The global spread of SARS-CoV-2 infection has deeply affected the world. The increasing numbers of patients and outbreak-affected countries have elicited public worry and thus increased the risk of mental health problems (insomnia, anxiety, depression, and stress-related disorders, including the post-traumatic stress disorder (PTSD)) [1
The psychological burden of healthcare workers (HCWs) has received heightened awareness, with research continuing to show high rates of mental disorders among them in most countries, including China, the U.K., U.S.A., India, and Italy [3
]. Thus, nearly 58% of HCWs in the U.K. met the threshold for clinically significant PTSD, anxiety, or depression [3
]; in China, the prevalence rates of these conditions were estimated at 9.8–50.4%, 27.1–44.6%, and 15.0–25.0%, respectively [7
]; and in Italy, about 22% and 40% of HCWs reported moderate-to-severe symptoms of anxiety and PTSD, respectively [5
]. In the U.S.A. and Australia, more than half of HCWs screened positive for PTSD symptoms, almost half screened positive for depression, and one-third screened positive for anxiety [9
]. Overall, the substantial proportion of HCWs self-reported moderate-to-severe symptoms of depression (13.5–44.7%;), anxiety (12.3–35.6%), and PTSD (7.4–37.4%) [6
Dentists may have a higher risk for SARS-CoV-2 transmission than the average HCWs. This is because dental healthcare delivery requires close physical contact between patients and specialists, while dental procedures generate aerosols, which pose potential risks to operators and patients [11
]. Moreover, for these reasons, severe restrictions in dental practice have been adopted by governments to avoid this source of contagion [12
]. In several countries, dentists have been allowed to practice only emergency/urgent procedures during the whole period of the lockdowns [12
]. The obtained perceived job insecurity has additionally affected their mental health [16
], having been positively associated with depressive symptoms [12
]. This is exemplified by the results of cross-sectional surveys among dentists from China, India, Israel, Italy, and the U.K., which indicated elevated levels of subjective overload, psychological distress, and anxiety among participants [19
]. Thus, more than two-thirds of the general dental practitioners (78%) from 30 countries questioned in the online survey of Ammar et al. (2020) were anxious and scared by the devastating effects of coronavirus disease 2019 (COVID-19) [20
]. During the lockdown, about half of Indian dentists exhibited a higher degree of perceived stress in comparison to the general population [21
]. The elevated levels of depression, anxiety, and stress were recorded at 60.64%, 37.02%, and 34.92%, respectively, among the dental students of Saudi Arabia [22
]. Generally, about 9–11.5% of dentists were heavily affected by the pandemic and reported severe anxiety and stress [20
Thus, despite having a high standard of knowledge and practice, dental practitioners around the globe are in a state of anxiety and fear while working during the COVID-19 pandemic [25
]. Given the above, this study aimed to explore the symptoms of depression, anxiety, and PTSD among dental HCWs in Russia during the COVID-19 pandemic.
3.1. Participant Demographic Characteristics
In the present study, 128 HCWs were included. Of the participants, 43 (33.6%) were dentists, 37 (28.9%) were dental assistants, and 48 (37.5%) were other healthcare workers (dental laboratory technicians, front desk receptionists, and nurse aides). Most of the participants were female (101 (78.9%)), and 80 (62.5%) had direct contact with patients. The mean age of the sample was 38.6 years (SD = 13.9). The participant demographic characteristics are presented in Table 1
3.2. Prevalence of Psychological Distress and PTSD in Healthcare Workers
presents the prevalence of psychological distress and PTSD symptoms in HCWs. In the sample, 20.3% had mild to extremely severe symptoms of depression, 24.2% had mild to extremely severe symptoms of anxiety, and 24.2% had mild to extremely severe symptoms of stress, determined using established cut-off scores for the DASS-21. Furthermore, 29.7% had moderate or severe PTSD symptoms using established cut-off scores for the PSS-SR, and 7.1% had mild to severe PTSD symptoms using established cut-off scores for the IES-R.
The descriptive statistics for DASS-21, PSS-SR, and IES-R scores are presented in Table 3
The Mann–Whitney U test showed no differences between females and males on the DASS-21, PSS-SR, and IES-R scores.
