Prevalence of depression, anxiety and stress among healthcare professionals at tertiary care hospitals, Karachi – Pakistan

Background: The prevalence and severity of mental health issues among the healthcare professionals (HPs) has escalated during the past few years. Depression, anxiety and stress are common complaints among the HP’s, having a profound impact on their personal and professional life. The purpose of this study was to assess the severity level of depression, anxiety and stress among HPs at tertiary care hospitals of Karachi. Methodology: A cross-sectional study was conducted from May to July 2019 at three tertiary care teaching hospitals of Karachi including Jinnah Post Graduate Medical Centre (JPMC), National Institute of Child Health (NICH) and National Institute of Cardiovascular Diseases (NICVD). Total 260 HPs (doctors, nurses, physiotherapist, pharmacist, laboratory technician and nursing technicians) were selected through convenience sampling method. In addition to the demographic details, the prevalence and severity score of depression, anxiety and stress was assessed using depression, anxiety and stress scale 42 (DASS 42). The collected data was analyzed using SPSS version 23. Results: Among 260 HP’s, 48.5% were males and 51.5% were females, moderate depression was found in 33(12.7%) HP’s, 2 8(10.8%) had severe depression while 6(2.3%) were suffering from extremely severe depression. Anxiety levels were moderate in 67(25.8%), 32(12.3%) and 21(8.1%) reported severe and very severe anxiety respectively. Moreover, stress levels were moderate among 45(17.3%) HP’s, while severe and very severe levels were observed among 13(5%) and 7(2.7%) responders respectively. There was no association in between the sociodemographic characteristics and depression, anxiety and stress (p>0.05). Conclusion: It was observed that most of the HP’s were suffering from mild to moderate depression, anxiety and stress. Further research is required to explore the possible contributing factors and methods for eradication of this health issue.


Introduction
Highly prevailing mental health condition of the era, depression along with anxiety and stress have become the major public health concern. Major etiological factors include unemployment, low socioeconomic status, long work hours, isolation, lack of socializing and substance abuse, etc 1 . These complaints are more frequent among females as compared to males which may be due to the pressure associated with their social roles in everyday life or it may also be linked to the hormonal imbalances associated with menstruation, childbirth, and menopause 1 .
Depression, anxiety and stress significantly affects the individual's personal, social and as well as professional life. It is evident that regardless of age, gender or professional seniority, the HP's are frequently exposed to stressful conditions especially in their work setting [2][3][4] . Modulating the work life, depression and stress associated mood disorders greatly affect the HP's concentration at work and also compromises the quality of healthcare services they provide 5,6,7 . Based on the systemic review conducted in 2015 including 15 countries, the estimated prevalence of depressive symptoms among the physicians of four Asian, seven European and four Middle Eastern countries was 28.8%, it was suggested that the prevalence ranges in between 20.9% to 43.2% and excel each year 8 .
The incidence rate varies among the different occupational categories i.e. nurses are more affected by depression, the increasing stress is mainly due to the overburdened work routine. A study reported high depression rate (18%) among nurses as compared to other HP's (9.4%) 9 . According to a local study including physiotherapists employed in major cities of Pakistan, 70.1% were suffering from depression, 53.17% from anxiety and 60.05% were in stress 10 . However, it is apparent that depression, anxiety and stress are primarily caused by workload while other secondary causes are financial status, job stress and dissatisfaction etc 10 . Nurses all around the world face it and it is linked to their long work hours, frequent night shifts and violence at work-place 11 and sometimes it even leads to intentions to quit job 12 . It not only alters the mental and physical health, also reported to increase the substance use, abuse and suicide risk among the HP's 7,13 .
The aim of the present study was to estimate the prevalence of depression, anxiety and stress among the HP's at tertiary care hospitals of Karachi. The targeted population for this study was HP's involved in preventive, curative and rehabilitative healthcare services at the study setting. The HP's demographic details including age, gender, marital status, education and profession etc. were taken after attaining the written informed consent.

Methodology
Depression, anxiety and stress was assessed using DASS 42 14 . The sum of scores was obtained from the 14 items in each scale and the scale severity was interpreted as per the details shown in the table below.

