Abstract

The aim of the present study was to map the available evidence on the mental health risk factors of frontline health professionals during the COVID-19 pandemic. This is a systematic review that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The search was independently carried out by four researchers, following the selection criteria in the electronic databases: PubMed Central, Ovid Technologies, GALE Academic Onefile, Science Citation Index Expanded. The data processing used Zotero software, responsible for creating and importing items according to the criteria established by the research. A total of 18,733 articles were found, of which 2,722 were excluded by the Zotero software because they were in duplicate, and another 366 were manually excluded. After applying the selection criteria, 43 articles entered the final analysis of this review. It is recommended that new scientific research be carried out, especially focusing on the analysis of health workers’ mental health, aiming at providing the basis to create and implement public mental health programs and policies for workers.

Key words:
Health professional; COVID-19; SARS-CoV-2; Mental health; Workers

Introduction

The outbreak of COVID-19 (acronym for coronavirus disease), originated in December 2019 in Wuhan, a city located in the Hubei province, in China. Due to the high transmissibility capacity of the coronavirus, it has spread all over the world, causing a major public health problem worldwide. Thus, on March 11, 2020, a global pandemic was declared by the World Health Organization (WHO)¹1 World Health Organizatio (WHO). Coronavirus Disease 2019 (COVID-19) Situation Report-87 [Internet]. 2019. [cited 2023 mar 9]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200416-sitrep-87-COVID-19.pdf?sfvrsn=9523115a_2
https://www.who.int/docs/default-source/... ^,22 Gold JA. COVID-19: adverse mental health outcomes for healthcare workers. BMJ 2020; 369:m1815. With the increase in the number of cases of people infected by the coronavirus, the health system experienced several problems due to the lack of scientific knowledge about the new disease, which had a high mortality rate¹1 World Health Organizatio (WHO). Coronavirus Disease 2019 (COVID-19) Situation Report-87 [Internet]. 2019. [cited 2023 mar 9]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200416-sitrep-87-COVID-19.pdf?sfvrsn=9523115a_2
https://www.who.int/docs/default-source/... .

With the arrival of the virus and its different mutations, health systems collapsed and faced great difficulties due to the lack of effective protocols to fight the virus and of scientific evidence-based treatments²2 Gold JA. COVID-19: adverse mental health outcomes for healthcare workers. BMJ 2020; 369:m1815. Also, the lack or the inadequacy of appropriate training in COVID-19 care teams regarding the prevention and control of infections resulted in a high number of contamination cases among health professionals. Moreover, the lack of personal protective equipment supply at the beginning of the pandemic made the situation of health workers who were on the frontlines of the fight against COVID-19 even more precarious.

Faced with the existing circumstances, which demanded great responsibility from health professionals and constituted a life-threatening situation, it is clear that it is necessary to be concerned about the possible impacts on the mental health of these professionals, especially those who were directly linked to coping with the pandemic, in the so-called frontlines. Therefore, it is important to carry out scientific research of the systematic review type, aiming to gather evidence from studies whose objective was to map the available evidence on risk factors for the mental health of health professionals working on the frontline during the COVID-19 pandemic.

Regarding the unprecedented character of this study, it was shown that at the time it was carried out, there were no reviews registered in the PROSPERO database addressing this subject. Emphasis is added on how the articles were categorized and on how the quality of the studies was assessed. PROSPERO is a free registration database for systematic review protocols. It should be noted that the scientific relevance of this database is internationally recognized and allows the identification of unpublished reviews, such as the present one, and also of outcome biases.

Method

This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, according to the guidelines of the PRISMA committee³3 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. A declaração PRISMA 2020: diretriz atualizada para relatar revisões sistemáticas. RevPanm Salud Publica 2022; 31(2):e112.. The research was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on April 26, 2021 under registration number CRD42021241088.

Eligibility criteria - study selection

The studies were selected using predefined criteria established by two lead researchers. For key question 1, the study sample/population consisted of health professionals who worked in the assistance and care of patients infected and diagnosed with COVID-19 and frontline workers in hospitals, clinics and/or rehabilitation and screening centers for COVID-19. For key question 2, the potential risk factors were demographic characteristics - assessed country and/or city, history of exposure, administrative factors - such as workload. Two researchers (BILB and MAXS) reviewed each selection stage of the studies included in this research and a judge’s opinion (MMAS) was requested when there was no consensus among the researchers.

According to the PICOS model, the following eligibility criteria were adopted: Participants (P): health professionals who care for or assist patients with COVID-19 infection and workers who work on the frontlines of hospitals, clinics and rehabilitation and screening centers for COVID-19; Outcome (O): Prevalence of common mental disorders reported in studies; Study(S): cross-sectional, or longitudinal, or cohort (baseline data). Because it is a systematic review, not all questions were able to receive a satisfactory answer.

The following were considered as inclusion criteria: the article indexed in the selected databases, with complete availability - as free and full form - of the text; peer-reviewed journal articles; research published in English, Spanish and/or Portuguese; with date filter related to the years 2019 to June 1, 2021. No restrictions were assigned to the place where the manuscript was produced.

Information sources and search strategy

A search was carried out independently by four researchers, following the selection criteria established by the PRISMA-2020 guideline. The following electronic databases were consulted: PubMed Central (PMC), OVID Technologies, OneFile (GALE) and Science Citation Index Expanded. Zotero software was used for data processing, responsible for creating and importing items according to the criteria established by the research team.

The terms used in the search were established by the Medical Subject Headings descriptors (MeSH Terms). A search was carried out in the literature based on the following descriptors: “Health professional” AND “COVID-19” OR “SARS-CoV-2” AND “Mental Health” AND “Workers”. The variations in the descriptors were used to find a greater range of significant results for this research.

Data collection process

Data management, import, synchronization, and storage were performed using Zotero software. Data extraction was initially carried out by two authors and then analyzed and revised by a third researcher, independently and without intervention at the time of the extraction and, after the data analysis, in case of disagreement; consensus was reached through a discussion among the researchers, and a final arbiter was not necessary. The selection process for the research hierarchically included a three-stage data collection procedure, identifying relevant studies: (1) analysis and selection by title screening; (2) analysis and selection by reading the abstracts, and (3) analysis and selection by reading the full text of eligible studies.

Data list

All articles reached the maximum level of relevance to the outcome measures chosen for this research. To map the characteristics of the articles, the following variables were collected: title and year; analyzed group and professional category; type of study and sample; research objective; outcome measures; and, the main outcomes and limitations of the studies, as shown in Chart 1(available from: https://drive.google.com/file/d/1L_9UvMQ5R329MYnfLFMErJIO_WNqMkjt/view?usp=sharing).

Synthesis methods

To assess the quality of the selected studies, two researchers participated in this process, by extracting data from the selected studies and organizing them into Chart 2(available from: https://drive.google.com/file/d/1Jwi0Zfot8K9ldwhTN-Ptf8G3yzUvHlDl/view?usp=sharing) results that contain the quality assessment that was carried out based on the criteria determined by the National Heart, Lung, and Blood Institute (NHLBI).

Considering the importance of measuring the quality of studies in systematic reviews, the National Heart, Lung, and Blood Institute (NHLBI) developed a set of customized tools that guide this measurement, such as the Guidance for Assessing the Quality of Observational Cohort and Cross- Sectional Studies⁴4 Ma LL, Wang YY, Yang ZH, Huang D, Weng H, Zeng XT. Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better? Military Med Res 2020; 7(1):7.. This tool consists of 14 items, and each one of them corresponds to a question, which can be answered with “yes”, “no” or “not reported”. In the tool, a score of 1 is attributed to each “yes” answer and zero to all other responses. Overall, the total study score would be the number of “yes” answers. Scores greater than 12 are considered “good,” meaning the study has a low risk of bias. Scores that are lower than 9 are considered “average”, which means that the study is considered as having acceptable quality. On the other hand, scores lower than 9 mean that the study is “reasonable”⁵5 National Heart, Lung, and Blood Institute (NIH). Quality Assessment Tool for Observation-al Cohort and Cross-Sectional Studies [Internet]. 2017. [cited 2021 abr 30]. Available from: https://www.nhlbi.nih.gov/health-topics/studyquality-assessment-tools.
https://www.nhlbi.nih.gov/health-topics/... , that is, it has strengths and weaknesses, but has a significant risk of bias. For this study, only observational cohort articles were assessed for quality.

Results

Study selection

The initial search using the keyword database returned 18,733 potentially eligible articles, in the following search databases: Pubmed Central: 9,987, Ovid Technologies: 6,864, GALE Academic Onefile: 1,354, Science Citation Index Expanded: 528.

The search results are shown in Figure 1 - PRISMA 2020 flow diagram for new systematic reviews, which included searches in databases and registers only. After selecting the 18,733 articles, the records were imported using the Zotero program, where 2,722 duplicate articles were excluded and 366 were manually excluded, leaving a total of 15,645 records, of which a total of 5,679 were eligible for abstract screening. After abstract screening, 4,632 studies were excluded, leaving 1,047 articles for full-text screening, of which 1,004 articles were excluded after the screening of full articles, leaving 43 articles for data extraction - selected and displayed in Charts 1(available from: https:/ /drive.google.com/file/d/1L_9UvMQ5R329MYnfLFMErJIO_WNqMkjt/view?usp=sharing) and 2 (available from: https://drive.google.com/file/d/1Jwi0Zfot8K9ldwhTN-Ptf8G3yzUvHlDl/view?usp=sharing) and in Figure 1.

Overall characteristics of included studies and quality assessment

The eligible articles had an average NHLBI quality assessment score, namely: seven studies scored above 9, being considered average 9/5^27.38-40,44; 10/1²⁶26 Tao J, Lin Y, Jiang L, Zhou Z, Zhao J, Qu D, Li W, Zhu Y. Psychological impact of the COVID-19 pandemic on emergency dental care providers on the front lines in China. Int Dent J 2020; 71(3):197-205.; 11/1³³33 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.. The studies considered reasonable were the vast majority 6/2²⁹29 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.^,4747 Xiong H, Yi S, Lin Y. The psychological status and self-efficacy of nurses during COVID-19 outbreak: a cross-sectional survey. Inquiry 2020; 57:46958020957114.; 7/5²⁸28 Ali S, Maguire S, Marks E, Doyle M, Sheehy C. Psychological impact of the COVID-19 pandemic on healthcare workers at acute hospital settings in the South-East of Ireland: an observational cohort multicentre study. BMJ Open 2020; 10(12):e042930.^,3030 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.

