Abstract

This study investigated the prevalence and the potential risk factors for anxiety and depression among physiotherapists during the pandemic. Physiotherapists answered a web-based questionnaire including 1) sociodemographic, professional and clinical information; 2) psychosocial demands; and 3) two validated questionnaires to measure anxiety and depression. Binary logistic regression identified the risk factors by means of odds ratio (OR) and 95% confidence interval (CI). In 417 participants, there was a high prevalence of anxiety (48.2%) and depression (53.0%). The risk factors for anxiety were female sex (OR 2.07; 95%CI 1.01-4.24), worsening in sleep patterns (OR 3.78; 95%CI 1.92-7.44), moderate (OR 2.24; 95%CI 1.00-5.00) and extreme concern about financial issues (OR 3.47; 95%CI 1.57-7.65), and extreme loneliness (OR 3.47; 95%CI 1.71-7.07). The risk factors for depression were female sex (OR 2.16; 95%CI 1.03-4.55), low family income (OR 2.43; 95%CI 1.21-4.89), worsening in sleep patterns (OR 5.97; 95%CI 3.02-11.82), extreme concern about financial issues (OR 2.61; 95%CI 1.15-5.94), and extreme loneliness (OR 4.38; 95%CI 2.00-9.63). This study found a high prevalence of anxiety and depression in the studied population and identified risk factors for both.

Key words:
COVID-19; Pandemics; Physical therapists; Anxiety; Depression

Resumo

Este estudo investigou a prevalência e potenciais fatores de risco para ansiedade e depressão em fisioterapeutas durante a pandemia. Fisioterapeutas responderam a um questionário na web, incluindo: dados sociodemográficos, profissionais e clínicos; demandas psicossociais; e dois questionários validados para medir ansiedade e depressão. Regressão logística binária identificou fatores de risco para ansiedade e depressão por meio de odds ratio (OR) e intervalo de confiança de 95% (IC). Em 417 participantes houve alta prevalência de ansiedade (48,2%) e depressão (53%). Os fatores de risco para ansiedade foram: sexo feminino (OR 2,07; IC95% 1,01-4,24), piora nos padrões de sono (OR 3,78; IC95% 1,92-7,44), moderada (OR 2,24; IC95% 1,00-5,00) e extrema preocupação financeira (OR 3,47; IC95% 1,57-7,65) e extrema solidão (OR 3,47; IC95% 1,71-7,07). Os fatores de risco para depressão foram: sexo feminino (OR 2,16; IC95% 1,03-4,55), baixa renda familiar (OR 2,43; IC95% 1,21-4,89), piora nos padrões de sono (OR 5,97; IC95% 3,02-11,82), extrema preocupação financeira (OR 2,61; IC95% 1,15-5,94) e extrema solidão (OR 4,38; IC95% 2,00-9,63). Este estudo mostrou alta prevalência de ansiedade e depressão na população estudada e identificou fatores de risco para ambos.

Palavras-chave:
COVID-19; Pandemia; Fisioterapeutas; Ansiedade; Depressão

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has a potential of dramatically affect the mental health and psychological well-been of healthcare professionals¹1 Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun 2020; 88:901-907.. Healthcare workers had a high prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), probably due to the increased exposure to virus²2 Gómez-Ochoa SA, Franco OH, Rojas LZ, Raguindin PF, Roa-Díaz ZM, Wyssmann BM, Guevara SLR, Echeverría LE, Glisic M, Muka T. COVID-19 in health-care workers: a living systematic review and meta-analysis of prevalence, risk factors, clinical characteristics, and outcomes. Am J Epidemiol 2021; 190(1):161-175.. Since, in several countries, physiotherapists often perform aerosol-generating procedures, they are among the health workers most exposed to the virus³3 Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cecchetto S, Colombo A, D'Abrosca F, Del Monaco C, Gaudiello G, Paneroni M, Privitera E, Retucci M, Rossi V, Santambrogio M, Sommariva M, Frigerio P. Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Arch Chest Dis 2020; 90(1). DOI:10.4081/monaldi.2020.1285.
https://doi.org/10.4081/monaldi.2020.128...

4 Righetti RF, Onoue MA, Politi FVA, Teixeira DT, Souza PN, Kondo CS, Moderno EV, Moraes IG, Maida ALV, Pastore Junior L, Silva FD, Brito CMM, Baia WRM, Yamaguti WP. Physiotherapy care of patients with coronavirus disease 2019 (COVID-19) - a Brazilian experience. Clinics (Sao Paulo) 2020; 75:e2017.^-55 Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, Hodgson C, Jones AY, Kho ME, Moses R, Ntoumenopoulos G, Parry SM, Patman S, van der Lee L. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother 2020; 66(2):73-82.. Many of the infected professionals are asymptomatic, favoring silent transmission to co-workers, family members and other people in the community²2 Gómez-Ochoa SA, Franco OH, Rojas LZ, Raguindin PF, Roa-Díaz ZM, Wyssmann BM, Guevara SLR, Echeverría LE, Glisic M, Muka T. COVID-19 in health-care workers: a living systematic review and meta-analysis of prevalence, risk factors, clinical characteristics, and outcomes. Am J Epidemiol 2021; 190(1):161-175.. This situation can cause a great fear of contamination in these professionals and can result in psychological disorders⁶6 Lu W, Wang H, Lin Y, Li L. Psychological status of medical workforce during the COVID-19 pandemic: a cross-sectional study. Psychiatry Res 2020; 288:112936., increasing the risk of anxiety and depression development⁷7 Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, Du H, Chen T, Li R, Tan H, Kang L, Yao L, Huang M, Wang H, Wang G, Liu Z, Hu S. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020; 3(3):e203976..