Result
During the study period, 260 HP's from diverse professions and specialties were included in the study, majority were nurses i.e. 58.1% followed 18.1% were doctors and 9.6% were nursing technicians with female predominance 134 vs 126 males. 94.6% had a work experience of <15 years.

* Depression, Anxiety & Stress subscales of DASS42 *Values are given as n(%)
The association of depression, anxiety and stress with various sociodemographic characteristics is given in table 3. No significant relationship observed between the observed variables and the prevalence of depression, anxiety and stress.

Discussion
The prevalence of depression, anxiety and stress was high among the HP's enrolled in the current study i.e. 48.46%, 60.38% and 41.92% respectively which is consistent with the findings of Alkhazrajy et al. 15 (70.25%) and Liezel 16 (55%). While in contrast studies conducted in Japan, China and Germany showed decreased prevalence of depressive symptoms among HP's i.e. 11.3%, 8.8%, 31.7%, and 17%, respectively [17][18][19] . Moreover, a local study in Pakistan also showed similar results to the mentioned studies i.e. 25.8% prevalence only 20 . The high prevalence of depression among the study population may be due to the increasing workload, lack of working staff, limited number of HP's and low income.

ISSN 2412 -3188
APP| Published By AEIRC| Volume 6 Issue 1 Stratification of sociodemographic characteristics of the study population with depression, anxiety and stress showed insignificant results i.e. no significant association was observed between age and depression levels (p=0.707) which is also supported by other studies concluding age as a nonsignificant contributing factor for depressive symptoms in medical profession 21,22 . Moreover, working hours are the significant contributing factors for depression, anxiety and stress as indicated by a number of studies 5,21 . The physicians who were working for more than 60 hours/week and in double shifts were more likely to experience depressive symptoms as compared to counterparts 22 . A study indicated that low income was also a common factor among the HP's with depressive symptoms 23 which is contradictory to other studies indicating no significant relationship between the two variables. Also supported by our results I indicating contradictory results (p=0.957) to the study conducted by El-Hamrawya 23 .
The current study indicated a higher rate of depression among males as compared to females i.e. 63/126 vs 63/134. While globally it is an evident fact that the prevalence of depressive symptoms is higher among females irrespective of professions, also showed by several studies where females were more depressed than males [24][25][26] . Furthermore, the marital status also plays a significant role in the prevalence of depression, anxiety and stress. It was reported by a study that married doctors are more likely to develop depression as compared to unmarried 23 . No significant associations observed in the current study which is also supported by Gu et al. 27 , Alkhazrajy et al. 15 , Becker et al. 21 and Fahrenkopf et al. 5 , concluding that no significant association exist between gender, marital status and prevalence of depressive symptoms.
There are several studies conducted both at national and international level determining the prevalence of depression, anxiety and stress among single category of HP's but our study is unique in the way that it brought various categories of HP's under one umbrella, like nurses, doctors, laboratory technicians, physiotherapist and pharmacist were all included in this study. Moreover, DASS 42 is valid tool for depression analysis and three major hospitals of Karachi were included for the study but sample size is very limited due to shortage of time and answers of some behaviour questions might be doubtful because participants might have lied about it. Therefore, our results do not provide a generalized view. It is recommended that hospitals should be aware of the increasing prevalence of depression, anxiety and stress among HP's, and assessments should be carried out periodically. Moreover, firm policies and campaigns must be designed and implemented to eradicate this health issue so that continuous and balanced services could be provided to the patients. It is also suggested that further studies with more participants from both government and private sectors should be conducted so the results can be properly estimated at whole community level.

Conclusion
The HP's enrolled in the study were mostly affected by moderate to severe level of depression, anxiety and stress. Periodic, monthly or bimonthly assessment of these measures are recommended to control this health concern among the HP's. As their physical and mental health status plays a very significant role in their practicing environment and also affects the quality of services they are providing. Programs and campaigns must be driven in order to increase the knowledge of these concerns among the HP's and in order to improve the mental health of the employees the ISSN 2412 -3188 APP| Published By AEIRC| Volume 6 Issue 1 healthcare sectors must take effective measures focusing on better health and healthy working environment.