Mental Health Outcomes Among Physicians Following the COVID-19 Pandemic

Abstract

The COVID-19 pandemic exposed the fragility of global health systems, as physicians faced extremely challenging conditions including excessive workloads, infection risk, and high patient mortality. We conducted a cross-sectional survey that aimed to assess the post-pandemic prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) in a sample of Greek physicians who worked on the frontline during the SARS-CoV-2 (COVID-19) pandemic. An online survey was conducted between 1 March and 31 July 2023, in which 200 Greek physicians were invited via e-mail to voluntarily answer a confidential online questionnaire, and 58 of them responded. The survey included two clinically validated tools: the Patient Health Questionnaire-4 (PHQ-4) and the Impact of Event Scale—Revised (IES-R). Univariate correlations of 26 exposure variables with anxiety, depression, combined anxiety/depression, and PTSD were performed. In total, 58 eligible physicians (46.6% female) participated in this study. The rates of anxiety, depression, combined anxiety/depression, and PTSD were 27.5% (95% CI: 16.7–40.9), 31.0% (19.5–44.5), 22.4% (12.5–35.3), and 24.1% (13.9–37.2), respectively. Notably none of the physicians working in a laboratory developed any mental health symptoms. The following factors were found to be associated with the development of higher mental health symptoms: age ≤ 30, employment in healthcare ≤ 10 years, working in COVID-19 wards, working in intensive care units or COVID-19 wards, a history of mental health symptoms, a history of physical conditions, shortages of materials and equipment for diagnosing or treating patients, development of a disease other than COVID-19, and the development of a new mental health condition during the pandemic (p < 0.05 for all associations). Our findings highlight the need to better prepare physicians with adequate materials, infrastructure, and psychological support such that, in a potential future health crisis, they will not be at such high risk of mental health problems.

1. Introduction

The pandemic caused by SARS-CoV-2 (COVID-19) has led humanity into unprecedented situations, revealing the vulnerabilities of the world’s health systems, which have often been stretched beyond their limits. Physicians have confronted intractable problems and situations, such as excessive overtime work, the need to apply strict personal protection measures against the virus, the risk of becoming infected, and an unusually high number of patient deaths [1].

Even before COVID-19, health workers, especially physicians, were found to be at an increased risk of developing mental health conditions such as anxiety, depression, alcoholism, and suicidal ideation [2,3,4]. Globally the healthcare sector is considered to be one of the most stressful and emotionally demanding workplaces [5].

In most disasters, frontline health professionals face two key ethical issues: whether to respond despite the personal risks involved and how to allocate limited life-saving medical resources. Indeed, several ethical dilemmas were raised during COVID-19. Globally some health professionals were reportedly forced to make resource-partitioning decisions regarding which patients should or should not be treated. Others had to struggle to provide a lesser degree of “substandard” care [6].

Moral distress occurs when external or internal constraints preclude the realization of a morally appropriate choice or action [7]. Multiple experiences of moral distress may lead to a moral residue or an accumulation of unresolved conflicts within the physician, thus rendering future situations that create moral distress even less tolerable [7,8]. Moral distress can lead to moral injury, a form of deep psychological harm associated with mental health outcomes such as anxiety, depression, and PTSD [9].

Tackling the psychological impact of the pandemic on healthcare staff has emerged as a critical priority in mental health research involving multiple disciplines [10].

This study aims to assess post-pandemic prevalence of anxiety, depression, and PTSD among physicians and examine their association with demographic, occupational and health-related factors (such as age, work setting, health history, and pandemic-related experience). It also seeks to understand the challenges and consequences of physicians’ working conditions during the pandemic, contributing to the scientific community’s dialogue in improving their working conditions in future emergencies. To the best of our knowledge, no studies have yet systematically examined the persistence of anxiety, depression, and PTSD symptoms among Greek physicians post-pandemic using validated instruments.

2. Materials and Methods

2.1. Study Design

A cross-sectional survey of physicians working in several Greek medical institutions in the public and private sectors, most of them in Northern Greece, was carried out between 1 March and 31 July 2023.