The impact of the pandemic on the mental health of physiotherapists and other health professionals goes far beyond the fear of being infected, and probably also involves financial and other personal aspects. Due to the high transmissibility of coronavirus, once the pandemic started, public restraining measures were necessary, generating important socio-economic and psychological impacts⁸8 Bhat BA, Khan S, Manzoor S, Niyaz A, Tak HJ, Anees S, Gull S, Ahmad I. A study on impact of COVID-19 lockdown on psychological health, economy and social life of people in Kashmir. Int J Behav Healthc Res 2020; 5(2):36-46.. Therefore, many physiotherapists and rehabilitation services had to interrupt or reduce their activities abruptly without prior planning, which probably caused an important economic impact, especially on self-employed professionals⁹9 Minghelli B, Soares A, Guerreiro A, Ribeiro A, Cabrita C, Vitoria C, Nunes C, Martins C, Gomes D, Goulart F, Santos RMD, Antunes R. Physiotherapy services in the face of a pandemic. Rev Assoc Med Bras 2020; 66(4):491-497..

However, other physiotherapists had to continue practicing, as they play an important role in the management of respiratory conditions in patients admitted to hospitals wards or intensive care units with suspected or confirmed COVID-19⁵5 Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, Hodgson C, Jones AY, Kho ME, Moses R, Ntoumenopoulos G, Parry SM, Patman S, van der Lee L. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother 2020; 66(2):73-82.. These professionals had to deal with an increase in workload¹⁰10 Chen J, Liu X, Wang D, Jin Y, He M, Ma Y, Zhao X, Song S, Zhang L, Xiang X, Yang L, Song J, Bai T, Hou X. Risk factors for depression and anxiety in healthcare workers deployed during the COVID-19 outbreak in China. Soc Psychiatry Psychiatr Epidemiol 2021; 56(1):47-55. due to a lack of personnel and to a high number of patients to attend in a short time¹⁰10 Chen J, Liu X, Wang D, Jin Y, He M, Ma Y, Zhao X, Song S, Zhang L, Xiang X, Yang L, Song J, Bai T, Hou X. Risk factors for depression and anxiety in healthcare workers deployed during the COVID-19 outbreak in China. Soc Psychiatry Psychiatr Epidemiol 2021; 56(1):47-55.^,1111 Lindsay R, Hanson L, Taylor M, McBurney H. Workplace stressors experienced by physiotherapists working in regional public hospitals. Aust J Rural Health 2008; 16(4):194-200.. The work overload is described as workplace stressor and has been experienced by physiotherapists in their daily routine, even before the current pandemic¹¹11 Lindsay R, Hanson L, Taylor M, McBurney H. Workplace stressors experienced by physiotherapists working in regional public hospitals. Aust J Rural Health 2008; 16(4):194-200.. To work in a front line of care, self-rated increases in workload, negative coping style, and fear of getting infected by the virus were identified as some risk factors for anxiety and depression in health professionals¹⁰10 Chen J, Liu X, Wang D, Jin Y, He M, Ma Y, Zhao X, Song S, Zhang L, Xiang X, Yang L, Song J, Bai T, Hou X. Risk factors for depression and anxiety in healthcare workers deployed during the COVID-19 outbreak in China. Soc Psychiatry Psychiatr Epidemiol 2021; 56(1):47-55..

During this pandemic, physiotherapists reported high levels of perceived stress¹²12 Duarte H, Daros Vieira R, Cardozo Rocon P, Andrade ACS, Wittmer VL, Capellini VK, Soares SCS, Paro FM. Factors associated with Brazilian physical therapists' perception of stress during the COVID-19 pandemic: a cross-sectional survey. Psychol Health Med 2022; 27(1):42-53.. However, we do not know to what extent the pandemic context is affecting the physiotherapists mental health, since we found only one study showing high levels of anxiety and depression on a small sample of South Korean physiotherapists¹³13 Yang S, Kwak SG, Ko EJ, Chang MC. The mental health burden of the COVID-19 pandemic on physical therapists. Int J Environ Res Public Health 2020; 17(10):3723.. Therefore, considering that physiotherapists are essential for both treatment of acute COVID-19 patients³3 Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cecchetto S, Colombo A, D'Abrosca F, Del Monaco C, Gaudiello G, Paneroni M, Privitera E, Retucci M, Rossi V, Santambrogio M, Sommariva M, Frigerio P. Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Arch Chest Dis 2020; 90(1). DOI:10.4081/monaldi.2020.1285.
https://doi.org/10.4081/monaldi.2020.128...

4 Righetti RF, Onoue MA, Politi FVA, Teixeira DT, Souza PN, Kondo CS, Moderno EV, Moraes IG, Maida ALV, Pastore Junior L, Silva FD, Brito CMM, Baia WRM, Yamaguti WP. Physiotherapy care of patients with coronavirus disease 2019 (COVID-19) - a Brazilian experience. Clinics (Sao Paulo) 2020; 75:e2017.^-55 Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, Hodgson C, Jones AY, Kho ME, Moses R, Ntoumenopoulos G, Parry SM, Patman S, van der Lee L. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother 2020; 66(2):73-82.^,1414 Wittmer VL, Paro FM, Duarte H, Capellini VK, Barbalho-Moulim MC. Early mobilization and physical exercise in patients with COVID-19: a narrative literature review. Complement Ther Clin Pract 2021; 43:101364. and rehabilitation of patients presenting possible sequelae¹⁵15 Barker-Davies RM, O'Sullivan O, Senaratne KPP, Baker P, Cranley M, Dharm-Datta S, Ellis H, Goodall D, Gough M, Lewis S, Norman J, Papadopoulou T, Roscoe D, Sherwood D, Turner P, Walker T, Mistlin A, Phillip R, Nicol AM, Bennett AN, Bahadur S. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med 2020; 54(16):949-959., we believe that knowing the factors that affect the mental health of these professionals is of utmost importance for creating strategies to prevent and/or mitigate possible psychological disorders.