35 Hong X, Cao J, Wei J, Duan Y, Zhao X, Jiang J, Jiang Y, Geng W, Zhu H. Stress and psychological impact of the COVID-19 outbreak on the healthcare staff at the fever clinic of a tertiary general hospital in Beijing: a cross-sectional study. BJPsych Open 2020; 7(3):e76.^-3636 Sorokin MY, Kasyanov ED, Rukavishnikov GV, Makarevich OV, Neznanov NG, Morozov PV, Lutova NB, Mazo GE. Stress and stigmatization in health-care workers during the COVID-19 pandemic. Indian J Psychiatry 2020; 62(Suppl 3):S445-S453.; 8/9²⁵25 Wang N, Li Y, Wang Q, Lei C, Liu Y, Zhu S. Psychological impact of COVID-19 pandemic on healthcare workers in China Xi'an central hospital. Brain Behav 2021; 11(3):e02028.^,3131 Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China. Med Sci Monit 2020; 92(10):1962-1970.^,3232 Zerbini G, Ebigbo A, Reicherts P, Kunz M, Messman H. Psychosocial burden of healthcare professionals in times of COVID-19 - a survey conducted at the University Hospital Augsburg. Ger Med Sci 2020; 18:Doc05.^,3737 Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, Ghosh K, Schroeder DR, Bhagra A. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health 2021; 12:21501327211008448.^,4242 Chen X, Arber A, Gao J, Zhang L, Ji M, Wang D, Wu J, Du J. The mental health status among nurses from low-risk areas under normalized COVID-19 pandemic prevention and control in China: a cross-sectional study. Int J Ment Health Nurs 2021; 30(4):975-987.

43 Ide K, Asami T, Suda A, Yoshimi A, Fujita J, Nomoto M, Roppongi T, Hino K, Takahashi Y, Watanabe K, Shimada T, Hamasaki T, Endo E, Kaneko T, Suzuki M, Kubota K, Saigusa Y, Kato H, Odawara T, Nakajima H, Takeuchi I, Goto T, Aihara M, Hishimoto A. The psychological effects of COVID-19 on hospital workers at the beginning of the outbreak with a large disease cluster on the Diamond Princess cruise ship. PLoS One 2021; 16(1):e0245294.^-4444 Al Muharraq EH. The psychological impact of coronavirus disease 2019 on nurses in Saudi Arabia and their coping strategies. SAGE Open Nurs 2021; 7:23779608211011322.^,4646 Al Mahyijari N, Badahdah A, Khamis F. The psychological impacts of COVID-19: a study of frontline physicians and nurses in the Arab world. Ir J Psychol Med 2021; 38(3):186-191.^,4747 Xiong H, Yi S, Lin Y. The psychological status and self-efficacy of nurses during COVID-19 outbreak: a cross-sectional survey. Inquiry 2020; 57:46958020957114. ; all studies eligible for the NHLBI quality assessment are shown in Chart 2(available from: https://drive.google.com/file/d/1Jwi0Zfot8K9ldwhTN-Ptf8G3yzUvHlDl/view?usp=sharing)

The research characteristics (analyzed group/professional categories; country of origin; objective) as well as the results of the study are shown in Chart 1(available from: https://drive.google.com/file/d/1L_9UvMQ5R329MYnfLFMErJIO_WNqMkjt/view?usp=sharing). Regarding the methodological characteristics of the eligible studies, of these, 34 were cross-sectional studies ⁶6 Kibret S, Teshome D, Fenta E, Hunie M, Tamire T. Prevalence of anxiety towards COVID-19 and its associated factors among healthcare workers in a Hospital of Ethiopia. PLoS One 2020; 15(12):e0243022.

7 Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study. J Family Med Prim Care 2020; 9(9):4904-4910.

8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.

9 Pan X, Xiao Y, Ren D, Xu ZM, Zhang Q, Yang LY, Liu F, Hao YS, Zhao F, Bai YH. Prevalence of mental health problems and associated risk factors among military healthcare workers in special. Asia Pac Psychiatry 2022; 14(1):e12427.^-1010 Guo WP, Min Q, Gu WW, Yu L, Xiao X, Yi WB, Li HL, Huang B, Li JL, Dai YJ, Xia J, Liu J, Li B, Zhou BH, Li M, Xu HX, Wang XB, Shi WY. Prevalence of mental health problems in frontline healthcare workers after the first outbreak of COVID-19 in China: a cross-sectional study. Health Qual Life Outcomes 2021; 19(1):103.^,1212 Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry 2021; 69:20-26.

13 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.^-1414 Skoda EM, Teufel M, Stang A, Jöckel KH, Junne F, Weismüller B, Hetkamp M, Musche V, Kohler H, Dörrie N, Schweda A, Bäuerle A. Psychological burden of healthcare professionals in Germany during the acute phase of the COVID-19 pandemic: differences and similarities in the international context. J Public Health (Oxf) 2020; 42(4):688-695.^,1616 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.

17 Sun D, Yang D, Li Y, Zhou J, Wang W, Wang Q, Lin N, Cao A, Wang H, Zhang Q. Psychological impact of 2019 novel coronavirus (2019-nCoV) outbreak in health workers in China. Epidemiol Infect 2020; 148:e96.

18 Fu Y, Wang M, Zhao B, Liu B, Sun J, Feng Y, Wang Z, Li Q, Shi C, Xuan Y, Long S, Liu H, Chi T, Liao Z, Li B, Liu Q. Psychological impact of COVID-19 cases on medical staff of Beijing Xiaotangshan Hospital. Psychol Res Behav Manag 2021; 14:41-47.

19 Ofori AA, Osarfo J, Agbeno EK, Manu DO, Amoah E. Psychological impact of COVID-19 on health workers in Ghana: a multicentre, cross-sectional study. SAGE Open Med 2021; 9:20503121211000919.

20 Si MY, Su XY, Jiang Y, Wang WJ, Gu XF, Ma L, Li J, Zhang SK, Ren ZF, Ren R, Liu YL, Qiao YL. Psychological impact of COVID-19 on medical care workers in China. Infect Dis Poverty 2020; 9(1):113.

21 Nie A, Su X, Zhang S, Guan W, Li J. Psychological impact of COVID-19 outbreak on frontline nurses: a cross-sectional survey study. J Clin Nurs 2020; 29(21-22):4217-4226.

22 Leira-Sanmartín M, Madoz-Gúrpide A, Ochoa-Mangado E, Ibáñez Á. Psychological impact of COVID-19 pandemic and related variables: a cross-sectional study in a sample of workers in a Spanish tertiary hospital. Int J Environ Res Public Health 2021; 18(7):3608.^-2323 Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, Zhang K, Chin HK, Ahmad A, Khan FA, Shanmugam GN, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH , Sagayanathan R, Chen JT, Ng AYY, Teoh HL, Ho CS, Ho RC, Sharma VK. Psychological impact of COVID-19 pandemic on health care professionals and workers. Ann Intern Med 2020; 173(4):317-320.^,2525 Wang N, Li Y, Wang Q, Lei C, Liu Y, Zhu S. Psychological impact of COVID-19 pandemic on healthcare workers in China Xi'an central hospital. Brain Behav 2021; 11(3):e02028.

26 Tao J, Lin Y, Jiang L, Zhou Z, Zhao J, Qu D, Li W, Zhu Y. Psychological impact of the COVID-19 pandemic on emergency dental care providers on the front lines in China. Int Dent J 2020; 71(3):197-205.^-2727 Amal M. Qasem Surrati, Farah M. Asad Mansuri, Abeer A. Ayadh Alihabi. Psychological impact of the COVID-19 pandemic on health care workers. J Taibah Univ Med Sci 2020; 15(6):536-543.^,3232 Zerbini G, Ebigbo A, Reicherts P, Kunz M, Messman H. Psychosocial burden of healthcare professionals in times of COVID-19 - a survey conducted at the University Hospital Augsburg. Ger Med Sci 2020; 18:Doc05.

33 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.

34 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.

35 Hong X, Cao J, Wei J, Duan Y, Zhao X, Jiang J, Jiang Y, Geng W, Zhu H. Stress and psychological impact of the COVID-19 outbreak on the healthcare staff at the fever clinic of a tertiary general hospital in Beijing: a cross-sectional study. BJPsych Open 2020; 7(3):e76.

36 Sorokin MY, Kasyanov ED, Rukavishnikov GV, Makarevich OV, Neznanov NG, Morozov PV, Lutova NB, Mazo GE. Stress and stigmatization in health-care workers during the COVID-19 pandemic. Indian J Psychiatry 2020; 62(Suppl 3):S445-S453.

37 Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, Ghosh K, Schroeder DR, Bhagra A. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health 2021; 12:21501327211008448.

38 Chatterjee SS, Chakrabarty M, Banerjee D, Grover S, Chatterjee SS, Dan U. Stress, sleep and psychological impact in healthcare workers during the early phase of COVID-19 in India: a factor analysis. Front Psychol 2021; 12:611314.^-3939 Korkmaz S, Kazgan A, Çekiç S, Tartar AS, Balci HN, Atmaca M. The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in COVID-19 services. J Clin Neurosci 2020; 80:131-136.^,4141 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.

42 Chen X, Arber A, Gao J, Zhang L, Ji M, Wang D, Wu J, Du J. The mental health status among nurses from low-risk areas under normalized COVID-19 pandemic prevention and control in China: a cross-sectional study. Int J Ment Health Nurs 2021; 30(4):975-987.

43 Ide K, Asami T, Suda A, Yoshimi A, Fujita J, Nomoto M, Roppongi T, Hino K, Takahashi Y, Watanabe K, Shimada T, Hamasaki T, Endo E, Kaneko T, Suzuki M, Kubota K, Saigusa Y, Kato H, Odawara T, Nakajima H, Takeuchi I, Goto T, Aihara M, Hishimoto A. The psychological effects of COVID-19 on hospital workers at the beginning of the outbreak with a large disease cluster on the Diamond Princess cruise ship. PLoS One 2021; 16(1):e0245294.

44 Al Muharraq EH. The psychological impact of coronavirus disease 2019 on nurses in Saudi Arabia and their coping strategies. SAGE Open Nurs 2021; 7:23779608211011322.

45 Chen B, Li QX, Zhang H, Zhu JY, Yang X, Wu YH, Xiong J, Li F, Wang H, Chen ZT. The psychological impact of COVID-19 outbreak on medical staff and the general public. Curr Psychol 2020; 41(8):5631-5639.

46 Al Mahyijari N, Badahdah A, Khamis F. The psychological impacts of COVID-19: a study of frontline physicians and nurses in the Arab world. Ir J Psychol Med 2021; 38(3):186-191.