The Kruskal–Wallis H test showed that HCWs aged 51–64 years, in comparison to HCWs aged 18–35 years and 36–50 years, had significantly higher DASS-21 depression scores (H = 10.47, p < 0.01), DASS-21 anxiety scores (H = 9.37, p < 0.01), DASS-21 stress scores (H = 7.83, p < 0.05), DASS-21 total scores (H = 10.54, p < 0.01), PSS-SR increased arousal scores (H = 6.70, p < 0.05), IES-R avoidance scores (H = 7.72, p < 0.05), and IES-R total scores (H = 7.21, p < 0.05).
The Mann–Whitney U test showed that HCWs who had direct contact with patients, in comparison with those who had no contacts, had significantly higher PSS-SR re-experiencing scores (U = 1503.0, z = −2.14, p < 0.05), PSS-SR total scores (U = 1482.5, z = −2.16, p < 0.05), IES-R intrusion scores (U = 1462.5, z = −2.35, p < 0.05), IES-R avoidance scores (U = 1491.5, z = −2.19, p < 0.05), and IES-R total scores (U = 1512.0, z = −0.2.03, p < 0.05).
Finally, the Kruskal–Wallis H test showed no differences between dentists, dental assistant, and dental auxiliaries, but pairwise comparisons using a Mann–Whitney U test showed that dentists, in contrast to other HCWs, had significantly higher PSS-SR re-experiencing scores (U = 762.5, z = −2.24, p < 0.05), PSS-SR increased arousal scores (U = 763.5, z = −0.2.16, p < 0.05), PSS-SR total scores (U = 733.0, z = −2.38, p < 0.05), and IES-R intrusions scores (U = 776.0, z = −2.15, p < 0.05). Furthermore, dental assistants, in contrast to other HCWs, had significantly higher IES-R avoidance scores (U = 663.0, z = −2.09, p < 0.05).
3.3. Risk Factors for PTSD Symptoms Development
Multiple regression analysis was used to examine the potentially varying influence of psychological distress and sociodemographic characteristics on the severity of PTSD symptoms (Table 4
). Sex, working position, age, depression, anxiety, and stress were used as predictors, and PTSD symptoms were used as the predicted variables (PSS-SR and IES-SR). The predictor “occupation” was excluded from the linear regression model because it was collinear with the “working position”. Model 1 was statistically significant, predicting 60% of the variance in PSS-SR scores (F[7, 120]
= 25.93, multiple R = 0.60, adjusted R2
= 0.58). Model 2 was also statistically significant, predicting 48% of the variance in IES-R scores (F[7, 120]
= 16.02, multiple R = 0.48, adjusted R2
= 0.46). In both models, the predictors “stress” and “working position” had a significant effect on PTSD symptoms.
Emerging evidence from research on the COVID-19 pandemic indicates high rates of mental disorders among HSCWs in most countries, including China, the U.S.A., India, and Italy [2
According to the obtained results in this study, 21.9% of the sample had moderate to severe symptoms of psychological distress using an established cut-off for the DASS-21, which was similar to the results (23.6%) of an online survey among the HCWs of various specialties of Russia [36
The revealed stress levels were significantly higher than those described among dental academics (9.9% using an established cut-off for the IES) [20
] and Israeli dentists (11.5% using Kessler’s K6 Distress Scale) [24
]. With that, the distress levels were significantly lower than in India, where about 50% of dentists had distress (using an established cut-off for the COVID-19 Peritraumatic Distress Index, CPDI) and 80% had perceived stress, as indicated by the PSS [21
]; and Saudi Arabia, where 34.92% of dental students had elevated levels of stress (using an established cut-off for the DASS-21 [22
]. This discrepancy could be attributed to the use of various scales (such as CAD-7, CPDI, DASS-21, and IES-R) for measuring distress and anxiety levels, to a period of the pandemic, when the studies were conducted, and even with the differences in the dental care systems and government restrictions in various countries. Thus, a strong dose–response relationship was observed in the association between country-level fatality rate and stress levels; a higher fatality rate was associated with higher odds of severe and moderate stress [20
]. The emotional and mental characteristics of HCWs in response to COVID-19 spread are also not static, and thus the results of surveys can change over time [46
]. For example, the adaptive type of response to a pandemic, in the form of a stress level reduction, observed in the initial stages of a pandemic, can be associated with an increase in awareness of a new infection [46
], while the economic changes or the uncontrolled infection spread can cause an increase in stress levels. As a result, the prevalence of psychological stress among HCWs may increase after the initial period of an outbreak [8