In view of this scenario, the objectives of this study were: 1) to quantify the prevalence and the magnitude of anxiety and depression among physiotherapists during the COVID-19 pandemic, 2) to verify whether sociodemographic, professional, clinical and psychosocial factors associate with anxiety and depression, and 3) to find out potential risk factors for anxiety and depression.

Methods

Design

A cross-sectional study was conducted from 22 May to 24 June 2020 (approximately 8 weeks after the implementation of the social distancing rules due to the COVID-19 pandemic in Brazil). A convenience sample of physiotherapists participated in an online survey. The Regional Physiotherapy Council sent an e-mail for all physiotherapists registered on it. The e-mail had a link to a questionnaire built on the Survey Monkey platform. A 3-step e-mailing process was implemented to optimize the response rate, with seven days apart among each step. Multiple entries from the same individual were prevented by the electronic survey system through e-mail addresses.

The Ethics Committee of Federal University of Espírito Santo approved this study (number 4.032.838 / CAAE: 31522720.2.0000.5060).

Participants

Physiotherapists registered on Regional Physiotherapy Council, who practice in Espírito Santo (ES), a Southeastern Brazilian state, and who agreed with the informed consent term, were included in this survey. It is worth mentioning that registration on Regional Physiotherapy Council is mandatory for all physiotherapists who work in the ES state. The physiotherapists who did not complete the questionnaire were excluded from the study.

According to Regional Physiotherapy Council, there were 4,173 physiotherapists registered on it in May 2020. Using this number, a confidence level of 0.95 with a margin of error of 5%, the sample size was estimated in 352 participants.

Questionnaire

The self-reported questionnaire was structured in five sections: 1) sociodemographic and professional characteristics, 2) clinical characteristics and information related to the COVID-19 pandemic, 3) psychosocial demands, 4) Generalized Anxiety Disorder-7 (GAD-7), and 5) Patient Health Questionnaire-9 (PHQ-9).

The section concerning sociodemographic and professional characteristics included questions about: 1) sex, 2) age, 3) marital status (with; without a partner), 4) children (yes; no), 5) number of children (1; > 2), 6) number of household members including the participant (1; 2; 3; ≥ 4 members), 7) ES areas (North, Central and South; Metropolitan), 8) family income (< 3; 3 to 5; > 5 minimum wage), 9) professional rolling before COVID-19 (patient care; other including teaching, research, administration, or not working), 10) workplace before COVID-19 (Physiotherapy clinic; hospital; home care; university/college; community-based primary health care center; other), 11) work sector (private; public; philanthropic; other), and 12) working face to face as a physiotherapist during the pandemic (yes; no).

The clinical characteristics and information related to the COVID-19 pandemic looked on: 1) confirmed diagnosis of COVID-19 (yes; no), 2) previous diagnosis of depressive, anxiety or any psychological or psychiatric disorder (yes; no), 3) change in sleep patterns during the pandemic (improved a little; kept the same; worsened), 4) change in family income during the pandemic (no change; small reduction; large reduction; improvement), 5) practicing social distancing appropriately (yes; no), 6) COVID-19 infected or dead people in your social environment (no; yes for far people; yes for close people like family or friends), and 7) psychological treatment (yes, I am doing psychotherapy; I was doing psychotherapy, but I stopped it due to pandemic; nowadays no, but I already had done; I have never done).

The section about psychosocial demands asked physiotherapists an answer on a five-point Likert scale (not at all; slightly; moderately; very; extremely) to the question “In the past seven days, how much the factors below did affect you psychologically?”: 1) housework, 2) care and relationship with children, 3) relationship with the partner, 4) excessive professional activities, 5) concern about financial issues, 6) concern about yourself being infected by coronavirus, 7) concern about close people/family members being infected or becoming ill by COVID-19, 8) restriction of leisure/social interaction, and 9) loneliness.

The GAD-7 is a self-reported scale used to screen for anxiety disorders and to assess its severity level¹⁶16 Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166(10):1092-1097.. The Brazilian version of GAD-7 was translated into the Portuguese language and was validated for the Brazilian population¹⁷17 Moreno AL, DeSousa DA, Souza AMFLP, Manfro GG, Salum GA, Koller SH, Lima O, Crippa JAS. Factor structure, reliability, and item parameters of the Brazilian-Portuguese version of the GAD-7 Questionnaire. Temas Psicol 2016; 24(1):367-376.. The GAD-7 consists of seven items about the frequency of symptoms over the last two weeks. The answer to each item is scored on a four-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day)¹⁷17 Moreno AL, DeSousa DA, Souza AMFLP, Manfro GG, Salum GA, Koller SH, Lima O, Crippa JAS. Factor structure, reliability, and item parameters of the Brazilian-Portuguese version of the GAD-7 Questionnaire. Temas Psicol 2016; 24(1):367-376.. The GAD-7 scores range from 0 to 21, and scores 5, 10, and 15 represent mild, moderate, and severe anxiety symptoms, respectively¹⁸18 Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007; 146(5):317-25.. According to a systematic review, the GAD-7 had acceptable properties for identifying generalized anxiety disorders at cutoff scores from 7 to 10¹⁹19 Plummer F, Manea L, Trepel D, McMillan D. Screening for anxiety disorders with the GAD-7 and GAD-2: a systematic review and diagnostic metaanalysis. Gen Hosp Psychiatry 2016; 39:24-31.. In the present study, a score of 10 was chosen as the cutoff.