47 Xiong H, Yi S, Lin Y. The psychological status and self-efficacy of nurses during COVID-19 outbreak: a cross-sectional survey. Inquiry 2020; 57:46958020957114.^-4848 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149., two were longitudinal studies¹¹11 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.^,2424 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1., one was a comparative study¹⁵15 Collantoni E, Saieva AM, Meregalli V, Girotto C, Carretta G, Boemo DG, Bordignon G, Capizzi A, Contessa C, Nesoti MV, Donato D, Flesia L, Favaro A. Psychological distress, fear of COVID-19, and resilient coping abilities among healthcare workers in a tertiary first-line hospital during the coronavirus pandemic. J Clin Med 2021; 10(7):1465., one was an observational cohort²⁸28 Ali S, Maguire S, Marks E, Doyle M, Sheehy C. Psychological impact of the COVID-19 pandemic on healthcare workers at acute hospital settings in the South-East of Ireland: an observational cohort multicentre study. BMJ Open 2020; 10(12):e042930., one was an observational and descriptive cross-sectional study³⁰30 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580., one was an observational cross-sectional³¹31 Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China. Med Sci Monit 2020; 92(10):1962-1970., and one was a prospective cohort study⁴⁰40 Sasaki N, Kuroda R, Tsuno K, Kawakami N. The deterioration of mental health among healthcare workers during the COVID-19 outbreak: a population-based cohort study of workers in Japan. Scand J Work Environment Health 2020; 46(6):639-644.. Of the 43 studies included, 42 were performed and published in 2020⁶6 Kibret S, Teshome D, Fenta E, Hunie M, Tamire T. Prevalence of anxiety towards COVID-19 and its associated factors among healthcare workers in a Hospital of Ethiopia. PLoS One 2020; 15(12):e0243022.

7 Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study. J Family Med Prim Care 2020; 9(9):4904-4910.^-88 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.^,1010 Guo WP, Min Q, Gu WW, Yu L, Xiao X, Yi WB, Li HL, Huang B, Li JL, Dai YJ, Xia J, Liu J, Li B, Zhou BH, Li M, Xu HX, Wang XB, Shi WY. Prevalence of mental health problems in frontline healthcare workers after the first outbreak of COVID-19 in China: a cross-sectional study. Health Qual Life Outcomes 2021; 19(1):103.

11 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.

12 Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry 2021; 69:20-26.

13 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.

14 Skoda EM, Teufel M, Stang A, Jöckel KH, Junne F, Weismüller B, Hetkamp M, Musche V, Kohler H, Dörrie N, Schweda A, Bäuerle A. Psychological burden of healthcare professionals in Germany during the acute phase of the COVID-19 pandemic: differences and similarities in the international context. J Public Health (Oxf) 2020; 42(4):688-695.

15 Collantoni E, Saieva AM, Meregalli V, Girotto C, Carretta G, Boemo DG, Bordignon G, Capizzi A, Contessa C, Nesoti MV, Donato D, Flesia L, Favaro A. Psychological distress, fear of COVID-19, and resilient coping abilities among healthcare workers in a tertiary first-line hospital during the coronavirus pandemic. J Clin Med 2021; 10(7):1465.

16 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.

17 Sun D, Yang D, Li Y, Zhou J, Wang W, Wang Q, Lin N, Cao A, Wang H, Zhang Q. Psychological impact of 2019 novel coronavirus (2019-nCoV) outbreak in health workers in China. Epidemiol Infect 2020; 148:e96.

18 Fu Y, Wang M, Zhao B, Liu B, Sun J, Feng Y, Wang Z, Li Q, Shi C, Xuan Y, Long S, Liu H, Chi T, Liao Z, Li B, Liu Q. Psychological impact of COVID-19 cases on medical staff of Beijing Xiaotangshan Hospital. Psychol Res Behav Manag 2021; 14:41-47.

19 Ofori AA, Osarfo J, Agbeno EK, Manu DO, Amoah E. Psychological impact of COVID-19 on health workers in Ghana: a multicentre, cross-sectional study. SAGE Open Med 2021; 9:20503121211000919.

20 Si MY, Su XY, Jiang Y, Wang WJ, Gu XF, Ma L, Li J, Zhang SK, Ren ZF, Ren R, Liu YL, Qiao YL. Psychological impact of COVID-19 on medical care workers in China. Infect Dis Poverty 2020; 9(1):113.

21 Nie A, Su X, Zhang S, Guan W, Li J. Psychological impact of COVID-19 outbreak on frontline nurses: a cross-sectional survey study. J Clin Nurs 2020; 29(21-22):4217-4226.

22 Leira-Sanmartín M, Madoz-Gúrpide A, Ochoa-Mangado E, Ibáñez Á. Psychological impact of COVID-19 pandemic and related variables: a cross-sectional study in a sample of workers in a Spanish tertiary hospital. Int J Environ Res Public Health 2021; 18(7):3608.

23 Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, Zhang K, Chin HK, Ahmad A, Khan FA, Shanmugam GN, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH , Sagayanathan R, Chen JT, Ng AYY, Teoh HL, Ho CS, Ho RC, Sharma VK. Psychological impact of COVID-19 pandemic on health care professionals and workers. Ann Intern Med 2020; 173(4):317-320.

24 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1.

25 Wang N, Li Y, Wang Q, Lei C, Liu Y, Zhu S. Psychological impact of COVID-19 pandemic on healthcare workers in China Xi'an central hospital. Brain Behav 2021; 11(3):e02028.

26 Tao J, Lin Y, Jiang L, Zhou Z, Zhao J, Qu D, Li W, Zhu Y. Psychological impact of the COVID-19 pandemic on emergency dental care providers on the front lines in China. Int Dent J 2020; 71(3):197-205.

27 Amal M. Qasem Surrati, Farah M. Asad Mansuri, Abeer A. Ayadh Alihabi. Psychological impact of the COVID-19 pandemic on health care workers. J Taibah Univ Med Sci 2020; 15(6):536-543.

28 Ali S, Maguire S, Marks E, Doyle M, Sheehy C. Psychological impact of the COVID-19 pandemic on healthcare workers at acute hospital settings in the South-East of Ireland: an observational cohort multicentre study. BMJ Open 2020; 10(12):e042930.

29 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.

30 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580.

31 Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China. Med Sci Monit 2020; 92(10):1962-1970.

32 Zerbini G, Ebigbo A, Reicherts P, Kunz M, Messman H. Psychosocial burden of healthcare professionals in times of COVID-19 - a survey conducted at the University Hospital Augsburg. Ger Med Sci 2020; 18:Doc05.

33 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.

34 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.

35 Hong X, Cao J, Wei J, Duan Y, Zhao X, Jiang J, Jiang Y, Geng W, Zhu H. Stress and psychological impact of the COVID-19 outbreak on the healthcare staff at the fever clinic of a tertiary general hospital in Beijing: a cross-sectional study. BJPsych Open 2020; 7(3):e76.

36 Sorokin MY, Kasyanov ED, Rukavishnikov GV, Makarevich OV, Neznanov NG, Morozov PV, Lutova NB, Mazo GE. Stress and stigmatization in health-care workers during the COVID-19 pandemic. Indian J Psychiatry 2020; 62(Suppl 3):S445-S453.

37 Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, Ghosh K, Schroeder DR, Bhagra A. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health 2021; 12:21501327211008448.

38 Chatterjee SS, Chakrabarty M, Banerjee D, Grover S, Chatterjee SS, Dan U. Stress, sleep and psychological impact in healthcare workers during the early phase of COVID-19 in India: a factor analysis. Front Psychol 2021; 12:611314.

39 Korkmaz S, Kazgan A, Çekiç S, Tartar AS, Balci HN, Atmaca M. The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in COVID-19 services. J Clin Neurosci 2020; 80:131-136.

40 Sasaki N, Kuroda R, Tsuno K, Kawakami N. The deterioration of mental health among healthcare workers during the COVID-19 outbreak: a population-based cohort study of workers in Japan. Scand J Work Environment Health 2020; 46(6):639-644.

41 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.

42 Chen X, Arber A, Gao J, Zhang L, Ji M, Wang D, Wu J, Du J. The mental health status among nurses from low-risk areas under normalized COVID-19 pandemic prevention and control in China: a cross-sectional study. Int J Ment Health Nurs 2021; 30(4):975-987.

43 Ide K, Asami T, Suda A, Yoshimi A, Fujita J, Nomoto M, Roppongi T, Hino K, Takahashi Y, Watanabe K, Shimada T, Hamasaki T, Endo E, Kaneko T, Suzuki M, Kubota K, Saigusa Y, Kato H, Odawara T, Nakajima H, Takeuchi I, Goto T, Aihara M, Hishimoto A. The psychological effects of COVID-19 on hospital workers at the beginning of the outbreak with a large disease cluster on the Diamond Princess cruise ship. PLoS One 2021; 16(1):e0245294.

44 Al Muharraq EH. The psychological impact of coronavirus disease 2019 on nurses in Saudi Arabia and their coping strategies. SAGE Open Nurs 2021; 7:23779608211011322.

45 Chen B, Li QX, Zhang H, Zhu JY, Yang X, Wu YH, Xiong J, Li F, Wang H, Chen ZT. The psychological impact of COVID-19 outbreak on medical staff and the general public. Curr Psychol 2020; 41(8):5631-5639.

46 Al Mahyijari N, Badahdah A, Khamis F. The psychological impacts of COVID-19: a study of frontline physicians and nurses in the Arab world. Ir J Psychol Med 2021; 38(3):186-191.

47 Xiong H, Yi S, Lin Y. The psychological status and self-efficacy of nurses during COVID-19 outbreak: a cross-sectional survey. Inquiry 2020; 57:46958020957114.^-4848 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149., and only one study was published in 2021⁹9 Pan X, Xiao Y, Ren D, Xu ZM, Zhang Q, Yang LY, Liu F, Hao YS, Zhao F, Bai YH. Prevalence of mental health problems and associated risk factors among military healthcare workers in special. Asia Pac Psychiatry 2022; 14(1):e12427..

Regarding the samples, the total number of the assessed population in the studies was 49,117. All studies had a detailed profile and studied population and most cross-sectional studies used non-probabilistic sampling methods. As for the demographic characteristics related to the origin of the studies, most of the them were Chinese (15), where the outbreak of COVID-19 started. However, studies were also carried out in Spain (4), the United States (3), Italy (3), Turkey (2), Germany (2), India (2), Japan (2), Saudi Arabia (2), Sri Lanka (1), Ghana (1), Ireland (1), France (1), United Kingdom (1), Russia (1), Oman (1) and Ethiopia (1).

The professional category most frequently reported in the studies was the nursing professional, followed by physicians, technical professionals, dentists, administration, cleaning and security workers.

Profile of the study population

The most frequently researched professional categories in the selected studies were Nurses and Physicians, and most of the studies pointed out these professionals experienced work overload, as reported in 37 studies^{6-17,20-25, 27-32,34,36-48}. The assessed nursing professionals were mostly women⁷7 Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study. J Family Med Prim Care 2020; 9(9):4904-4910.^,88 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.^,1616 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.^,3030 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580.^,3131 Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China. Med Sci Monit 2020; 92(10):1962-1970.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.^,3737 Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, Ghosh K, Schroeder DR, Bhagra A. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health 2021; 12:21501327211008448.^,4141 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.^,4848 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149.. The predictors for the emergence of mental disorders and/or mental suffering most often described in these 37 studies were: constant exposure to infected patients or carriers of the virus; lack of personal protective equipment; high possibility of contagion in the work environment; discomfort caused by continuous use of personal protective equipment; chronic shortage of health professionals; high workload day; lack of a more efficient global policy regarding infection control. These were the most impactful factors in the daily lives of these professionals.