Physicians working as frontline staff during the COVID-19 pandemic in secondary or tertiary healthcare institutions in Greece were considered eligible to participate in this study. Receiving leave for any reason for more than 50% of the time during any of the three consecutive waves of the pandemic was considered an exclusion criterion from the study.

2.2. Sample and Sampling Procedure

In total, 200 potential participants were recruited via e-mail through the Thessaloniki Medical Association to voluntarily answer a confidential Google Forms questionnaire posted online.

2.3. Instruments

The survey required approximately 20 min to complete. It included 12 questions related to the sociodemographic, employment, health, and lifestyle data of the participants: gender, age, marital status, family dependents (children or other financially supported family members), duration of employment in healthcare, location within medical units, whether they treated COVID-19 patients and/or treated patients with other diseases, mental health history (if yes, whether medication or psychotherapy was received), history of physical conditions (if yes, whether medication was received), smoking, and alcohol consumption.

The survey also included 13 questions related to the participants’ experiences during the pandemic including whether they faced material and equipment shortages with respect to diagnosing or treating patients and shortages of personal protection equipment (PPE), redeployment in a different position due to the pandemic, overtime work, morally uncomfortable occupational changes, decisions on patient triage, whether they started or increased smoking and/or alcohol consumption, whether they developed COVID-19, whether one of their family members developed COVID-19, whether they or one of their family members were hospitalized for COVID-19, and whether they developed other physical conditions (if yes, whether medication was received) and/or developed a mental condition (if yes, whether medication or psychotherapy was received).

To assess symptoms of anxiety and depression, the standard PHQ-4 questionnaire, which has been validated as a screening tool for the detection of these mental health issues, was used [11]; the questionnaire has also been validated in the Greek general population [12]. For generalized anxiety disorder, it has been found to have a sensitivity of 86% and a specificity of 83% [13]. For major depressive disorder, it has been found to have a sensitivity of 83% and a specificity of 90% [14]. Its Cronbach’s α has been measured at 0.807 [15].

PTSD symptoms were assessed using the official Greek translation of the IES-R questionnaire (IES-R-Gr) [16]. The IES-R has been evaluated, validated, and proven useful for predicting PTSD [17]. Its sensitivity and specificity have been assessed to be 83% and 72%, respectively [18].

2.4. Data Analysis

The data were stored and processed in accordance with the European Union General Data Protection Regulations. Only complete cases were analyzed, and there was no missing data handling. Continuous variables were summarized with median and interquartile ranges (Q1, Q3) due to asymmetric distribution. Categorical variables were presented with frequencies and relative frequencies. The internal reliability of the questionnaires was evaluated with Cronbach’s α. The presence of anxiety or/and depression symptoms was considered when the subjects scored ≥ 3 in anxiety questions or depression questions of the PHQ-4 questionnaire. Subjects who scored ≥ 33 in the IES-R-Gr were considered to have PTSD symptoms. Logistic regression was used to assess the association of the exposure variables and the presence of anxiety, depression, or PTSD symptoms as outcome variables. The final multivariable model was built after backward selection of significant univariate variables. Odds ratios (ORs) with 95% confidence intervals (CIs) were presented. The significance level was set at 5%, and all p-values were two-tailed. Data were analyzed with SPSS Statistics, version 23 (IBM, Armonk, NY, USA).

2.5. Ethical Considerations

Informed consent was obtained from all participants in the study, and the research was approved by the Research Ethics Committee of the International Hellenic University (reference number 21/21.02.2023), in accordance with the Declaration of Helsinki of 1975 and its current amendment [19]. There was no way to link the name of the participating physician to the anonymous responses or to any information that could lead to personal identification. The data were stored and processed in accordance with the European Union General Data Protection Regulations, ensuring data protection.