The PHQ-9 is a brief self-administered tool widely used to screen for the signs and symptoms of major depression and to assess their severity²⁰20 Osório FL, Mendes AV, Crippa JA, Loureiro SR. Study of the discriminative validity of the PHQ-9 and PHQ-2 in a sample of Brazilian women in the context of primary health care. Perspect Psychiatr Care 2009; 45(3):216-227.. It was translated into Brazilian Portuguese (Copyright© 2005 Pfizer Inc., New York, NY) and validated²⁰20 Osório FL, Mendes AV, Crippa JA, Loureiro SR. Study of the discriminative validity of the PHQ-9 and PHQ-2 in a sample of Brazilian women in the context of primary health care. Perspect Psychiatr Care 2009; 45(3):216-227.^,2121 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9):606-613.. The PHQ-9 consists of nine questions assessing the rate of depressive symptoms and signs, in the last two weeks, with answers presented as a four-point Likert scale ranging from 0 (none) to 3 (almost every day)²⁰20 Osório FL, Mendes AV, Crippa JA, Loureiro SR. Study of the discriminative validity of the PHQ-9 and PHQ-2 in a sample of Brazilian women in the context of primary health care. Perspect Psychiatr Care 2009; 45(3):216-227.. The final score ranges from 0 to 27. Scores from 0 to 4 indicate the absence of depressive disorders. The depressive symptoms may be classified as mild (5-9), moderated (10-14), moderately severe (15-19), and severe (≥ 20)²¹21 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9):606-613.. In the present study, a cut-off score ≥ 10 was used because it has high sensitivity (88%) and specificity (88%) for major depression²¹21 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9):606-613., and it has proven to be the most suitable for depression screening²⁰20 Osório FL, Mendes AV, Crippa JA, Loureiro SR. Study of the discriminative validity of the PHQ-9 and PHQ-2 in a sample of Brazilian women in the context of primary health care. Perspect Psychiatr Care 2009; 45(3):216-227..

Data analysis

The Statistical Package for the Social Sciences (SPSS), version 22 (IBM, Armonk, NY, United States), was used for data analysis. The normality was evaluated by the Kolmogorov-Smirnov test. Categorical data are presented as absolute and relative frequencies. Continuous variables are shown as median and interquartile range (IQR). Chi-square test for independence was used to explore the relationship between each dependent variable (GAD-7 and PHQ-9) with each independent (sociodemographic, professional, clinical and psychosocial factors). Some sociodemographic and professional characteristics were not considered as independent variables and were used only for sample characterization. The independent variables that were associated with each outcome in these previous univariate analyses entered in binary logistic regression models, being the results presented as odds ratio (OR) and 95% confidence interval (95%CI). The assumptions of multicollinearity and outliers were evaluated. A significance level of 5% was adopted in all statistical steps.

Results

Participants

A total of 533 individuals accessed the link sent by Regional Physiotherapy Council. Among them, five people did not accept to participate, and six did not meet the inclusion criteria. Therefore, 522 physiotherapists started filling the questionnaire and 417 subjects fully answered it, yielding a completion rate of 79.9%.

Regarding sample (n = 417) characterization: 339 (81.3%) participants were female; the median age was 35 (IQR 28; 40) years; 348 (83.7%) physiotherapists lived in the Metropolitan Region of the ES State; 203 (48.7%) subjects had children, among which 107 (52.7%) had one child and 96 (47.3%) had two or more children; 31 (7.4%) lived alone, 114 (27.3%), 126 (30.2%) and 146 (35.1%) had two, three and four or over members (including the study participant) sharing the house, respectively; 266 (63.8%), 111 (26.6%), 26 (6.2%) and 14 (3.4%) physiotherapists worked in private, public, philanthropic and other sectors, respectively.

Prevalence and magnitude of anxiety and depression

The prevalence of anxiety and depression among the physiotherapists in this study were 48.2% and 53.0%, respectively. The medians of GAD-7 and PHQ-9 scores were 9 and 10, respectively. More details about prevalence and magnitude of anxiety and depression can be seen in Table 1.

Factors associated with anxiety and depression

Table 2 shows the associations between sociodemographic and professional characteristics and the outcomes - anxiety and depression. Anxiety and depression were significantly associated with sex and professional rolling before COVID-19. Depression was also significantly associated with marital status, children and family income.

Table 3 demonstrates the associations between clinical characteristics and information related to the COVID-19 pandemic and the outcomes - anxiety and depression. Anxiety and depression were significantly associated with previous diagnosis of depressive, anxiety or any psychological or psychiatric disorder, change in sleep patterns, change in family income, COVID-19 infected or dead people in social environment, and psychological treatment.

Table 4 presents the associations between psychosocial demands and the outcomes - anxiety and depression. Depression was significantly associated with all psychosocial demands. Anxiety did not associate only with care and relationship with children.

Risk factors for anxiety and depression

After the multiple binary logistic regression results, controlling for confounders, the risk factors for anxiety were female sex, worsening in sleep patterns, moderate and very/extreme concern about financial issues, and very/extreme loneliness. Similarly, the risk factors for depression were female sex, family income < 3 minimum wage, worsening in sleep patterns, very/extreme concern about financial issues, and very/extreme loneliness. Among all these risk factors, the worsening in sleep patterns was the strongest one, increasing 3.78 and 5.97 times the risk for anxiety and depression, respectively, in comparison to those that kept the same sleep pattern (Table 5).