Final selection: description of the risks to which health workers involved in the care of patients diagnosed with COVID-19 are exposed during the pandemic

During the final selection, 43 articles were included for full-text reading and data extraction. Four main risks to which health workers involved in the care of patients diagnosed with COVID-19 are exposed during the pandemic were highlighted, which were grouped into three categories, two that deal with the risks and a third that aims to describe the incidence of symptoms/mental disorders in the studied population, namely: i) description of the risks associated with the occupation and environment, ii) description of the risks associated with the lack of educational and training programs, and iii) description of the impact on the mental health of professionals: incidence of symptoms/disorders related to mental health described in the studies.

Description of the risks associated with the occupation and the work environment

With regard to issues involving work organization and lack of personal protective equipment, all 43 studies reported some type of PPE deficit, something that was considered a factor that increased the level of stress among health professionals.

Exposure to infected patients, mainly through work in high-risk departments/environments, such as the Intensive Care Unit (ICU) and other places with large circulation of contaminated fluids/aerosols, have been reported as an important risk factor for COVID-19 contamination among health professionals⁸8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.^,1919 Ofori AA, Osarfo J, Agbeno EK, Manu DO, Amoah E. Psychological impact of COVID-19 on health workers in Ghana: a multicentre, cross-sectional study. SAGE Open Med 2021; 9:20503121211000919.^,2121 Nie A, Su X, Zhang S, Guan W, Li J. Psychological impact of COVID-19 outbreak on frontline nurses: a cross-sectional survey study. J Clin Nurs 2020; 29(21-22):4217-4226.^,2828 Ali S, Maguire S, Marks E, Doyle M, Sheehy C. Psychological impact of the COVID-19 pandemic on healthcare workers at acute hospital settings in the South-East of Ireland: an observational cohort multicentre study. BMJ Open 2020; 10(12):e042930..

Fatigue, sleep and insomnia, which are related to working hours and work overload, were the main predictors for the onset of stress and anxiety at work³3 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. A declaração PRISMA 2020: diretriz atualizada para relatar revisões sistemáticas. RevPanm Salud Publica 2022; 31(2):e112.^,44 Ma LL, Wang YY, Yang ZH, Huang D, Weng H, Zeng XT. Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better? Military Med Res 2020; 7(1):7.^,66 Kibret S, Teshome D, Fenta E, Hunie M, Tamire T. Prevalence of anxiety towards COVID-19 and its associated factors among healthcare workers in a Hospital of Ethiopia. PLoS One 2020; 15(12):e0243022.^,1111 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.^,1818 Fu Y, Wang M, Zhao B, Liu B, Sun J, Feng Y, Wang Z, Li Q, Shi C, Xuan Y, Long S, Liu H, Chi T, Liao Z, Li B, Liu Q. Psychological impact of COVID-19 cases on medical staff of Beijing Xiaotangshan Hospital. Psychol Res Behav Manag 2021; 14:41-47.^,2424 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1.^,2929 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.^,3333 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.. Four studies showed data on this association, which resulted in lack of rest, sleep deprivation, insomnia and prolonged exposure to infected patients⁴4 Ma LL, Wang YY, Yang ZH, Huang D, Weng H, Zeng XT. Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better? Military Med Res 2020; 7(1):7.^,66 Kibret S, Teshome D, Fenta E, Hunie M, Tamire T. Prevalence of anxiety towards COVID-19 and its associated factors among healthcare workers in a Hospital of Ethiopia. PLoS One 2020; 15(12):e0243022.^,1818 Fu Y, Wang M, Zhao B, Liu B, Sun J, Feng Y, Wang Z, Li Q, Shi C, Xuan Y, Long S, Liu H, Chi T, Liao Z, Li B, Liu Q. Psychological impact of COVID-19 cases on medical staff of Beijing Xiaotangshan Hospital. Psychol Res Behav Manag 2021; 14:41-47.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285. as factors that led workers to stress.

The combined effects of stressors, viral load and environments that were unprepared to meet the needs to fight the virus were some of the items identified in the screening of the systematic review⁸8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.^,2323 Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, Zhang K, Chin HK, Ahmad A, Khan FA, Shanmugam GN, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH , Sagayanathan R, Chen JT, Ng AYY, Teoh HL, Ho CS, Ho RC, Sharma VK. Psychological impact of COVID-19 pandemic on health care professionals and workers. Ann Intern Med 2020; 173(4):317-320..

The findings by Chang et al.⁸8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177. showed that emergency department workers (31.64%) were more likely to contract COVID-19, when compared to healthcare professionals in the ICU (23.17%) and hospital admission environments (25.53%); these findings are related to the work environment and the organizational structure and education of each environment.

Description of the risks associated with the shortage of training and educational programs

Inadequate training of health professionals was a factor reported as a predictor of the emergence of mental disorders and/or mental suffering and, consequently, of COVID-19 contamination. The lack of adherence to infection control protocols, associated with the lack of a psychosocial support system, which would accompany workers outside work shifts, as well as training and updating of access and use of personal protective equipment, were also issues related to educational risks [29,39,43], increasing the possibility of mental disorders among the workers.

Description of the impact on the professionals’ mental health: incidence of symptoms/disorders related to mental health described in the studies

The studies described a wide variety of findings on mental health effects. These effects, considered to be a result of the COVID-19 pandemic on the health workers’ mental health, were grouped into two categories, namely: i) issues related to mental disorders, and ii) issues related to the work process.

Regarding the aforementioned symptoms/disorders, anxiety, depressed mood, insomnia, distress, emotional exhaustion, fatigue and/or obsessive-compulsive disorder (OCD) were the most frequently reported ones in the 43 analyzed studies⁶6 Kibret S, Teshome D, Fenta E, Hunie M, Tamire T. Prevalence of anxiety towards COVID-19 and its associated factors among healthcare workers in a Hospital of Ethiopia. PLoS One 2020; 15(12):e0243022.

7 Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study. J Family Med Prim Care 2020; 9(9):4904-4910.

8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.

9 Pan X, Xiao Y, Ren D, Xu ZM, Zhang Q, Yang LY, Liu F, Hao YS, Zhao F, Bai YH. Prevalence of mental health problems and associated risk factors among military healthcare workers in special. Asia Pac Psychiatry 2022; 14(1):e12427.

10 Guo WP, Min Q, Gu WW, Yu L, Xiao X, Yi WB, Li HL, Huang B, Li JL, Dai YJ, Xia J, Liu J, Li B, Zhou BH, Li M, Xu HX, Wang XB, Shi WY. Prevalence of mental health problems in frontline healthcare workers after the first outbreak of COVID-19 in China: a cross-sectional study. Health Qual Life Outcomes 2021; 19(1):103.

11 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.

12 Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry 2021; 69:20-26.

13 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.

14 Skoda EM, Teufel M, Stang A, Jöckel KH, Junne F, Weismüller B, Hetkamp M, Musche V, Kohler H, Dörrie N, Schweda A, Bäuerle A. Psychological burden of healthcare professionals in Germany during the acute phase of the COVID-19 pandemic: differences and similarities in the international context. J Public Health (Oxf) 2020; 42(4):688-695.

15 Collantoni E, Saieva AM, Meregalli V, Girotto C, Carretta G, Boemo DG, Bordignon G, Capizzi A, Contessa C, Nesoti MV, Donato D, Flesia L, Favaro A. Psychological distress, fear of COVID-19, and resilient coping abilities among healthcare workers in a tertiary first-line hospital during the coronavirus pandemic. J Clin Med 2021; 10(7):1465.

16 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.^-1717 Sun D, Yang D, Li Y, Zhou J, Wang W, Wang Q, Lin N, Cao A, Wang H, Zhang Q. Psychological impact of 2019 novel coronavirus (2019-nCoV) outbreak in health workers in China. Epidemiol Infect 2020; 148:e96.^,2020 Si MY, Su XY, Jiang Y, Wang WJ, Gu XF, Ma L, Li J, Zhang SK, Ren ZF, Ren R, Liu YL, Qiao YL. Psychological impact of COVID-19 on medical care workers in China. Infect Dis Poverty 2020; 9(1):113.

21 Nie A, Su X, Zhang S, Guan W, Li J. Psychological impact of COVID-19 outbreak on frontline nurses: a cross-sectional survey study. J Clin Nurs 2020; 29(21-22):4217-4226.

22 Leira-Sanmartín M, Madoz-Gúrpide A, Ochoa-Mangado E, Ibáñez Á. Psychological impact of COVID-19 pandemic and related variables: a cross-sectional study in a sample of workers in a Spanish tertiary hospital. Int J Environ Res Public Health 2021; 18(7):3608.

23 Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, Zhang K, Chin HK, Ahmad A, Khan FA, Shanmugam GN, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH , Sagayanathan R, Chen JT, Ng AYY, Teoh HL, Ho CS, Ho RC, Sharma VK. Psychological impact of COVID-19 pandemic on health care professionals and workers. Ann Intern Med 2020; 173(4):317-320.

24 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1.

25 Wang N, Li Y, Wang Q, Lei C, Liu Y, Zhu S. Psychological impact of COVID-19 pandemic on healthcare workers in China Xi'an central hospital. Brain Behav 2021; 11(3):e02028.

26 Tao J, Lin Y, Jiang L, Zhou Z, Zhao J, Qu D, Li W, Zhu Y. Psychological impact of the COVID-19 pandemic on emergency dental care providers on the front lines in China. Int Dent J 2020; 71(3):197-205.

27 Amal M. Qasem Surrati, Farah M. Asad Mansuri, Abeer A. Ayadh Alihabi. Psychological impact of the COVID-19 pandemic on health care workers. J Taibah Univ Med Sci 2020; 15(6):536-543.

28 Ali S, Maguire S, Marks E, Doyle M, Sheehy C. Psychological impact of the COVID-19 pandemic on healthcare workers at acute hospital settings in the South-East of Ireland: an observational cohort multicentre study. BMJ Open 2020; 10(12):e042930.

29 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.

30 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580.

31 Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China. Med Sci Monit 2020; 92(10):1962-1970.

32 Zerbini G, Ebigbo A, Reicherts P, Kunz M, Messman H. Psychosocial burden of healthcare professionals in times of COVID-19 - a survey conducted at the University Hospital Augsburg. Ger Med Sci 2020; 18:Doc05.

33 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.^-3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.^,3636 Sorokin MY, Kasyanov ED, Rukavishnikov GV, Makarevich OV, Neznanov NG, Morozov PV, Lutova NB, Mazo GE. Stress and stigmatization in health-care workers during the COVID-19 pandemic. Indian J Psychiatry 2020; 62(Suppl 3):S445-S453.

37 Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, Ghosh K, Schroeder DR, Bhagra A. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health 2021; 12:21501327211008448.

38 Chatterjee SS, Chakrabarty M, Banerjee D, Grover S, Chatterjee SS, Dan U. Stress, sleep and psychological impact in healthcare workers during the early phase of COVID-19 in India: a factor analysis. Front Psychol 2021; 12:611314.

39 Korkmaz S, Kazgan A, Çekiç S, Tartar AS, Balci HN, Atmaca M. The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in COVID-19 services. J Clin Neurosci 2020; 80:131-136.

