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A cross-sectional study of coping strategies and resilience and its association with psychological symptoms of doctors working in a dedicated COVID-19 care center
Shankar Kumar, Sushmitha Kota, Anvitha Kayarpady, Archana Gopal, Prashanth N Rudra
Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||02-Jun-2021|
|Date of Acceptance||06-Jan-2022|
|Date of Web Publication||10-Nov-2022|
Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Health-care professionals who are involved in treating COVID patients use multiple coping strategies to overcome stress. Studies have shown that individuals having poor coping strategies and resilience are more prone toward psychological symptoms. Aims: The study was conducted to assess the coping strategies and resilience and its association with psychological symptoms of frontline doctors working in a COVID care center. Settings and Design: It was a cross-sectional study using convenient sampling conducted among 150 frontline doctors working in a COVID care center. Materials and Methods: The study tools included were sociodemographic questionnaire, Depression, Anxiety, and Stress Scale 21, Brief-COPE Scale, and Connor-Davidson Resilience Scale which was sent using Google Forms to participants after obtaining informed consent. Statistical Analysis Used: Statistical analysis was conducted using Chi-square test for categorical variables, t-test for continuous variables, and Mann–Whitney U test for ordinal data, Spearman correlation for correlations, and backward multiple linear regression to predict psychological symptoms. Results: Doctors with severe stress had higher dysfunctional coping and lower resilience scores (P = 0.001). There was a positive correlation of stress, anxiety, and depression with problem-focused, emotional-focused, and dysfunctional coping, and there was a negative correlation between total resilience scores with stress and depression. Stress and anxiety were predicted by dysfunctional coping and resilience. Depression was predicted by dysfunctional coping (β = 1.25, P < 0.001), resilience (β = −0.08, P = 0.005), and duration of working hours per month (β = −0.008, P = 0.05). Conclusions: There is an urgent need to look at therapeutic strategies and factors which enhance resilience and promote better coping in this population.
Keywords: Anxiety, depression, psychological, resilience
|How to cite this URL:|
Kumar S, Kota S, Kayarpady A, Gopal A, Rudra PN. A cross-sectional study of coping strategies and resilience and its association with psychological symptoms of doctors working in a dedicated COVID-19 care center. Ind Psychiatry J [Epub ahead of print] [cited 2022 Nov 30]. Available from: https://www.industrialpsychiatry.org/preprintarticle.asp?id=360855
The novel coronavirus disease has been declared a global pandemic by the WHO in March 2020. This time of crisis has affected the mental health of health-care professionals to a great extent who are continuously involved in treating COVID patients.
Sources of distress may include emotions of vulnerability or loss of control, health of the family or others due to the spreading of the virus, changes at the working conditions, and environment or isolation anxieties., Health-care workers who are directly involved in the diagnosis, treatment, and care of patients with COVID-19 are at a higher risk of developing psychological distress and other mental health symptoms. Several studies have shown anxiety and depression being common mental disorders among health-care professionals in pandemics.,,,
Health-care professionals use multiple coping strategies to tide over threat associated with COVID-19. Psychological resilience is the ability of the individual to cope with and overcome obstacles, uncertainties, and other similar circumstances., Studies have shown that individuals having poor coping strategies and resilience are more prone toward psychological symptoms. However, there is a scarcity of literature on resilience and coping mechanisms used by the health-care professionals and its association with psychological symptoms. Hence, the study was undertaken to assess the coping strategies and resilience and its association with psychological symptoms of frontline doctors working in a COVID care center.
| Materials and Methods|| |
Institutional ethical committee clearance was obtained before initiating the study with reference number BMCRI/PS/99/2020-21 obtained on July 29, 2020. Participant consent statement was taken from each participant.
This study was a cross-sectional study conducted in a tertiary care center exclusively treating COVID-19 patients. The study sample was 150 doctors. Convenience sampling was used. Most of the participants included in our study were postgraduates and senior residents, and self-administered questionnaires were sent to the participants through Google Forms. This study was conducted for a duration of 1 month.
Inclusion criteria were as follows:
- Doctors who were involved in treating COVID patients
- Doctors who were willing to give consent.
The tools used in our study were as follows:
- Depression, Anxiety, and Stress Scale 21 (DASS-21): It is a self-report scale with 21 items that measures depressive symptoms, anxiety symptoms, and stress. Each domain has seven items. It has excellent Cronbach's alpha values of 0.81, 0.89, and 0.78 for subscales of depression, anxiety, and stress, respectively
- Brief-COPE Scale: It is a self-report questionnaire with 28 items designed to measure effective and ineffective ways of coping. We followed Carver method of categorization into emotion-focused, problem-focused, and dysfunctional coping strategies
- Conner-Davidson Resilience Scale (CD-RISC): It is also a self-report questionnaire comprising 25 items. The response to each item is on Likert type of scale (0–4), scoring from 0 to 100 overall. Responses were categorized into total resilience scores and subdomain scores on hardiness, coping/flexibility, meaningfulness/purpose, optimism, regulation of emotion and cognition, and self-efficacy. All three scales (DASS-21, Brief-COPE Scale, and CD-RISC) have good reliability and validity.,,
The doctors fulfilling the inclusion criteria were enrolled in the study. A semi-structured questionnaire containing sociodemographic data, past and family history of psychiatric illness and medical illness, DASS-21, Brief-COPE Scale, and CD-RISC was sent to the participants using snowball technique who consented to be a part of the study. The Google Forms was sent to 256 doctors and 150 responses were obtained. Confidentiality of the participants was ensured.