Discussion

In the present study, 1) Brazilian physiotherapists presented a high prevalence of anxiety and depression; 2) female sex, worsening in sleep patterns, concern about financial issues, and loneliness were found as risk factors for both anxiety and depression, being the worsening in sleep patterns the strongest one; and 3) family income lower than 3 minimum wage was also found as a risk factor for depression.

When a score of 10 on the GAD-7 was used as a cutoff, the prevalence of anxiety among Brazilian physiotherapists was 48.2%, which was higher than 12.3%⁷7 Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, Du H, Chen T, Li R, Tan H, Kang L, Yao L, Huang M, Wang H, Wang G, Liu Z, Hu S. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020; 3(3):e203976. and 12.9%²²22 Zhang C, Yang L, Liu S, Ma S, Wang Y, Cai Z, Du H, Li R, Kang L, Su M, Zhang J, Liu Z, Zhang B. Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psychiatry 2020; 11:306. found in Chinese healthcare workers and 19%²³23 Palgi Y, Shrira A, Ring L, Bodner E, Avidor S, Bergman Y, Cohen-Fridel S, Keisari S, Hoffman Y. The loneliness pandemic: loneliness and other concomitants of depression, anxiety and their comorbidity during the COVID-19 outbreak. J Affect Disord 2020; 275:109-111. reported in Israeli population. In addition, when 9, 8 and 5 were used as GAD-7 cutoff points, the anxiety prevalence rates were 35.1%²⁴24 Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. Psychiatry Res 2020; 288:112954. and 24.1%²⁵25 Zhu Z, Xu S, Wang H, Liu Z, Wu J, Li G, Miao J, Zhang C, Yang Y, Sun W, Zhu S, Fan Y, Chen Y, Hu J, Liu J, Wang W. COVID-19 in Wuhan: Sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers. EClinicalMedicine 2020; 24:100443. in Chinese health professionals, and 32.3% in South Korean physiotherapists¹³13 Yang S, Kwak SG, Ko EJ, Chang MC. The mental health burden of the COVID-19 pandemic on physical therapists. Int J Environ Res Public Health 2020; 17(10):3723., respectively. Regarding depression, when 10 was used as the cutoff score for PHQ-9, the prevalence among Brazilian physiotherapists was 53%, which was higher than 18.5% found in South Korean physiotherapists¹³13 Yang S, Kwak SG, Ko EJ, Chang MC. The mental health burden of the COVID-19 pandemic on physical therapists. Int J Environ Res Public Health 2020; 17(10):3723., and 13.5%²⁵25 Zhu Z, Xu S, Wang H, Liu Z, Wu J, Li G, Miao J, Zhang C, Yang Y, Sun W, Zhu S, Fan Y, Chen Y, Hu J, Liu J, Wang W. COVID-19 in Wuhan: Sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers. EClinicalMedicine 2020; 24:100443., 14.8%⁷7 Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, Du H, Chen T, Li R, Tan H, Kang L, Yao L, Huang M, Wang H, Wang G, Liu Z, Hu S. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020; 3(3):e203976., and 17.2%²²22 Zhang C, Yang L, Liu S, Ma S, Wang Y, Cai Z, Du H, Li R, Kang L, Su M, Zhang J, Liu Z, Zhang B. Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psychiatry 2020; 11:306. found in health professionals from other countries.

Professional characteristics could justify the high prevalence of anxiety and depression among physiotherapists. A recent systematic review showed that nurses had higher prevalence of anxiety and depression than physicians did, probably because nurses work closer to patients and are more exposed to contamination risk, suffering and death issues, and ethical dilemmas than physicians do¹1 Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun 2020; 88:901-907.. It is worth mentioning that Physical Therapy practice demands close and long-term contact with patients and frequently includes aerosol-generating procedures, increasing the contamination risk⁵5 Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, Hodgson C, Jones AY, Kho ME, Moses R, Ntoumenopoulos G, Parry SM, Patman S, van der Lee L. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother 2020; 66(2):73-82.. However, comparing the findings of the present work with another study¹³13 Yang S, Kwak SG, Ko EJ, Chang MC. The mental health burden of the COVID-19 pandemic on physical therapists. Int J Environ Res Public Health 2020; 17(10):3723., which are the only one research sampled exclusively by physiotherapists, Brazilian professionals still showed greater anxiety and depression prevalence rates than South Korean pairs. Beyond the enormous differences among Latin American and Asian culture, experience in previous pandemics, sociodemographic and economic aspects, South Korea was recognized for its precocious and proactive approach to prevent and treat pandemic related mental health diseases, including national policies on mental health²⁶26 Hyun J, You S, Sohn S, Kim SJ, Bae J, Baik M, Cho IH, Choi H, Choi KS, Chung CS, Jeong C, Joo H, Kim E, Kim H, Kim HS, Ko J, Lee JH, Lee SM, Lee SH, Chung US. Psychosocial support during the COVID-19 outbreak in Korea: activities of multidisciplinary mental health professionals. J Korean Med Sci 2020; 35(22):e211.^,2727 Shin YJ, Lee JY. South Korea's proactive approach to the COVID-19 global crisis. Psychol Trauma 2020; 12(5):475-477., which was not adopted in Brazil. Another possible explanation for the higher prevalence of anxiety and depression among Brazilian physiotherapists in comparison with health professionals from other countries might be the higher incidence of COVID-19 in Brazil compared to these countries²⁸28 World Health Organization (WHO). Coronavirus disease (COVID-19). Situation Report - 162. 2020. [cited 2023 jun 17]. Available from: https://www.who.int/docs/default-source/coronaviruse/20200630-covid-19-sitrep-162.pdf?sfvrsn=e00a5466_2
https://www.who.int/docs/default-source/... . A recent study found higher distress levels in healthcare workers who lives in the geographical areas with the highest incidence of COVID-19²⁹29 Romero CS, Delgado C, Catalá J, Ferrer C, Errando C, Iftimi A, Benito A, de Andrés J, Otero M; PSIMCOV group. COVID-19 psychological impact in 3109 healthcare workers in Spain: The PSIMCOV group. Psychol Med 2022; 52(1):188-194..