40 Sasaki N, Kuroda R, Tsuno K, Kawakami N. The deterioration of mental health among healthcare workers during the COVID-19 outbreak: a population-based cohort study of workers in Japan. Scand J Work Environment Health 2020; 46(6):639-644.

41 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.

42 Chen X, Arber A, Gao J, Zhang L, Ji M, Wang D, Wu J, Du J. The mental health status among nurses from low-risk areas under normalized COVID-19 pandemic prevention and control in China: a cross-sectional study. Int J Ment Health Nurs 2021; 30(4):975-987.

43 Ide K, Asami T, Suda A, Yoshimi A, Fujita J, Nomoto M, Roppongi T, Hino K, Takahashi Y, Watanabe K, Shimada T, Hamasaki T, Endo E, Kaneko T, Suzuki M, Kubota K, Saigusa Y, Kato H, Odawara T, Nakajima H, Takeuchi I, Goto T, Aihara M, Hishimoto A. The psychological effects of COVID-19 on hospital workers at the beginning of the outbreak with a large disease cluster on the Diamond Princess cruise ship. PLoS One 2021; 16(1):e0245294.

44 Al Muharraq EH. The psychological impact of coronavirus disease 2019 on nurses in Saudi Arabia and their coping strategies. SAGE Open Nurs 2021; 7:23779608211011322.

45 Chen B, Li QX, Zhang H, Zhu JY, Yang X, Wu YH, Xiong J, Li F, Wang H, Chen ZT. The psychological impact of COVID-19 outbreak on medical staff and the general public. Curr Psychol 2020; 41(8):5631-5639.

46 Al Mahyijari N, Badahdah A, Khamis F. The psychological impacts of COVID-19: a study of frontline physicians and nurses in the Arab world. Ir J Psychol Med 2021; 38(3):186-191.

47 Xiong H, Yi S, Lin Y. The psychological status and self-efficacy of nurses during COVID-19 outbreak: a cross-sectional survey. Inquiry 2020; 57:46958020957114.^-4848 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149..

In general terms, the proportion of severe to extremely severe symptoms of depression and anxiety was reported by 40% of the population assessed in this review, in 27 studies, allowing the understanding there is a significant association between the workers’ contact and interventions with patients infected by COVID-19 and symptoms of anxiety and stress at work, respectively⁶6 Kibret S, Teshome D, Fenta E, Hunie M, Tamire T. Prevalence of anxiety towards COVID-19 and its associated factors among healthcare workers in a Hospital of Ethiopia. PLoS One 2020; 15(12):e0243022.

7 Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study. J Family Med Prim Care 2020; 9(9):4904-4910.

8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.

9 Pan X, Xiao Y, Ren D, Xu ZM, Zhang Q, Yang LY, Liu F, Hao YS, Zhao F, Bai YH. Prevalence of mental health problems and associated risk factors among military healthcare workers in special. Asia Pac Psychiatry 2022; 14(1):e12427.^-1010 Guo WP, Min Q, Gu WW, Yu L, Xiao X, Yi WB, Li HL, Huang B, Li JL, Dai YJ, Xia J, Liu J, Li B, Zhou BH, Li M, Xu HX, Wang XB, Shi WY. Prevalence of mental health problems in frontline healthcare workers after the first outbreak of COVID-19 in China: a cross-sectional study. Health Qual Life Outcomes 2021; 19(1):103.^,1212 Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry 2021; 69:20-26.

13 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.

14 Skoda EM, Teufel M, Stang A, Jöckel KH, Junne F, Weismüller B, Hetkamp M, Musche V, Kohler H, Dörrie N, Schweda A, Bäuerle A. Psychological burden of healthcare professionals in Germany during the acute phase of the COVID-19 pandemic: differences and similarities in the international context. J Public Health (Oxf) 2020; 42(4):688-695.

15 Collantoni E, Saieva AM, Meregalli V, Girotto C, Carretta G, Boemo DG, Bordignon G, Capizzi A, Contessa C, Nesoti MV, Donato D, Flesia L, Favaro A. Psychological distress, fear of COVID-19, and resilient coping abilities among healthcare workers in a tertiary first-line hospital during the coronavirus pandemic. J Clin Med 2021; 10(7):1465.

16 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.^-1717 Sun D, Yang D, Li Y, Zhou J, Wang W, Wang Q, Lin N, Cao A, Wang H, Zhang Q. Psychological impact of 2019 novel coronavirus (2019-nCoV) outbreak in health workers in China. Epidemiol Infect 2020; 148:e96.^,2323 Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, Zhang K, Chin HK, Ahmad A, Khan FA, Shanmugam GN, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH , Sagayanathan R, Chen JT, Ng AYY, Teoh HL, Ho CS, Ho RC, Sharma VK. Psychological impact of COVID-19 pandemic on health care professionals and workers. Ann Intern Med 2020; 173(4):317-320.^,2424 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1.^,2626 Tao J, Lin Y, Jiang L, Zhou Z, Zhao J, Qu D, Li W, Zhu Y. Psychological impact of the COVID-19 pandemic on emergency dental care providers on the front lines in China. Int Dent J 2020; 71(3):197-205.

27 Amal M. Qasem Surrati, Farah M. Asad Mansuri, Abeer A. Ayadh Alihabi. Psychological impact of the COVID-19 pandemic on health care workers. J Taibah Univ Med Sci 2020; 15(6):536-543.

28 Ali S, Maguire S, Marks E, Doyle M, Sheehy C. Psychological impact of the COVID-19 pandemic on healthcare workers at acute hospital settings in the South-East of Ireland: an observational cohort multicentre study. BMJ Open 2020; 10(12):e042930.

29 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.^-3030 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580.^,3232 Zerbini G, Ebigbo A, Reicherts P, Kunz M, Messman H. Psychosocial burden of healthcare professionals in times of COVID-19 - a survey conducted at the University Hospital Augsburg. Ger Med Sci 2020; 18:Doc05.^,3333 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.^,3737 Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, Ghosh K, Schroeder DR, Bhagra A. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health 2021; 12:21501327211008448.^,4141 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.^,4444 Al Muharraq EH. The psychological impact of coronavirus disease 2019 on nurses in Saudi Arabia and their coping strategies. SAGE Open Nurs 2021; 7:23779608211011322.

45 Chen B, Li QX, Zhang H, Zhu JY, Yang X, Wu YH, Xiong J, Li F, Wang H, Chen ZT. The psychological impact of COVID-19 outbreak on medical staff and the general public. Curr Psychol 2020; 41(8):5631-5639.

46 Al Mahyijari N, Badahdah A, Khamis F. The psychological impacts of COVID-19: a study of frontline physicians and nurses in the Arab world. Ir J Psychol Med 2021; 38(3):186-191.

47 Xiong H, Yi S, Lin Y. The psychological status and self-efficacy of nurses during COVID-19 outbreak: a cross-sectional survey. Inquiry 2020; 57:46958020957114.^-4848 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149.. Psychological symptoms were evaluated across studies using different validated measures. To measure levels of professional burnout, for example, the Maslach Burnout Inventory (MBI) was used¹²12 Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry 2021; 69:20-26.

13 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.^-1414 Skoda EM, Teufel M, Stang A, Jöckel KH, Junne F, Weismüller B, Hetkamp M, Musche V, Kohler H, Dörrie N, Schweda A, Bäuerle A. Psychological burden of healthcare professionals in Germany during the acute phase of the COVID-19 pandemic: differences and similarities in the international context. J Public Health (Oxf) 2020; 42(4):688-695.^,4141 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.. These findings suggest marked differences in the prevalence of depressive symptoms among the studies assessed in this review.

Three cross-sectional studies, all from China, reported resilience, good preparedness of the professional team, good management of the health system, as well as good psychological coping capacity of professionals and management when facing public health emergencies as positive factors, which could prevent or alleviate the health professionals’ mental illness¹⁸18 Fu Y, Wang M, Zhao B, Liu B, Sun J, Feng Y, Wang Z, Li Q, Shi C, Xuan Y, Long S, Liu H, Chi T, Liao Z, Li B, Liu Q. Psychological impact of COVID-19 cases on medical staff of Beijing Xiaotangshan Hospital. Psychol Res Behav Manag 2021; 14:41-47.^,1919 Ofori AA, Osarfo J, Agbeno EK, Manu DO, Amoah E. Psychological impact of COVID-19 on health workers in Ghana: a multicentre, cross-sectional study. SAGE Open Med 2021; 9:20503121211000919.^,3535 Hong X, Cao J, Wei J, Duan Y, Zhao X, Jiang J, Jiang Y, Geng W, Zhu H. Stress and psychological impact of the COVID-19 outbreak on the healthcare staff at the fever clinic of a tertiary general hospital in Beijing: a cross-sectional study. BJPsych Open 2020; 7(3):e76..

Discussion

The SARS-CoV-2 pandemic was declared in March 2020 by the World Health Organization (WHO), putting more than 200 countries on alert. While the world was concerned about it and committed to saving lives, counting on the quality and speed of the health professionals’ work who cared for the individuals diagnosed with the virus, the mental health of these workers was neglected¹1 World Health Organizatio (WHO). Coronavirus Disease 2019 (COVID-19) Situation Report-87 [Internet]. 2019. [cited 2023 mar 9]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200416-sitrep-87-COVID-19.pdf?sfvrsn=9523115a_2
https://www.who.int/docs/default-source/... ^,1111 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.

12 Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry 2021; 69:20-26.^-1313 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.^,2121 Nie A, Su X, Zhang S, Guan W, Li J. Psychological impact of COVID-19 outbreak on frontline nurses: a cross-sectional survey study. J Clin Nurs 2020; 29(21-22):4217-4226.^,4646 Al Mahyijari N, Badahdah A, Khamis F. The psychological impacts of COVID-19: a study of frontline physicians and nurses in the Arab world. Ir J Psychol Med 2021; 38(3):186-191.^,4848 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149.

49 Organização Pan-Americana da Saúde (OPAS). Avaliação de risco e gerenciamento da exposição de profissionais de saúde no contexto da COVID-19 [Internet]. 2020. [acessado 2022 nov 2]. Disponível em: https://iris.paho.org/handle/10665.2/52290
https://iris.paho.org/handle/10665.2/522...

50 Sun P, Wang M, Song T, Wu Y, Luo J, Chen L, Yan L. The psychological impact of COVID-19 pandemic on health care workers: a systematic review and meta-analysis. Front. Psychol 2021; 12:626547.

51 Fundação Oswaldo Cruz (Fiocruz). Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021. [acessado 2022 nov 4]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude
https://portal.fiocruz.br/noticia/pesqui... ^-5252 Organização Pan-Americana da Saúde (OPAS). Pandemia de COVID-19 desencadeia aumento de 25% na prevalência de ansiedade e depressão em todo o mundo [Internet]. 2022. [acessado 2022 nov 2]. Disponível em: https://www.paho.org/pt/noticias/2-3-2022-pandemia-COVID-19-desencadeia-aumento-25-na-prevalencia-ansiedade-e-depressao-em
https://www.paho.org/pt/noticias/2-3-202... .