3. Results

3.1. Participant Characteristics

A total of 58 eligible individuals responded (response rate 29%), of whom 56 were physicians and 2 were medical students during the pandemic; however, at the time of the study, they had graduated and were practicing as medical doctors and members of the Thessaloniki Medical Association. During the pandemic, the participants worked in 13 healthcare institutions (medical students voluntarily), the majority in public hospitals in Thessaloniki, the city in which our institute is based, while the rest worked in public hospitals in Athens and other parts of Greece, as well as in the private sector. Most participants were male (n = 31, 53.4%), married (n = 30, 53.6%), and did not have family dependents (n = 31, 53.4%). The majority (60.3%) had worked in healthcare for 10 years or more. During the pandemic, over one third (n = 23, 39.7%) of the participants worked in COVID-19 wards. The laboratory staff were not examined for correlations due to zero events in some categories, which, on the other hand, is noteworthy. All non-laboratory physicians (n = 48, 87.9%) had treated COVID-19 patients, in addition to patients with other diseases. Only three participants (5.2%) reported a mental health history, of whom only two (3.5%) received medical or psychological treatment. Sixteen participants (28.1%) had a history of physical conditions before the pandemic, of whom most received treatment (75%). Finally, over half of the participants were non-smokers (n = 37, 63.8%), and only three (5.2%) of them consumed significant amounts of alcohol. The results of the sociodemographic, employment, health, and lifestyle data of the sample are summarized in

Table 1. Sociodemographic, employment, health, and lifestyle data of the sample (n = 58).

Variable	Categories	n	%
Gender	Female	27	46.6
	Male	31	53.4
Age	≤30	9	15.5
	31–40	14	24.1
	41–50	17	29.3
	51–60	15	25.9
	>60	3	5.2
Marital status	Married	30	53.6
	Divorced	5	8.9
	Unmarried, in a steady relationship	13	23.2
	Unmarried, not in a steady relationship	8	14.3
	Prefer not to say	2	−
Family dependents	Yes	27	46.6
	No	31	53.4
Duration of employment in healthcare	≤10 years	23	39.7
	>10 years	35	60.3
Location within medical unit	ICU	7	12.1
	COVID-19 ward	23	39.7
	Regular ward	14	24.1
	Laboratory	10	17.2
	Emergency room	4	6.9
Treated COVID-19 patients	Yes	51	87.9
	No	7	12.1
Treated non-COVID-19 patients	Yes	51	87.9
	No	7	12.1
History of mental health conditions	Yes	3	5.2
	No	55	94.8
History of physical conditions	Yes	16	28.1
	No	41	71.9
	Prefer not to say	1	−
Smoker	Yes	21	36.2
	No	37	63.8
Alcohol consumer	Yes	3	5.2
	No	55	94.8

.

Most participants (n = 34, 58.6%) reported that they encountered shortages of materials and equipment for diagnosing and treating patients, while almost half (n = 28, 48.3%) reported having experienced shortages of PPE during the pandemic. Over one third of the participants (34.5%) were redeployed due to the pandemic, and 40 (69%) had to work beyond their normal working hours, ranging from a minimum of 3 h per week minimum to a maximum of 100 h per week, with substantial deviations from each other, median 20.00, IQR (7.25−30.00), hours per week. Nine (15.8%) participants started or increased their smoking, and six (10.5%) their alcohol consumption during the pandemic. Most participants (69%) were diagnosed with COVID-19, even more participants (n = 45, 77.6%) had a family member who developed COVID-19, and ten (17.2%) reported that they or a member of their family was hospitalised for COVID-19 during the pandemic. Almost a quarter of the participants (22.4%) developed another physical condition, and four (7%) developed a new mental health condition during the pandemic. The results of the participants’ experiences during the pandemic are summarized in

Table 2. Experiences during the COVID-19 pandemic.