Another factor that contributed to these high rates of anxiety and depression was the female predominance (81.3%) in the present sample, since the female sex emerged as a risk factor for anxiety and depression in the present study and in previous ones⁷7 Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, Du H, Chen T, Li R, Tan H, Kang L, Yao L, Huang M, Wang H, Wang G, Liu Z, Hu S. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020; 3(3):e203976.^,3030 Zhang WR, Wang K, Yin L, Zhao WF, Xue Q, Peng M, Min BQ, Tian Q, Leng HX, Du JL, Chang H, Yang Y, Li W, Shangguan FF, Yan TY, Dong HQ, Han Y, Wang YP, Cosci F, Wang HX. Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China. Psychother Psychosom 2020; 89(4):242-250.. Moreover, even before COVID-19 context, the preponderance of anxiety³¹31 Eaton NR, Keyes KM, Krueger RF, Balsis S, Skodol AE, Markon KE, Grant BF, Hasin DS. An invariant dimensional liability model of gender differences in mental disorder prevalence: evidence from a national sample. J Abnorm Psychol 2012; 121(1):282-288.^,3232 McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res 2011; 45(8):1027-1035. and depression³³33 Kuehner C. Why is depression more common among women than among men? Lancet Psychiatry 2017; 4(2):146-158.^,3434 Salk RH, Hyde JS, Abramson LY. Gender differences in depression in representative national samples: Meta-analyses of diagnoses and symptoms. Psychol Bull 2017; 143(8):783-822. disorders among women was already well evidenced in the literature. Considering 1) the female sex as a risk factor for anxiety and depression; 2) the global tendency of higher proportion of female workers in the health workforce than in the general workforce³⁵35 Shannon G, Minckas N, Tan D, Haghparast-Bidgoli H, Batura N, Mannell J. Feminisation of the health workforce and wage conditions of health professions: an exploratory analysis. Hum Resour Health 2019; 17(1):72., which was also observed in the present study; 3) that women and men are exposed differently to the social and psychological consequences from a pandemic³⁶36 Gausman J, Langer A. Sex and Gender Disparities in the COVID-19 Pandemic. J Womens Health (Larchmt) 2020; 29(4):465-466.; and 4) the highest degree of gender equality has been related to low depression scores among men and women³³33 Kuehner C. Why is depression more common among women than among men? Lancet Psychiatry 2017; 4(2):146-158.; future researches and mental health policies should pay attention to biological, psychological, social, environmental, and economic factors that contribute to this sex/gender gap, especially in healthcare professionals during pandemic contexts³⁶36 Gausman J, Langer A. Sex and Gender Disparities in the COVID-19 Pandemic. J Womens Health (Larchmt) 2020; 29(4):465-466.^,3737 Li LZ, Wang S. Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom. Psychiatry Res 2020; 291:113267..

In this sample, 69.5% of physiotherapists reported worsening in sleep patterns, which was identified as a risk factor for anxiety and depression. By the way, it appeared as the most potential risk factor, increasing in 3.78 and 5.97 times the probability of those who have worsening in sleep patterns to present anxiety and depression, respectively. Previous studies also described the sleep disorders-anxiety/depression association in healthcare workers during the COVID-19 outbreak³⁸38 Mosheva M, Hertz-Palmor N, Dorman Ilan S, Matalon N, Pessach IM, Afek A, Ziv A, Kreiss Y, Gross R, Gothelf D. Anxiety, pandemic-related stress and resilience among physicians during the COVID-19 pandemic. Depress Anxiety 2020; 37(10):965-971.^,3939 Wu K, Wei X. Analysis of psychological and sleep status and exercise rehabilitation of front-line clinical staff in the fight against COVID-19 in China. Med Sci Monit Basic Res 2020; 26:e924085.. Difficulty sleeping was one of the risk factors most strongly associated with anxiety in physicians³⁸38 Mosheva M, Hertz-Palmor N, Dorman Ilan S, Matalon N, Pessach IM, Afek A, Ziv A, Kreiss Y, Gross R, Gothelf D. Anxiety, pandemic-related stress and resilience among physicians during the COVID-19 pandemic. Depress Anxiety 2020; 37(10):965-971. and positive correlation between depression and sleep disturbance was demonstrated in frontline medical staff from a designated hospital for COVID-19 infection³⁹39 Wu K, Wei X. Analysis of psychological and sleep status and exercise rehabilitation of front-line clinical staff in the fight against COVID-19 in China. Med Sci Monit Basic Res 2020; 26:e924085.. Moreover, during the COVID-19 pandemic, health professionals have shown worse sleep quality when compared to other occupational groups²⁴24 Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. Psychiatry Res 2020; 288:112954.^,4040 Qi J, Xu J, Li BZ, Huang JS, Yang Y, Zhang ZT, Yao DA, Liu QH, Jia M, Gong DK, Ni XH, Zhang QM, Shang FR, Xiong N, Zhu CL, Wang T, Zhang X. The evaluation of sleep disturbances for Chinese frontline medical workers under the outbreak of COVID-19. Sleep Med 2020; 72:1-4. and the disruption of the circadian rhythm, due to the overwork imposed to health professionals during the pandemic, was pointed as a possible cause of insomnia and difficulty sleeping³⁸38 Mosheva M, Hertz-Palmor N, Dorman Ilan S, Matalon N, Pessach IM, Afek A, Ziv A, Kreiss Y, Gross R, Gothelf D. Anxiety, pandemic-related stress and resilience among physicians during the COVID-19 pandemic. Depress Anxiety 2020; 37(10):965-971.. Sleep deprivation can impair cognitive domains such as attention, memory, decision making, as well as psychomotor speed, all of which can affect performance in more complex cognitive tasks⁴¹41 Goel N, Basner M, Rao H, Dinges DF. Circadian rhythms, sleep deprivation, and human performance. Prog Mol Biol Transl Sci 2013; 119:155-190.. Complex procedures, such as handling the mechanical ventilation, caring for artificial airways, weaning and extubation, demand high degree of attention and decision making by physiotherapists. In addition, physiotherapists need increased attention with personal and environmental protection measures to avoid aerosol particles exposure and themselves and team contamination⁴4 Righetti RF, Onoue MA, Politi FVA, Teixeira DT, Souza PN, Kondo CS, Moderno EV, Moraes IG, Maida ALV, Pastore Junior L, Silva FD, Brito CMM, Baia WRM, Yamaguti WP. Physiotherapy care of patients with coronavirus disease 2019 (COVID-19) - a Brazilian experience. Clinics (Sao Paulo) 2020; 75:e2017.. Therefore, managers should guarantee adequate rest time for health workers in an attempt to minimize anxiety, depression, and negative impacts of worsening sleep on professional performance.