A study carried out by the Oswaldo Cruz Foundation, which considered the Working Conditions of Health Professionals in the Context of COVID-19 in Brazil, had 25,000 participants and portrayed the reality of professionals who worked on the frontline, who described being marked by physical and mental pain, suffering and sadness, with strong signs of physical and mental exhaustion. In most cases, the work was carried out in strenuous environments, where the work and activity overload was a constant, as a way to compensate for the high degree of absenteeism that occurred. Moreover, the fear of contamination and imminent death were experienced on a daily basis, in actions marked by the risk of sequestration of the worker’s rights (loss of labor rights, outsourcing, unemployment, loss of income, low wages, extra expenses with PPE purchases, alternative transport and food)⁵¹51 Fundação Oswaldo Cruz (Fiocruz). Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021. [acessado 2022 nov 4]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude
https://portal.fiocruz.br/noticia/pesqui... .

Although most countries managed to control the COVID-19 pandemic over the last few years through vaccination, incipient research has addressed the mental/psychiatric health issues of health professionals who worked on the frontlines during the pandemic, and there are few studies with descriptions of the most frequently reported mental disorders/illnesses during the pandemic period. It is understood that the mental health dimension is an essential aspect that should be more valued in the universe of research performance in pandemic situations, understanding that these scientific studies are important documents for the creation and implementation of professional practices, organization, management and creation of public health and work policies.

The World Health Organization presented relevant data, warning that the first year of the COVID-19 pandemic caused an increase in the global prevalence of anxiety and depression, an increase of 25% of reported and diagnosed cases. These concerns with presumed increases in these conditions led 90% of the assessed countries to include mental health and psychosocial support in their plans to respond to COVID-19 in the workplace. However, there are still significant gaps and concerns related to the workers’ health⁵⁰50 Sun P, Wang M, Song T, Wu Y, Luo J, Chen L, Yan L. The psychological impact of COVID-19 pandemic on health care workers: a systematic review and meta-analysis. Front. Psychol 2021; 12:626547..

The Pan American Health Organization (PAHO) in 2022 highlighted the impact of COVID-19 on the mental health of the world’s population as being only the tip of the iceberg. Therefore, the aforementioned organization pointed out that all countries (especially developing countries, which suffer more from economic issues and inequality in mental health care) need to consider mental health as an important element, because only then would it be possible to offer decent work, in terms of better support to the mental health of populations in pandemic periods⁵²52 Organização Pan-Americana da Saúde (OPAS). Pandemia de COVID-19 desencadeia aumento de 25% na prevalência de ansiedade e depressão em todo o mundo [Internet]. 2022. [acessado 2022 nov 2]. Disponível em: https://www.paho.org/pt/noticias/2-3-2022-pandemia-COVID-19-desencadeia-aumento-25-na-prevalencia-ansiedade-e-depressao-em
https://www.paho.org/pt/noticias/2-3-202... .

The director of the WHO Department of Mental Health and Substance Use, in turn, underlined that even though the pandemic has generated interest and concern for mental health, a framework was revealed, related to the historical underinvestment in services that offered care focused on this issue⁴⁹49 Organização Pan-Americana da Saúde (OPAS). Avaliação de risco e gerenciamento da exposição de profissionais de saúde no contexto da COVID-19 [Internet]. 2020. [acessado 2022 nov 2]. Disponível em: https://iris.paho.org/handle/10665.2/52290
https://iris.paho.org/handle/10665.2/522... ^,5151 Fundação Oswaldo Cruz (Fiocruz). Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021. [acessado 2022 nov 4]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude
https://portal.fiocruz.br/noticia/pesqui... ^,5252 Organização Pan-Americana da Saúde (OPAS). Pandemia de COVID-19 desencadeia aumento de 25% na prevalência de ansiedade e depressão em todo o mundo [Internet]. 2022. [acessado 2022 nov 2]. Disponível em: https://www.paho.org/pt/noticias/2-3-2022-pandemia-COVID-19-desencadeia-aumento-25-na-prevalencia-ansiedade-e-depressao-em
https://www.paho.org/pt/noticias/2-3-202... . Thus, countries need to act urgently, aiming to guaranteeing mental health support that is available to all, especially in the pandemic and post-pandemic periods⁵¹51 Fundação Oswaldo Cruz (Fiocruz). Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021. [acessado 2022 nov 4]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude
https://portal.fiocruz.br/noticia/pesqui... .

Description of the risks associated with occupation and the work environment

Frontline workers, when facing the COVID-19 pandemic, were directly involved in the reception, care, embracement, diagnosis and treatment of individuals with COVID-19. The increasing numbers of confirmed cases in 2020 in Europe, Asia and America, and in the beginning of 2021, mainly in Latin America and Africa⁴⁹49 Organização Pan-Americana da Saúde (OPAS). Avaliação de risco e gerenciamento da exposição de profissionais de saúde no contexto da COVID-19 [Internet]. 2020. [acessado 2022 nov 2]. Disponível em: https://iris.paho.org/handle/10665.2/52290
https://iris.paho.org/handle/10665.2/522...

50 Sun P, Wang M, Song T, Wu Y, Luo J, Chen L, Yan L. The psychological impact of COVID-19 pandemic on health care workers: a systematic review and meta-analysis. Front. Psychol 2021; 12:626547.

51 Fundação Oswaldo Cruz (Fiocruz). Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021. [acessado 2022 nov 4]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude
https://portal.fiocruz.br/noticia/pesqui... ^-5252 Organização Pan-Americana da Saúde (OPAS). Pandemia de COVID-19 desencadeia aumento de 25% na prevalência de ansiedade e depressão em todo o mundo [Internet]. 2022. [acessado 2022 nov 2]. Disponível em: https://www.paho.org/pt/noticias/2-3-2022-pandemia-COVID-19-desencadeia-aumento-25-na-prevalencia-ansiedade-e-depressao-em
https://www.paho.org/pt/noticias/2-3-202... , increased the rates of contamination by different variants among health professionals. The worsening of contamination associated with the high workload, insufficient beds and hospitals, lack of PPE, increased risk of infection for family members and the immediate community, in addition to the lack of adequate planning and support and inability to adhere to prevention strategies, contributed to the health professionals’ mental overload⁷7 Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study. J Family Med Prim Care 2020; 9(9):4904-4910.^,99 Pan X, Xiao Y, Ren D, Xu ZM, Zhang Q, Yang LY, Liu F, Hao YS, Zhao F, Bai YH. Prevalence of mental health problems and associated risk factors among military healthcare workers in special. Asia Pac Psychiatry 2022; 14(1):e12427.^,1313 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.^,2828 Ali S, Maguire S, Marks E, Doyle M, Sheehy C. Psychological impact of the COVID-19 pandemic on healthcare workers at acute hospital settings in the South-East of Ireland: an observational cohort multicentre study. BMJ Open 2020; 10(12):e042930.

29 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.

30 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580.

31 Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China. Med Sci Monit 2020; 92(10):1962-1970.

32 Zerbini G, Ebigbo A, Reicherts P, Kunz M, Messman H. Psychosocial burden of healthcare professionals in times of COVID-19 - a survey conducted at the University Hospital Augsburg. Ger Med Sci 2020; 18:Doc05.

33 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.

34 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.

35 Hong X, Cao J, Wei J, Duan Y, Zhao X, Jiang J, Jiang Y, Geng W, Zhu H. Stress and psychological impact of the COVID-19 outbreak on the healthcare staff at the fever clinic of a tertiary general hospital in Beijing: a cross-sectional study. BJPsych Open 2020; 7(3):e76.

36 Sorokin MY, Kasyanov ED, Rukavishnikov GV, Makarevich OV, Neznanov NG, Morozov PV, Lutova NB, Mazo GE. Stress and stigmatization in health-care workers during the COVID-19 pandemic. Indian J Psychiatry 2020; 62(Suppl 3):S445-S453.

37 Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, Ghosh K, Schroeder DR, Bhagra A. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health 2021; 12:21501327211008448.

38 Chatterjee SS, Chakrabarty M, Banerjee D, Grover S, Chatterjee SS, Dan U. Stress, sleep and psychological impact in healthcare workers during the early phase of COVID-19 in India: a factor analysis. Front Psychol 2021; 12:611314.

39 Korkmaz S, Kazgan A, Çekiç S, Tartar AS, Balci HN, Atmaca M. The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in COVID-19 services. J Clin Neurosci 2020; 80:131-136.

40 Sasaki N, Kuroda R, Tsuno K, Kawakami N. The deterioration of mental health among healthcare workers during the COVID-19 outbreak: a population-based cohort study of workers in Japan. Scand J Work Environment Health 2020; 46(6):639-644.

41 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.

42 Chen X, Arber A, Gao J, Zhang L, Ji M, Wang D, Wu J, Du J. The mental health status among nurses from low-risk areas under normalized COVID-19 pandemic prevention and control in China: a cross-sectional study. Int J Ment Health Nurs 2021; 30(4):975-987.

43 Ide K, Asami T, Suda A, Yoshimi A, Fujita J, Nomoto M, Roppongi T, Hino K, Takahashi Y, Watanabe K, Shimada T, Hamasaki T, Endo E, Kaneko T, Suzuki M, Kubota K, Saigusa Y, Kato H, Odawara T, Nakajima H, Takeuchi I, Goto T, Aihara M, Hishimoto A. The psychological effects of COVID-19 on hospital workers at the beginning of the outbreak with a large disease cluster on the Diamond Princess cruise ship. PLoS One 2021; 16(1):e0245294.

44 Al Muharraq EH. The psychological impact of coronavirus disease 2019 on nurses in Saudi Arabia and their coping strategies. SAGE Open Nurs 2021; 7:23779608211011322.

45 Chen B, Li QX, Zhang H, Zhu JY, Yang X, Wu YH, Xiong J, Li F, Wang H, Chen ZT. The psychological impact of COVID-19 outbreak on medical staff and the general public. Curr Psychol 2020; 41(8):5631-5639.

46 Al Mahyijari N, Badahdah A, Khamis F. The psychological impacts of COVID-19: a study of frontline physicians and nurses in the Arab world. Ir J Psychol Med 2021; 38(3):186-191.

47 Xiong H, Yi S, Lin Y. The psychological status and self-efficacy of nurses during COVID-19 outbreak: a cross-sectional survey. Inquiry 2020; 57:46958020957114.

48 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149.^-4949 Organização Pan-Americana da Saúde (OPAS). Avaliação de risco e gerenciamento da exposição de profissionais de saúde no contexto da COVID-19 [Internet]. 2020. [acessado 2022 nov 2]. Disponível em: https://iris.paho.org/handle/10665.2/52290
https://iris.paho.org/handle/10665.2/522... . Exposure to infected patients in areas of high flow and turnover of people, such as the intensive care unit (ICU) and places with high contamination due to contaminated fluids/aerosols, operating rooms and dental offices were shown as environmental risk factors for health professionals¹³13 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.^,2424 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1.^,2626 Tao J, Lin Y, Jiang L, Zhou Z, Zhao J, Qu D, Li W, Zhu Y. Psychological impact of the COVID-19 pandemic on emergency dental care providers on the front lines in China. Int Dent J 2020; 71(3):197-205.^,3333 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132..