The data collected were analyzed using t-test, Mann–Whitney U test for ordinal variables, Spearman's correlation coefficient for correlations, and backward stepwise multiple linear regression using SPSSv20 SPSS Inc, IBM, Chicago, USA.
| Results|| |
Our study had 150 participants, of which 53 (35.33%) were males and 97 (52.67%) were females.
| Discussion|| |
Most of the population in our study were unmarried (n = 121, 80.66%) and were staying without family (n = 96, 64%) as most of the participants in our study were postgraduates and senior residents who were relatively young. In our study, the presence of severe stress was higher among married doctors (P = 0.007) which is discordant with other studies which have found lower stress levels among married doctors., This finding could be due to difficulty in balancing professional and personal life simultaneously during this pandemic. Those with severe stress had higher average working hours per month (P = 0.04). This is consistent with many studies which have found a positive correlation between stress and working hours.,,, This association could be explained by a higher fear of getting infected along with infecting family members and social isolation [Table 1].
We also found that the doctors with past psychiatric illness had low resilience and hardiness than those without psychiatric illness (P = 0.002 and 0.005). Previous studies have established that there is a strong interplay between resilience and mental illness. There is some evidence that resilience is lower among people who develop mental disorder, and high level of resilience may prevent the development of an illness or minimize the severity of illness. Another study also stated that early life stress and chronic stress during adulthood can produce a situation of enhanced vulnerability and a reduced resilience of the brain [Table 2].
|Table 2: Comparison of parameters between subjects with and without past psychiatric illness|
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In our study, we found a significant positive correlation of dysfunctional, problem- and emotional-focused coping with stress, anxiety, and depression. Furthermore, a negative correlation was established between self-efficacy with stress [Table 3]. Backward multiple linear regression also revealed dysfunctional coping as a predictor for stress, anxiety, and depression (P-value: ≤ 0.001 each for stress, anxiety and depression; β: 1.18, 0.90, 1.25 respectively) [Table 4], [Table 5], [Table 6]. A study which studied SARS-related psychiatric and posttraumatic comorbidities in medical staff in Singapore concluded that psychological morbidity was positively associated with dysfunctional coping strategies such as behavioral disengagement, denial, and self-distraction in addition to less use of venting, humor, and acceptance. This is in concordance with the present study. In another study, health-care workers who chose adaptive coping such as humor and religion in response to the SARS outbreak reported low psychiatric morbidity. Maladaptive coping styles have been associated with worse psychological outcomes. This could be explained by the negative attribution of individuals leading to a negative way of adapting to the environment affecting mental health.,,
|Table 3: Correlations between psychological symptoms with coping and resilience|
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|Table 4: Predicting stress using different variables in a backward stepwise multiple linear regression|
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|Table 5: Predicting anxiety using different variables in a backward stepwise multiple linear regression|
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|Table 6: Predicting depression using different variables in a backward stepwise multiple linear regression|
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We found that resilience scores were lower in doctors with severe stress. In addition to this, scores on all the subscales of resilience: self efficacy (u-value: 10.69, v : 3.21, SD-0.91), regulation of emotion and cognition (u-7.88, v-3.43, SD-0.69), optimism (u-8.79, v-3.11, SD-0.49), meaningfulness/purpose (u-7.75, v-1.65, SD-1.65), adaptability/flexibility (u-9.89, v-2.91, SD-1.43), hardiness (u-11.73, v-2.98, SD- 2.25), coping (u-12.79, v-3.12, SD-2.16) were also lower among doctors with severe stress [Table 7]. There was a negative correlation of hardiness with stress, anxiety, and depression and emotion and cognition regulation with stress and depression. Furthermore, there was a negative correlation observed between total resilience scores with stress and depression [Table 3]. Total resilience scores were predictors of stress, anxiety, and depression on backward multiple linear regression [Table 4], [Table 5], [Table 6].
|Table 7: Comparison of coping scores and resilience scores between those with and without severe stress|
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This finding is supported by many studies which have reported a negative relationship between psychological symptoms and resilience.,, Studies have also reported that individuals with a higher level of hardiness experience lower levels of stress and secondary trauma., Hardiness and coping strategies were predictors of stress among rescue workers in another study.,,, Pro-resilience factors are known to act through neuroendocrine mechanisms to reduce hyperactivity of the prefrontal cortex-amygdala circuits which are believed to be hyperactive in stressful situations which could explain the relationship between stress and resilience observed in the study. Another review also states that resilience would protect individuals against future onset of mental health and mental health problems.
Limitations of the study
We have used convenient sampling and snowball technique which can lead to sampling bias. This was a survey, we could not avoid the subjectivity among the study subjects while answering. We have measured resilience of doctors, but we did not assess the factors promoting resilience among those with mild or no stress. Quantification of study patients with psychiatric illness was not done.
Implications and future research directions of the study
This study adds to the literature on association between coping, resilience, and mental health among frontline workers involved in COVID-19 pandemic. Thus, it is important to improve coping strategies and enhance resilience in this population which is known to buffer stress. Future studies need to assess factors promoting resilience and therapies which enhance coping and resilience which can have a bearing on promoting mental health and decreasing stress among frontline workers.
| Conclusions|| |
There was an association between stress, anxiety, and depression with dysfunctional, emotional- and problem-focused coping. There was a negative correlation of stress, anxiety, and depression with domains of resilience. Dysfunctional coping and resilience predicted the presence of stress, anxiety, and depression in this population. There is an urgent need to look at therapeutic strategies and factors which enhance resilience and promote better coping in this population.
We acknowledge the support rendered by Dr. Chandrashekar H, Professor and HOD, Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, in conducting the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]