Concern about financial issues was also identified as a risk factor for anxiety and depression in Brazilian physiotherapists. It was already demonstrated that the economic situation plays a role in anxiety development during the pandemic⁴²42 Bareket-Bojmel L, Shahar G, Margalit M. COVID-19-related economic anxiety is as high as health anxiety: findings from the USA, the UK, and Israel. Int J Cogn Ther 2021; 14(3):566-574.. The COVID-19 pandemic has globally increased fears of an impending economic crisis and recession, causing a reduction in workforce demand across most of the economic sectors and many jobs lost⁴³43 Nicola M, Alsafi Z, Sohrabi C, Kerwan A, Al-Jabir A, Iosifidis C, Agha M, Agha R. The socio-economic implications of the coronavirus pandemic (COVID-19): a review. Int J Surg 2020; 78:185-193.. Although intensive care and inpatient units have faced unprecedented demand during pandemic, that increases the need for health professionals⁴⁴44 Willan J, King AJ, Jeffery K, Bienz N. Challenges for NHS hospitals during covid-19 epidemic. BMJ 2020; 368:m1117., a distinct economic reality emerged in other health sectors due to elective surgeries cancel⁴⁴44 Willan J, King AJ, Jeffery K, Bienz N. Challenges for NHS hospitals during covid-19 epidemic. BMJ 2020; 368:m1117.^,4545 Vaccaro AR, Getz CL, Cohen BE, Cole BJ, Donnally CJ 3rd. Practice management during the COVID-19 pandemic. J Am Acad Orthop Surg 2020; 28(11):464-470., outpatient rehabilitation close⁴⁶46 Besnier F, Gayda M, Nigam A, Juneau M, Bherer L. Cardiac rehabilitation during quarantine in COVID-19 pandemic: challenges for center-based programs. Arch Phys Med Rehabil 2020; 101(10):1835-1838.^,4747 Karloh M, Sousa Matias T, Fleig Mayer A. The COVID-19 pandemic confronts the motivation fallacy within pulmonary rehabilitation programs. COPD 2020; 17(4):343-345., patient office visits reduction, resulting in salaries decrease and many groups demission⁴⁵45 Vaccaro AR, Getz CL, Cohen BE, Cole BJ, Donnally CJ 3rd. Practice management during the COVID-19 pandemic. J Am Acad Orthop Surg 2020; 28(11):464-470..

Beyond the concern about financial issues, family income was associated with depression in the current study. Physiotherapists who had family income lower than three minimum wages had 2.43 more chances of having depression than those who had a family income higher than or equal to three and lower than or equal to five minimum wages. Previous studies in general population have been demonstrating this association⁴⁸48 Crowe L, Butterworth P. The role of financial hardship, mastery and social support in the association between employment status and depression: results from an Australian longitudinal cohort study. BMJ Open 2016; 6(5):e009834.

49 Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of US adults. J Epidemiol Community Health 2020; jech-2020-215213.^-5050 Lorant V, Deliège D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol 2003; 157(2):98-112.. A meta-analysis indicated that a 1 percent increase in relative ranking on income led to a 0.74 percent decrease in the log odds ratio of being depressed⁵⁰50 Lorant V, Deliège D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol 2003; 157(2):98-112.. An Australian longitudinal cohort study showed that underemployment was associated with increased risk of depression and that inadequate remuneration associated with underemployment is a determinant of the poorer mental health⁴⁸48 Crowe L, Butterworth P. The role of financial hardship, mastery and social support in the association between employment status and depression: results from an Australian longitudinal cohort study. BMJ Open 2016; 6(5):e009834.. Recently, a cross-sectional observational study done during COVID-19 pandemic also demonstrated the association between lower income and depression⁴⁹49 Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S. Low assets and financial stressors associated with higher depression during COVID-19 in a nationally representative sample of US adults. J Epidemiol Community Health 2020; jech-2020-215213.. Moreover, evidence has shown that the COVID‐19 pandemic exacerbated previous inequalities and created others. While higher-income families could have a reduction in expenditure due to social distancing, since they spend a larger part of their total expenditure on services affected by the quarantine (i.e. leisure, holidays, restaurants, personal care), lower-income families spend a larger part of their income on primary necessities that are difficult to adjust to any earning reduction. In addition, lower-income workers are more likely to have their earnings reduced and are more likely to have lost their job⁵¹51 Blundell R, Costa Dias M, Joyce R, Xu X. COVID-19 and inequalities. Fisc Stud 2020; 41(2):291-319.. Therefore, there is a need to protect the economically vulnerable people in times of financial crisis⁵²52 Pereira JM. Financial crisis increases the risk of depression relapse. J Psychiatr Res 2015; 61:235-236..