The differences in regulation and restriction measures among countries could strongly affect both the practice and mental health of HCWs. Thus, in Italy, all respondents reported practice closure or strong activity reduction, and the majority of them (89.6%) reported concerns about their professional future and the hope for economic measures to help dental practitioners [23
]. A vast decrease in the number of treated patients was also observed in other countries as well [13
In contrast to some other studies, no differences between females and males on the DASS-21, PSS-SR, and IES-R scores were revealed. This finding is similar to the results of cross-sectional surveys among dentists from China, India, Israel, Italy, and the U.K. [19
], as well as U.K. frontline HCWs, where no gender differences were revealed [3
]. By contrast, several other studies have revealed that female dentists showed significantly higher levels of self-reported anxiety [13
], depression [12
], and stress [21
], confirming that women are at higher risk of depressive symptoms than men [47
]. Therefore, our findings should be treated with caution, because the majority of participants identified as women (78.9%) and it may be that there was insufficient power to detect differences.
According to the conducted analyses, the highest DASS-21 depression, anxiety, and stress scores, as well as PSS-SR arousal scores, and IES-R avoidance and total scores, were revealed in HCWs aged 51–64. In contrast to our findings, in India [21
] and Italy [12
], age was negatively correlated with depressive symptoms. The probable explanation could lie in the fact that persons over 65 years were not permitted to work during the pandemic, and thus were not included in our study. Moreover, HCWs aged 51–64 (the pre-retirement age in Russia) are the most vulnerable to the economic situation [48
] and therefore economic anxiety—levels during the pandemic are essentially equal to the health anxiety [49
], and could affect their stress and depression scores. This explanation is in line with the findings of U Consolo et al. (2020), who revealed that the majority of dental practitioners were quite concerned about their professional future, due to the uncertainty about the end of the emergency [23
According to the results (Table 2
), 7–17.2% of dental HCWs had clinical symptoms of PTSD (using established cut-offs for the IES-R, and the PSS-SR, respectively). The revealed prevalence of PTSD symptoms is similar to that of comparable studies [32
HCWs working in patient-facing roles had significantly higher PSS-SR re-experiencing scores, PSS-SR total scores, IES-R intrusion, IES-R avoidance scores, and IES-R total scores than their colleagues in non-patient-facing roles. Moreover, according to the multiple regression analysis (Table 3
), work in a patient-facing role was a strong predictor for PTSD development. The obtained results are similar to those reported by other researchers, who identified differences in the depression scores of face-to-patient HCWs vs HCWs who were not seeing any patients [28
] and established that patient-facing roles were the predictors of burnout [29
]. These findings can be explained by the HCWs’ awareness of the higher chances for patient-facing specialists to become infected [4
]. According to the previous surveys, the majority of practitioners feared infection, and that fear of contracting COVID-19 from a patient was strongly associated with elevated psychological distress [23
Notably, an examination of the levels of PTSD, anxiety, and depression symptoms among the study groups have revealed that dentists (who hold MD degrees), in contrast to other dental HCWs, had significantly higher PSS-SR re-experiencing, arousal, intrusions, and total scores, while dental assistants (persons without an MD degree), in contrast to other participants, had significantly higher IES-R avoidance scores. This is somewhat interesting, because nurses (which is the closest analog to dental assistant in general medicine) typically reported higher levels of symptoms and distress than doctors [3
], with a few studies reporting no difference [53
] and only one study reporting higher rates in doctors [30
Overall, our study has identified a vulnerable group susceptible to psychological distress. However, mental health problems have also been found to be associated with increased risk for cardiovascular diseases, diabetes, and even premature mortality [55
], and thus future studies, as well as special clinical and policy strategies, are needed.