In 2021, the WHO released interim guidelines on health professionals’ risk assessment and management in the context of COVID-19⁴⁹49 Organização Pan-Americana da Saúde (OPAS). Avaliação de risco e gerenciamento da exposição de profissionais de saúde no contexto da COVID-19 [Internet]. 2020. [acessado 2022 nov 2]. Disponível em: https://iris.paho.org/handle/10665.2/52290
https://iris.paho.org/handle/10665.2/522... ^,5252 Organização Pan-Americana da Saúde (OPAS). Pandemia de COVID-19 desencadeia aumento de 25% na prevalência de ansiedade e depressão em todo o mundo [Internet]. 2022. [acessado 2022 nov 2]. Disponível em: https://www.paho.org/pt/noticias/2-3-2022-pandemia-COVID-19-desencadeia-aumento-25-na-prevalencia-ansiedade-e-depressao-em
https://www.paho.org/pt/noticias/2-3-202... . Guidance was offered to healthcare professionals and their workplace. The scarcity of personal protective equipment, an important issue always pointed out by the WHO, was widely reported in all 43 studies that were included in this review, in addition to the lack of trained and qualified professionals to act on the frontline in pandemics with still unknown viruses⁸8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.^,1919 Ofori AA, Osarfo J, Agbeno EK, Manu DO, Amoah E. Psychological impact of COVID-19 on health workers in Ghana: a multicentre, cross-sectional study. SAGE Open Med 2021; 9:20503121211000919.^,2121 Nie A, Su X, Zhang S, Guan W, Li J. Psychological impact of COVID-19 outbreak on frontline nurses: a cross-sectional survey study. J Clin Nurs 2020; 29(21-22):4217-4226.^,2828 Ali S, Maguire S, Marks E, Doyle M, Sheehy C. Psychological impact of the COVID-19 pandemic on healthcare workers at acute hospital settings in the South-East of Ireland: an observational cohort multicentre study. BMJ Open 2020; 10(12):e042930.. This review highlighted the importance of more effective and preventive measures to protect frontline health professionals, preventing psychological damage from the insecurity and fear of contracting a virus that had high lethality rates³3 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. A declaração PRISMA 2020: diretriz atualizada para relatar revisões sistemáticas. RevPanm Salud Publica 2022; 31(2):e112.^,44 Ma LL, Wang YY, Yang ZH, Huang D, Weng H, Zeng XT. Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better? Military Med Res 2020; 7(1):7.^,66 Kibret S, Teshome D, Fenta E, Hunie M, Tamire T. Prevalence of anxiety towards COVID-19 and its associated factors among healthcare workers in a Hospital of Ethiopia. PLoS One 2020; 15(12):e0243022.^,1111 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.^,1818 Fu Y, Wang M, Zhao B, Liu B, Sun J, Feng Y, Wang Z, Li Q, Shi C, Xuan Y, Long S, Liu H, Chi T, Liao Z, Li B, Liu Q. Psychological impact of COVID-19 cases on medical staff of Beijing Xiaotangshan Hospital. Psychol Res Behav Manag 2021; 14:41-47.^,2424 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1.^,2929 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.^,3333 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285..

Description of the risks associated with the scarcity of training and educational programs

Regarding issues related to the number of working hours, the proximity between health professionals and infected patients, and training programs, the study by Rodríguez-Rey et al.⁴⁸48 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149. demonstrated that many frontline health workers in Spain suffered from depression and anxiety. Some of the reasons given in the study were prolonged exposure to the virus, with the lack of personal protective equipment, the fear of infecting family members and the lack of training of the medical team in relation to the spread of the disease, since frontline healthcare workers who treat patients with COVID-19 are likely to be at the highest risk of infection due to close and frequent contact with patients.

The study carried out by Croghan et al.³⁷37 Croghan IT, Chesak SS, Adusumalli J, Fischer KM, Beck EW, Patel SR, Ghosh K, Schroeder DR, Bhagra A. Stress, resilience, and coping of healthcare workers during the COVID-19 pandemic. J Prim Care Community Health 2021; 12:21501327211008448. disclosed several forms of support and training programs for professionals in the work environment, as short and long-term processes of systematic interventions to mitigate stress for the health team. Moreover, the lack of training can lead to an increase in the rates of contamination among workers³3 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. A declaração PRISMA 2020: diretriz atualizada para relatar revisões sistemáticas. RevPanm Salud Publica 2022; 31(2):e112.^,44 Ma LL, Wang YY, Yang ZH, Huang D, Weng H, Zeng XT. Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better? Military Med Res 2020; 7(1):7.^,66 Kibret S, Teshome D, Fenta E, Hunie M, Tamire T. Prevalence of anxiety towards COVID-19 and its associated factors among healthcare workers in a Hospital of Ethiopia. PLoS One 2020; 15(12):e0243022.^,1111 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.^,1818 Fu Y, Wang M, Zhao B, Liu B, Sun J, Feng Y, Wang Z, Li Q, Shi C, Xuan Y, Long S, Liu H, Chi T, Liao Z, Li B, Liu Q. Psychological impact of COVID-19 cases on medical staff of Beijing Xiaotangshan Hospital. Psychol Res Behav Manag 2021; 14:41-47.^,2424 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1.^,2929 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.^,3333 Mahendran K, Patel S, Sproat C. Psychosocial effects of the COVID-19 pandemic on staff in a dental teaching hospital. Br Dent J 2020; 229(2):127-132.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.^,5151 Fundação Oswaldo Cruz (Fiocruz). Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021. [acessado 2022 nov 4]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude
https://portal.fiocruz.br/noticia/pesqui... .

Reports of acute psychological impact and psychosocial risks were evidenced in study by Tan et al.²³23 Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, Zhang K, Chin HK, Ahmad A, Khan FA, Shanmugam GN, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH , Sagayanathan R, Chen JT, Ng AYY, Teoh HL, Ho CS, Ho RC, Sharma VK. Psychological impact of COVID-19 pandemic on health care professionals and workers. Ann Intern Med 2020; 173(4):317-320. In addition, several other studies have reported high levels of distress, depression, anxiety, fear and frustration, as well as the need to establish follow-up programs for frontline workers¹⁵15 Collantoni E, Saieva AM, Meregalli V, Girotto C, Carretta G, Boemo DG, Bordignon G, Capizzi A, Contessa C, Nesoti MV, Donato D, Flesia L, Favaro A. Psychological distress, fear of COVID-19, and resilient coping abilities among healthcare workers in a tertiary first-line hospital during the coronavirus pandemic. J Clin Med 2021; 10(7):1465.

16 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.^-1717 Sun D, Yang D, Li Y, Zhou J, Wang W, Wang Q, Lin N, Cao A, Wang H, Zhang Q. Psychological impact of 2019 novel coronavirus (2019-nCoV) outbreak in health workers in China. Epidemiol Infect 2020; 148:e96.^,2020 Si MY, Su XY, Jiang Y, Wang WJ, Gu XF, Ma L, Li J, Zhang SK, Ren ZF, Ren R, Liu YL, Qiao YL. Psychological impact of COVID-19 on medical care workers in China. Infect Dis Poverty 2020; 9(1):113.^,2424 Lasalvia A, Bonetto C, Porru S, Carta A, Tardivo S, Bovo C, Ruggeri M, Amaddeo F. Psychological impact of COVID-19 pandemic on healthcare workers in a highly burdened area of north-east Italy. Epidemiol Psychiatr Sci 2020; 30:e1.^,2626 Tao J, Lin Y, Jiang L, Zhou Z, Zhao J, Qu D, Li W, Zhu Y. Psychological impact of the COVID-19 pandemic on emergency dental care providers on the front lines in China. Int Dent J 2020; 71(3):197-205.^,4040 Sasaki N, Kuroda R, Tsuno K, Kawakami N. The deterioration of mental health among healthcare workers during the COVID-19 outbreak: a population-based cohort study of workers in Japan. Scand J Work Environment Health 2020; 46(6):639-644.^,4444 Al Muharraq EH. The psychological impact of coronavirus disease 2019 on nurses in Saudi Arabia and their coping strategies. SAGE Open Nurs 2021; 7:23779608211011322..

Description of the effects on the professionals’ mental health: incidence of symptoms/disorders related to mental health described in the studies

A study carried out in Brazil by Fiocruz⁵¹51 Fundação Oswaldo Cruz (Fiocruz). Pesquisa analisa o impacto da pandemia entre profissionais de saúde [Internet]. 2021. [acessado 2022 nov 4]. Disponível em: https://portal.fiocruz.br/noticia/pesquisa-analisa-o-impacto-da-pandemia-entre-profissionais-de-saude
https://portal.fiocruz.br/noticia/pesqui... showed, among other aspects, severe and harmful consequences for the mental health of those who worked in the care of infected patients in critical moments of the pandemic. The most common alterations in their daily lives, mentioned by the professionals, were sleep disorders (15.8%), irritability/frequent crying/disorders in general (13.6%), inability to relax/stress (11.7%), difficulty concentrating or slow thinking (9.2%), loss of career or life satisfaction/sadness/apathy (9.1%), negative feelings about the future/negative thinking, suicidal thoughts (8.3%) and changes in appetite/weight alterations (8.1%).

The study by Trumello et al. [13] highlights that workers who worked directly with patients with COVID-19 had an increased risk rate for the development of stress, burnout, secondary trauma, depression and anxiety, and health professionals who worked in the geographical areas most affected by the virus, had a higher risk of developing burnout and stress, in addition to having low job satisfaction. The mental health of health professionals who worked on the frontline demanded greater attention than other professionals in the same health service, requiring the implementation and use of targeted prevention and intervention programs¹³13 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.^,1515 Collantoni E, Saieva AM, Meregalli V, Girotto C, Carretta G, Boemo DG, Bordignon G, Capizzi A, Contessa C, Nesoti MV, Donato D, Flesia L, Favaro A. Psychological distress, fear of COVID-19, and resilient coping abilities among healthcare workers in a tertiary first-line hospital during the coronavirus pandemic. J Clin Med 2021; 10(7):1465.

16 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.

17 Sun D, Yang D, Li Y, Zhou J, Wang W, Wang Q, Lin N, Cao A, Wang H, Zhang Q. Psychological impact of 2019 novel coronavirus (2019-nCoV) outbreak in health workers in China. Epidemiol Infect 2020; 148:e96.

18 Fu Y, Wang M, Zhao B, Liu B, Sun J, Feng Y, Wang Z, Li Q, Shi C, Xuan Y, Long S, Liu H, Chi T, Liao Z, Li B, Liu Q. Psychological impact of COVID-19 cases on medical staff of Beijing Xiaotangshan Hospital. Psychol Res Behav Manag 2021; 14:41-47.