Another risk factor for anxiety and depression among Brazilian physiotherapists was loneliness. Similarly, loneliness, due to COVID-19 measures of social distancing, was the most prominent risk factor for anxiety and depression in Israeli general population²³23 Palgi Y, Shrira A, Ring L, Bodner E, Avidor S, Bergman Y, Cohen-Fridel S, Keisari S, Hoffman Y. The loneliness pandemic: loneliness and other concomitants of depression, anxiety and their comorbidity during the COVID-19 outbreak. J Affect Disord 2020; 275:109-111.. Although social distancing and lockdown have shown efficacy in reducing viral transmission⁵³53 Lavezzo E, Franchin E, Ciavarella C, Cuomo-Dannenburg G, Barzon L, Del Vecchio C, Rossi L, Manganelli R, Loregian A, Navarin N, Abate D, Sciro M, Merigliano S, De Canale E, Vanuzzo MC, Besutti V, Saluzzo F, Onelia F, Pacenti M, Parisi SG, Carretta G, Donato D, Flor L, Cocchio S, Masi G, Sperduti A, Cattarino L, Salvador R, Nicoletti M, Caldart F, Castelli G, Nieddu E, Labella B, Fava L, Drigo M, Gaythorpe KAM; Imperial College COVID-19 Response Team; Brazzale AR, Toppo S, Trevisan M, Baldo V, Donnelly CA, Ferguson NM, Dorigatti I, Crisanti A; Imperial College COVID-19 Response Team. Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo'. Nature 2020; 584(7821):425-429., these control measures can trigger or increase lonely feelings⁵⁴54 Smith BJ, Lim MH. How the COVID-19 pandemic is focusing attention on loneliness and social isolation. Public Health Res Pract 2020; 30(2):3022008.. Three months after the first case of COVID-19, 35.86% of 15,530 people in the United Kingdom reported that sometimes or often felt lonely³⁷37 Li LZ, Wang S. Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom. Psychiatry Res 2020; 291:113267.. A study performed during this pandemic in 50 states of the United States of America showed that loneliness was significantly higher than reported previously, and it was associated with higher levels of depression and ideation of suicide⁵⁵55 Killgore WDS, Cloonan SA, Taylor EC, Dailey NS. Loneliness: a signature mental health concern in the era of COVID-19. Psychiatry Res 2020; 290:113117.. Although loneliness has been shown as an important risk factor for anxiety and/or depression during the pandemic in general population²³23 Palgi Y, Shrira A, Ring L, Bodner E, Avidor S, Bergman Y, Cohen-Fridel S, Keisari S, Hoffman Y. The loneliness pandemic: loneliness and other concomitants of depression, anxiety and their comorbidity during the COVID-19 outbreak. J Affect Disord 2020; 275:109-111.^,3737 Li LZ, Wang S. Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom. Psychiatry Res 2020; 291:113267.^,5555 Killgore WDS, Cloonan SA, Taylor EC, Dailey NS. Loneliness: a signature mental health concern in the era of COVID-19. Psychiatry Res 2020; 290:113117., the role of loneliness in depression and anxiety among health professionals was fair investigated. It was demonstrated that loneliness was related to lower mental health in healthcare professionals⁵⁶56 Cabello M, Izquierdo A, Leal I. Loneliness and not living alone is what impacted on the healthcare professional's mental health during the COVID-19 outbreak in Spain. Health Soc Care Community 2022; 30(3):968-975.. Therefore, it is important to access feelings of loneliness among health professionals to plan strategies to increase social support for these professionals.

This study has some limitations. First, the cross-sectional design used does not allow address the long-term changes in anxiety and depression over the pandemic period. Second, answering all questions was mandatory to continue through the survey, which may have discouraged some participants from completion, reducing the sample size. However, the number of participants exceeded the estimated sample size to meet a 95% confidence level. Third, the convenience sample added to the fact that this survey was conducted in Brazil, where pandemic scenario was worse than in other countries, preclude the external generalization of the findings. On the other hand, it can help to strength evidence that urgent measures are needed in all scenarios when dealing with a global health issue. Finally, the self-reporting nature of the clinical variables, although using validated scales, may have less reliability than the assessment by mental health professionals.

Conclusion

This research found a high prevalence of anxiety and depression among studied physiotherapists during the COVID-19 pandemic. Female sex, worsening in sleep patterns, concern about financial issues, and loneliness were identified as risk factors for both anxiety and depression. In addition, family income lower than 3 minimum wage also emerged as a risk factor for depression. Among all these risk factors, the worsening in sleep patterns appeared as the strongest one. Therefore, a proactive approach to prevent and treat physiotherapists mental burdens due to this and future pandemics should be implemented.

Acknowledgements

Conselho Regional de Fisioterapia e Terapia Ocupacional da 15ª Região (CREFITO-15).

References

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