada R, Ribeiro O, Frisardi V, Hopper L, Rashid A, Nasser H,
König A, Rudofsky G, Weidt S, Zafar A, Gronewold N, Mayer G, Schultz JH
Mental Health Among Medical Professionals During the COVID-19 Pandemic in Eight European Countries: Cross-sectional Survey
Study
J Med Internet Res 2021;23(1):e24983
URL: http://www.jmir.org/2021/1/e24983/
doi: 10.2196/24983
PMID:

©Svenja Hummel, Neele Oetjen, Junfeng Du, Elisabetta Posenato, Rosa Maria Resende de Almeida, Raquel Losada, Oscar
Ribeiro, Vincenza Frisardi, Louise Hopper, Asarnusch Rashid, Habib Nasser, Alexandra König, Gottfried Rudofsky, Steffi Weidt,
Ali Zafar, Nadine Gronewold, Gwendolyn Mayer, Jobst-Hendrik Schultz. Originally published in the Journal of Medical Internet
Research (http://www.jmir.org), 18.01.2021. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
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