19 Ofori AA, Osarfo J, Agbeno EK, Manu DO, Amoah E. Psychological impact of COVID-19 on health workers in Ghana: a multicentre, cross-sectional study. SAGE Open Med 2021; 9:20503121211000919.^-2020 Si MY, Su XY, Jiang Y, Wang WJ, Gu XF, Ma L, Li J, Zhang SK, Ren ZF, Ren R, Liu YL, Qiao YL. Psychological impact of COVID-19 on medical care workers in China. Infect Dis Poverty 2020; 9(1):113..

The prevalence of anxiety and depression among frontline health professionals showed higher indicators than health professionals who did not work on the frontline. Furthermore, nurses had higher rates of anxiety, insomnia and depression than physicians, dentists and other frontline professionals⁷7 Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study. J Family Med Prim Care 2020; 9(9):4904-4910.^,88 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.^,1616 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.^,3030 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580.^,3131 Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China. Med Sci Monit 2020; 92(10):1962-1970.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.^,3838 Chatterjee SS, Chakrabarty M, Banerjee D, Grover S, Chatterjee SS, Dan U. Stress, sleep and psychological impact in healthcare workers during the early phase of COVID-19 in India: a factor analysis. Front Psychol 2021; 12:611314.^,4141 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.^,4848 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149.. In a systematic review with meta-analysis, carried out by Sun et al.⁵⁰50 Sun P, Wang M, Song T, Wu Y, Luo J, Chen L, Yan L. The psychological impact of COVID-19 pandemic on health care workers: a systematic review and meta-analysis. Front. Psychol 2021; 12:626547., significant levels of anxiety were identified among frontline workers, 37% (95%CI: 0.31-0.42, I²2 Gold JA. COVID-19: adverse mental health outcomes for healthcare workers. BMJ 2020; 369:m1815 = 99.9%) , further corroborating other authors, in which the prevalence of depression and insomnia showed significant levels⁸8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.^,99 Pan X, Xiao Y, Ren D, Xu ZM, Zhang Q, Yang LY, Liu F, Hao YS, Zhao F, Bai YH. Prevalence of mental health problems and associated risk factors among military healthcare workers in special. Asia Pac Psychiatry 2022; 14(1):e12427.^,1111 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.^,1616 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.^,2323 Tan BYQ, Chew NWS, Lee GKH, Jing M, Goh Y, Yeo LLL, Zhang K, Chin HK, Ahmad A, Khan FA, Shanmugam GN, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH , Sagayanathan R, Chen JT, Ng AYY, Teoh HL, Ho CS, Ho RC, Sharma VK. Psychological impact of COVID-19 pandemic on health care professionals and workers. Ann Intern Med 2020; 173(4):317-320.^,2929 Raj R, Koyalada S, Kumar A, Kumari S, Pani P, Nishant, Singh KK. Psychological impact of the COVID-19 pandemic on healthcare workers in India: an observational study. Fam Med Prim Care 2021; 9(12):5921-5926.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.^,3838 Chatterjee SS, Chakrabarty M, Banerjee D, Grover S, Chatterjee SS, Dan U. Stress, sleep and psychological impact in healthcare workers during the early phase of COVID-19 in India: a factor analysis. Front Psychol 2021; 12:611314.^,3939 Korkmaz S, Kazgan A, Çekiç S, Tartar AS, Balci HN, Atmaca M. The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in COVID-19 services. J Clin Neurosci 2020; 80:131-136..

The study by Sun et al.⁵⁰50 Sun P, Wang M, Song T, Wu Y, Luo J, Chen L, Yan L. The psychological impact of COVID-19 pandemic on health care workers: a systematic review and meta-analysis. Front. Psychol 2021; 12:626547. further triggered the structural crisis that the COVID-19 pandemic brought to the world of work, especially to work performed by women. In a subgroup analysis carried out in the aforementioned study, high rates of depression were displayed by female professionals, compared to male ones, who worked on the frontline, corroborating the findings in this review⁷7 Alzaid EH, Alsaad SS, Alshakhis N, Albagshi D, Albesher R, Aloqaili M. Prevalence of COVID-19-related anxiety among healthcare workers: a cross-sectional study. J Family Med Prim Care 2020; 9(9):4904-4910.^,88 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.^,1616 Perera B, Wickramarachchi B, Samanmalie C, Hettiarachchi M. Psychological experiences of healthcare professionals in Sri Lanka during COVID-19. BMC Psychol 2021; 9(1):49.^,3030 Del Pozo-Herce P, Garrido-García R, Santolalla-Arnedo I, Gea-Caballero V, García-Molina P, Ruiz de Viñaspre-Hernández R, Rodríguez-Velasco FJ, Juárez-Vela R. Psychological impact on the nursing professionals of the Rioja Health Service (Spain) due to the SARS-CoV-2 virus. Int J Environ Res Public Health 2021; 18(2):580.^,3131 Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, Zhuang Q. Psychological impacts and coping strategies of front-line medical staff during COVID-19 outbreak in Hunan, China. Med Sci Monit 2020; 92(10):1962-1970.^,3434 Florin M, Pinar U, Chavigny E, Bouaboula M, Jarboui L, Coulibaly A, Lemogne C, Fournier L. Socio-economic and psychological impact of the COVID-19 outbreak on private practice and public hospital radiologists. Eur J Radiol 2020; 132:109285.^,3838 Chatterjee SS, Chakrabarty M, Banerjee D, Grover S, Chatterjee SS, Dan U. Stress, sleep and psychological impact in healthcare workers during the early phase of COVID-19 in India: a factor analysis. Front Psychol 2021; 12:611314.^,4141 Çelmeçe N, Menekay M. The effect of stress, anxiety and burnout levels of healthcare professionals caring for COVID-19 patients on their quality of life. Front Psicol 2020; 11:597624.^,4848 Rodríguez-Rey R, Garrido-Hernansaiz H, Bueno-Guerra N. Working in the times of COVID-19. Psychological impact of the pandemic in frontline workers in Spain. Int J Environ Res Public Health 2020; 17(21):8149..

The results found in this review suggest that the intervention process in the work environment needs to be carried out early, aiming to reduce the high levels of adverse mental health problems in health professionals, especially regarding the incidence of anxiety. and depression⁸8 Sahin MK, Aker S, Sahin G, Karabekiroglu A. Prevalence of depression, anxiety, distress and insomnia and related factors in healthcare workers during COVID-19 pandemic in Turkey. J Community Health 2020; 45(6):1168-1177.

9 Pan X, Xiao Y, Ren D, Xu ZM, Zhang Q, Yang LY, Liu F, Hao YS, Zhao F, Bai YH. Prevalence of mental health problems and associated risk factors among military healthcare workers in special. Asia Pac Psychiatry 2022; 14(1):e12427.

10 Guo WP, Min Q, Gu WW, Yu L, Xiao X, Yi WB, Li HL, Huang B, Li JL, Dai YJ, Xia J, Liu J, Li B, Zhou BH, Li M, Xu HX, Wang XB, Shi WY. Prevalence of mental health problems in frontline healthcare workers after the first outbreak of COVID-19 in China: a cross-sectional study. Health Qual Life Outcomes 2021; 19(1):103.

11 Zhou Y, Ding H, Zhang Y, Zhang B, Guo Y, Cheung T, Hall BJ, Shi T, Xiang YT, Tang Y. Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers during and after the COVID-19 outbreak: a longitudinal study. Transl Psychiatry 2021; 11(1):223.

12 Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry 2021; 69:20-26.^-1313 Trumello C, Bramanti SM, Ballarotto G, Candelori C, Cerniglia L, Cimino S, Crudele M, Lombardi L, Pignataro S, Viceconti ML, Babore A. Psychological adjustment of healthcare workers in Italy during the COVID-19 pandemic: differences in stress, anxiety, depression, burnout, secondary trauma, and compassion satisfaction between frontline and non-frontline professionals. Int J Environ Res Public Health 2020; 17(22):8358.^,1515 Collantoni E, Saieva AM, Meregalli V, Girotto C, Carretta G, Boemo DG, Bordignon G, Capizzi A, Contessa C, Nesoti MV, Donato D, Flesia L, Favaro A. Psychological distress, fear of COVID-19, and resilient coping abilities among healthcare workers in a tertiary first-line hospital during the coronavirus pandemic. J Clin Med 2021; 10(7):1465.

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There are numerous strengths and some limitations in the present review study, among which are the issues involving the division of professional categories that worked with patients with Covid-19, something that made the analysis a complex one. To minimize these limitations, the review also included studies that assessed technical professionals, who, despite not being from the health area, worked daily in health services and dealt with interventions related to the frontline. Another factor related to limitations is related to the inherent heterogeneity of studies. While numerous studies showed levels of prevalence of anxiety, depression, burnout, and insomnia, others used the same tests, but different assessment scales, thus establishing different thresholds.

Although in the year 2023 the World Health Organization declared the long-awaited end of the Public Health Emergency of International Concern (PHEIC) for COVID-19⁵³53 Organização Pan-Americana da Saúde (OPAS). OMS declara fim da Emergência de Saúde Pública de Importância Internacional referente à COVID-19 [Internet]. 2023. [acessado 2023 maio 5]. Disponível em: https://www.paho.org/pt/noticias/5-5-2023-oms-declara-fim-da-emergencia-saude-publica-importancia-internacional-referente#:~:text=%C3%A0%20COVID%2D19-,OMS%20declara%20fim%20da%20Emerg%C3%AAncia%20de%20Sa%C3%BAde%20P%C3%BAblica,Internacional%20referente%20%C3%A0%20COVID%2D19&text=Bras%C3%ADlia%2C%205%20de%20maio%20de,)%20referente%20%C3%A0%20COVID%2D19
https://www.paho.org/pt/noticias/5-5-202... , all the studies that were analyzed in this systematic review included discussions about the fear of being infected and the distress caused by the fear of spreading it to family members, stigmatization by the population at the critical moment of the pandemic, low self-confidence, low occupational safety and long working hours/high workloads, as crucial risk factors, which need to be considered in the design and implementation of future psychological support services for health professionals who have experienced this pandemic and those who may experience future ones.

Conclusion

This systematic review sought to identify articles related to the effects of the COVID-19 pandemic on the mental health of health workers who worked to fight the virus and the prevalence of impacts for these professionals. The review of the articles showed the description of the characteristics of the included studies, measured their quality, identified the target audience of these studies (most frequently involved professionals), identified different types of risk factors related to the performance of this work (occupational/environmental, training/ education, and focused on mental health), and carried out reflections based on the need for investment by companies and governments in care programs aimed at mental health worldwide.

Finally, the study disclosed the need to develop new scientific research, with different methodologies, but which deal with the description and analysis of the work experience of professionals who were involved in interventions with patients diagnosed with COVID-19, especially having as an object for the analysis the mental health of these workers. This study has as a limitation, the time period of the bibliographic search.

References

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