Variable	Categories	n	%
Shortages of materials and equipment for diagnosing and treating patients	Yes	34	58.6
	No	24	41.4
Shortages of PPE	Yes	28	48.3
	No	30	51.7
Redeployment	Yes	20	34.5
	No	38	65.5
Overtime work	Yes	40	69.0
	No	18	31.0
Morally uncomfortable occupational changes	Yes	15	31.2
	No	33	68.8
	Prefer not to say	10	−
Needed to decide on patient triage	Yes	26	49.1
	No	27	50.9
	Prefer not to say	5	−
Started or increased smoking	Yes	9	15.8
	No	48	84.2
	Prefer not to say	1	−
Started or increased alcohol consumption	Yes	6	10.5
	No	51	89.5
	Prefer not to say	1	−
Developed COVID-19	Yes	40	69.0
	No	18	31.0
Family members developed COVID-19	Yes	45	77.6
	No	13	22.4
Participant or a family member hospitalized for COVID-19	Yes	10	17.2
	No	48	82.8
Developed other physical conditions	Yes	13	22.4
	No	45	77.6
Developed a mental condition	Yes	4	7.0
	No	53	93.0
	Prefer not to say	1	−

.

3.2. Mental Health Outcomes

The median PHQ4 score was 2.00, IQR (0.00, 6.00). For the anxiety subscale the median score was 1.00, IQR (0.00, 3.00), and for the depression subscale it was 1.00, IQR (0.00, 3.00). The median IES-R-Gr score was 13.50 IQR (2.00, 31.25). In total, 16 (27.5%) participants scored ≥3 on the anxiety subscale, and 18 (31.0%) scored ≥3 on the depression subscale, while 13 (22.4%) scored ≥3 on both subscales of the PHQ-4 (combined symptoms of anxiety/depression). Almost a quarter of the participants (24.1%) scored ≥33 in the IES-R-Gr questionnaire. The median IES-R-Gr score was 13.50, IQR (2.00, 31.75), and 14 (24.1%, 13.9–37.2) participants scored ≥33 on the IES-R-Gr questionnaire. PHQ-4 Cronbach’s alphas were 0.83 for the anxiety subscale and 0.84 for the stress subscale. IES-R Cronbach’s alphas for the intrusion, avoidance, and hyperarousal scales of 0.94, 0.90, and 0.89, respectively.

3.3. Factors Associated with Outcomes

After mutivariable analysis, younger age and the development of other physical disease were associated with increased odds of anxiety symptoms (OR: 6.46, 95%CI: 1.21, 34.50 and OR: 6.40, 95%CI: 1.52, 26.92, respectively;

Table 3. Association between exposure variables and anxiety symptoms (PHQ-4 Anxiety subscale ≥ 3).

	Univariate			Multivariable
	OR	95%CI	p-Value	OR	95%CI	p-Value
Age ≤ 30	7.8	1.66, 36.76	0.009	6.46	1.21, 34.50	0.029
Gender (female vs. male)	1.71	0.54, 5.48	0.363
Employment in healthcare ≤ 10 years	3.72	1.11, 12.41	0.033
Worked in ICU or COVID-19 ward	4	1.11, 14.47	0.035
History of mental illness	10.25	0.98, 107.78	0.053
History of physical diseases	2.77	0.81, 9.50	0.106
(regardless of treatment)
History of physical diseases	5.76	1.48, 22.41	0.012
(received treatment)
Developed other physical disease	7.4	1.91, 28.65	0.004	6.4	1.52, 26.92	0.011
Shortages of materials and equipment	1.82	0.54, 6.15	0.337

OR: odds ratio; 95%CI: confidence interval.

). The odds of depression increased with a history of physical diseases that received treatment and in subjects who developed other physical diseases (OR: 6.10, 95%CI: 1.19, 31.39 and OR: 21.16, 95%CI: 3.56, 125.77, respectively;

Table 4. Association between exposure variables and depression symptoms (PHQ-4 Depression subscale ≥ 3).

	Univariate			Multivariable
	OR	95%CI	p-Value	OR	95%CI	p-Value
Age ≤ 30	3.46	0.80, 14.90	0.095
Gender (female vs. male)	1.22	0.40, 3.73	0.724
Employment in healthcare ≤ 10 years	2.6	0.83, 8.13	0.101
Worked in ICU or COVID-19 ward	5.25	0.47, 18.86	0.011
History of mental illness	8.36	0.80, 87.11	0.076
History of physical diseases	6.88	0.19, 24.56	0.003
(regardless of treatment)
History of physical diseases	7.2	1.79, 28.90	0.005	6.1	1.19, 31.39	0.03
(received treatment)
Developed other physical disease	15.42	3.44, 69.06	<0.001	21.16	3.56, 125.77	<0.001
Shortages of materials and equipment	3.5	0.98, 12.49	0.054

OR: odds ratio; 95%CI: confidence interval.

). The same exposure variables were associated with the increased odds of both anxiety and depression symptoms (OR: 7.64, 95%CI: 1.36, 42.97 and OR: 13.78, 95%CI: 2.53, 75.18, respectively;

Table 5. Association between exposure variables with anxiety and depression symptoms (PHQ-4 Anxiety + Depression subscales ≥ 3).

	Univariate			Multivariable
	OR	95%CI	p-Value	OR	95%CI	p-Value
Age ≤ 30	6.41	1.41, 29.22	0.016
Gender (female vs. male)	2.19	0.62, 7.75	0.224
Employment in healthcare ≤ 10 years	4.98	1.31, 18.96	0.018
Worked in ICU or COVID-19 ward	4.17	1.01, 17.20	0.049
History of mental illness	14.67	1.37, 157.53	0.027
History of physical diseases	4.54	1.22, 16.88	0.024
(regardless of treatment)
History of physical diseases	9.33	2.23, 39.12	0.002	7.64	1.36, 42.97	0.021
(received treatment)
Developed other physical disease	7.4	1.91, 28.65	0.004	13.78	2.53, 75.18	0.002
Shortages of materials and equipment	2.92	0.71, 12.03	0.139

OR: odds ratio; 95%CI: confidence interval.

). The odds of PTSD symptoms increased with younger age and in subjects that worked in ICU or COVID-19 ward (OR: 5.53, 95%CI: 1.01, 31.18 and OR: 5.10, 95%CI: 1.12, 23.25, respectively;

Table 6. Association between exposure variables and PTSD symptoms (IES-R-Gr ≥ 33).

	Univariate			Multivariable
	OR	95%CI	p-Value	OR	95%CI	p-Value
Age ≤ 30	5.56	1.24, 24.91	0.025	5.53	1.01, 31.18	0.049
Gender (female vs. male)	1.75	0.52, 5.91	0.365
Employment in healthcare ≤ 10 years	2.58	0.76, 8.81	0.131
Worked in ICU or COVID-19 ward	4.83	1.18, 19.74	0.029	5.1	1.12, 23.25	0.035
History of mental illness	12.9	1.21, 137.37	0.034
History of physical diseases	1.62	0.45, 5.87	0.466
(regardless of treatment)
History of physical diseases	2.94	0.75, 11.43	0.12
(received treatment)
Developed other physical disease	6.33	0.16, 24.58	0.008
Shortages of materials and equipment	6	1.20, 30.00	0.029

OR: odds ratio; 95%CI: confidence interval.

).

4. Discussion

In brief, about one quarter of our participants exhibited symptoms of mental disorders, with about one third showing signs of depression. Younger age, fewer years of employment in healthcare, work in ICU or COVID-19 wards, history of physical conditions (when treatment was received), and development of a disease other than COVID-19 during the pandemic were associated with increased anxiety; work in ICU or COVID-19 wards, history of mental illness, history of physical conditions (regardless of treatment), history of physical conditions (when treatment was received), and development of a disease other than COVID-19 during the pandemic were associated with increased depression; younger age, less years of employment in healthcare, work in ICU or COVID-19 wards, history of physical conditions (regardless of treatment and when treatment was received), development of a disease other than COVID-19 during the pandemic, and development of a new mental condition during the pandemic were associated with increased combined anxiety/depression; younger age, work in ICU or COVID-19 wards, shortages of materials and equipment to diagnose or treat patients, development of a disease other than COVID-19 during the pandemic, and development of a new mental condition during the pandemic were associated with increased PTSD. Τhe physicians working in the laboratory did not develop any mental health symptoms, suggesting that the lack of direct contact with patients may reduce the psychological burden; however, we found no reference to this phenomenon in the literature.

Before the pandemic, not many studies were conducted in Greece regarding the psychological symptoms experienced by both the general population and medical staff. Nevertheless, data from the reliable statistical website “Our World in Data” shows that, in 2019, levels of anxiety in Greece were 5.8%, while depression was reported at 5% in the general population [20].

In a study conducted in 2017, prior to the pandemic, considerably lower rates of clinically significant anxiety and depression were reported in a sample of 217 psychiatric care workers, using the Symptoms Rating Scale for Depression and Anxiety [21].

It is quite expected that, under the circumstances of COVID-19, the rates of mental health symptoms increased among health workers especially physicians. However, in a population of 110 mental health nurses from all over Greece, Tsaras et al. reported much higher levels of anxiety and depression, using the PHQ-2 and GAD-2 questionnaires, which are very similar to PHQ-4 [22].

For the pandemic period and with respect to healthcare workers, our results agree with those of Pappa et al. [23] and Gavana et al. [24], and they are also consistent with the results of Ilias et al. [25] in the subset of physicians of their sample. In a study among 270 healthcare workers, while using different psychometric tools, Blekas et al. (2020) observed a considerably lower PTSD symptom level [26].

A study from Cyprus found lower rates of depression and PTSD in physicians; however, the spread of the virus was significantly lower in Cyprus than in Greece [27].

Wanigasooriya et al. also reported results comparable to our findings in a sample of 2638 health professionals (460 physicians) from the UK [1]. In a sample of 1580 health professionals (282 physicians) from France, Azoulay et al. found much higher levels of anxiety and slightly higher levels of PTSD and similar rates of depression [28].

Among the systematic reviews and meta-analyses, which included studies from around the world, some reported similar results to ours [29,30], while other researchers found lower rates of anxiety and higher rates of depression in physicians [30], and others slightly lower anxiety rates and PTSD but substantially lower depression in healthcare workers [31]. Notably, certain studies observed differences in mental health outcomes across countries and regions [29,32].

Gender did not exhibit an association with any of the mental health symptoms examined. This finding contradicts several studies that reported significantly higher levels of anxiety, depression, or PTSD in females than in males [1,24,26,27,28]. However, other studies have found no significant differences between genders [23,25,33,34]. Among the four systematic reviews and meta-analyses mentioned, three found no association with gender. However, they reported that many of the included studies did not conduct a gender analysis [30,31,32]. In contrast, the largest systematic review observed associations related to gender [29].

Participants who were younger than 30 were significantly more likely to exhibit anxiety, anxiety/depression, and PTSD symptoms, but not symptoms related to depression. In general, several studies agree with this finding [1,24,27], while a few disagree [34]. This is attributed to the limited clinical experience in younger individuals and to the resilience built over the years by older individuals [35,36]. However, less work experience was only associated with anxiety symptoms, which is partially consistent with a single study [36].

Service in direct contact with COVID-19 patients, where difficult ethical decisions may have had to be made, was shown to be associated with anxiety, depression, and PTSD. Several studies agree with this finding [1,27,28], while a few disagree [25].

Mental health history was associated with depression symptoms. Other studies have found associations not only with depression but also with anxiety [34], anxiety and PTSD [1], and PTSD [27]. These disparities are probably due to our relatively small sample size.

A history of physical conditions was associated with depression and with combined anxiety/depression. Wanigasooriya et al. found associations with anxiety, depression, and PTSD, but only PTSD was confirmed by the multiple logistic regression model they constructed [1].

In our study, receiving treatment for a physical condition correlated with anxiety, depression, and anxiety/depression. We did not find a similar reference in the literature. Nevertheless, research has found that people with pre-existing physical and mental health conditions are more vulnerable to the negative effects of the pandemic for social and/or biological reasons [37,38,39].

The development of a disease other than COVID-19 during the pandemic was associated with anxiety, depression, and anxiety/depression, in addition to PTSD. This was the only exposure variable that was associated with all the examined mental health symptoms. The development of a mental condition during the pandemic exhibited an association with combined anxiety/depression and PTSD symptoms. To the best of our knowledge the present study is the first to investigate these two risk factors.

Facing shortages of materials and equipment for diagnosing or treating patients correlated with increased PTSD symptoms. We did not find similar references in the literature. Other studies have observed an association of shortages of PPE with mental health symptoms [1,23], which was not observed in this study; this is possibly due to our relatively small sample.

Facing shortages of essential medical materials—such as medications, ventilators, or PPE—can profoundly affect physicians’ mental health. These shortages often force physicians into situations in which they cannot provide the standard of care they know is necessary, which can lead to intense stress, frustration, and feelings of helplessness [40]. When resources are scarce, physicians may also experience moral distress—an emotional state arising when they know the ethically appropriate action to take but are unable to do so due to institutional or systemic constraints [41].

Ethical dilemmas compound this distress. During crises such as pandemics or disasters, doctors may face decisions about which patients receive limited life-saving interventions. Making such choices can lead to moral injury, a deep psychological harm resulting from violating one’s moral or professional values. Over time, this can contribute to burnout, anxiety, depression, and post-traumatic stress symptoms [9].

It is interesting, however, that, in our study, there was an association between PTSD symptoms and the lack of materials for the diagnosis and treatment of patients but not with the lack of protective equipment for the doctors themselves, which suggests an altruistic attitude on the part of the participating doctors, since they were more traumatized psychologically by their concern for their patients than for themselves.

The high prevalence of mental health symptoms has serious implications for the mental of healthcare workers. By extension, it also has serious implications for the health of the general population. Indeed, the poor health status of health workers ultimately affects the quality of the health services they provide [42]. There is also clear evidence that those with mental disorders are more likely to experience excess morbidity and premature mortality, as well as a negative impact on their work, education, and social life [43].

5. Strengths and Limitations

A strong point of this study is that it focused exclusively on physicians, which most other studies did not do, as they either focused on nurses or included various other categories of healthcare workers alongside doctors and nurses. This study also brings together experiences from the entire long period of successive waves of COVID-19 and the corresponding social distancing measures, lockdowns, etc., while most of those reported in the literature, especially in Greece, focus mainly on the first wave of the pandemic. Thus, this paper offers a hint of the persistence of mental health symptoms in physicians after the end of the pandemic. Another strength of the present study is that it examined combined symptoms of anxiety/depression among mental health symptoms, something that none of the aforementioned studies studied.

Given the limited sample size of 58 responses and the possible selection bias of convenience sampling, our findings should be interpreted cautiously and may not be generalizable to all Greek physicians. In fact, our initial goal was to recruit far more people for the survey, but the response rate was very low, which ultimately proved to be the most significant drawback of our analysis. The low response rate (29%) suggests that many physicians were reluctant to talk about their experiences. The inclusion of two medical students was decided on the basis that the university courses were paused during the pandemic and instead they volunteered to work as first-line medical staff, even a bit prematurely, to help the Health System and the patients and gain real-word experience. Nonetheless, this may introduce a confounding element, as students experience different stressors (e.g., academic pressure) unrelated to frontline work. Another limitation was the use of a questionnaire, which of course could not be avoided in this case. However, self-report questionnaires, in which participants are asked to assess their own mental health status, may induce a self-report bias, as no one can be completely objective when it comes to themselves. We acknowledge that our study’s cross-sectional design and lack of pre-pandemic baseline date limit our ability to evaluate actual changes in mental health symptom rates during the pandemic. However, the results highlight important mental health concerns that warrant further investigation in larger, representative samples. Our findings provide a snapshot of the current prevalence, but they cannot establish whether these rates increased compared with pre-pandemic levels. Future longitudinal research is warranted to assess trends over time.

6. Conclusions

Preliminary findings suggest a concerning prevalence of mental health symptoms in Greek physicians facing the circumstances imposed by the COVID-19 pandemic. The psychological burden they bear when working in challenging conditions and the risk of mental disorders not only compromises the well-being of physicians but it also reduces the quality of care delivered to patients. The main limitations of the study are the small sample size and the convenience sample; therefore, further research is necessary on the factors associated with mental health challenges among physicians, with larger, randomized longitudinal studies.