Depression, anxiety and coping mechanisms among mental healthcare...

[Full title: Depression, anxiety and coping mechanisms among mental healthcare practitioners during COVID-19]

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[Find the meaning and references behind the names: Alexander, Paul, Smart, Boateng, Edwin]

http://www.sajpsychiatry.org Open Access South African Journal of Psychiatry ISSN: (Online) 2078-6786, (Print) 1608-9685 Page 1 of 10 Original Research Read online: Scan this QR code with your smart phone or mobile device to read online Authors: Yolandi Stals 1 Edwin du Plessis 2 Paul J. Pretorius 1 Mariette Nel 3 Alexander Boateng 3 Affiliations: 1 Department of Psychiatry, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa 2 Department of Psychology, Faculty of Humanities, University of the Free State, Bloemfontein, South Africa 3 Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: Paul Pretorius, pretorpj@ufs.ac.za Dates: Received: 19 Apr. 2024 Accepted: 15 July 2024 Published: 09 Oct. 2024 How to cite this article: Stals Y, Du Plessis E, Pretorius PJ, Nel M, Boateng A. Depression, anxiety and coping mechanisms among mental healthcare practitioners during COVID-19. S Afr J Psychiat. 2024;30(0), a 2307. https://doi.org/10.4102/ sajpsychiatry.v 30 i 0.2307 Copyright: © 2024. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License Introduction The coronavirus disease 2019 (COVID-19) pandemic caused high levels of psychosocial stress and posed significant challenges in providing healthcare, including in South Africa. 1,2 The risk of acute and longstanding mental health consequences among healthcare practitioners resulting from a pandemic may compromise work performance and increase the risk of clinical error 2 Significant anxiety and distress have been reported in up to 36 % of adults in the general population during the pandemic 3 Clinically significant psychological stress is more likely to occur in healthcare practitioners exposed to the COVID-19 virus, with high rates of depression (50.4 % ), anxiety (44.6 % ), insomnia (34 % ) and distress (71.5 % ) reported among healthcare practitioners during the pandemic 3 Although previous studies have reported on psychological distress and coping behaviours in the general population, students and healthcare practitioners during the pandemic, very few explored responses of those working in mental healthcare settings 3,4,5,6,7,8,9,10,11 Managing highly infectious diseases does not fall within mental healthcare practitioners’ normal scope of practice. Furthermore, before the availability of vaccines, preventative measures were often not practical in mental healthcare settings 12 Evidence suggests that mental healthcare practitioners exposed to poor work conditions, poorer patient outcomes, high stress levels and emotional exhaustion during the COVID-19 pandemic resulted in an increased risk of burnout. 13,14 In addition, the prevalence of psychiatric symptoms during the pandemic exceeded baseline prevalence. 15,16 Background: The coronavirus disease 2019 (COVID-19) pandemic has placed the psychological functioning of mental healthcare practitioners under severe strain. Coping methods may affect mental health outcomes Aim: The study examined the relationship between depression, anxiety, stress, and coping styles utilised by mental healthcare practitioners during the COVID-19 pandemic Setting: Three private and one public mental healthcare facility in Bloemfontein, South Africa Methods: Respondents completed the Depression, Anxiety and Stress Scale (DASS-21) and Brief Coping Orientation to Problems Experienced (Brief-COPE) inventories. An ordinal regression model was used to assess the relationship between coping styles, anxiety and depression Results: A total of 212 practitioners were included in the analysis. According to DASS-21 measures, approximately 41 % and 28 % of respondents had moderate to severe depressive and anxiety symptoms, respectively, with the highest prevalence among younger female respondents and nurses. The association between stress severity, anxiety and depression was significant. Avoidant coping methods and two approach coping strategies (planning and acceptance) were associated with depression and anxiety. Anxiety was linked to an increased likelihood of transitioning to higher avoidant categories, while participants with depression were less likely to move to higher avoidant or approach categories Conclusion: Mental healthcare practitioners, especially nurses, experienced significant COVID-19-related psychological distress during the pandemic. Avoidant coping mechanisms may increase the risk of poor mental health outcomes Contribution: This study added data on the mental health effects of COVID-19 on mental healthcare practitioners, as well as psychological methods used to cope during the pandemic Keywords: COVID-19; depression; anxiety; mental healthcare; coping; coping strategies; mental healthcare practitioners; stress Depression, anxiety and coping mechanisms among mental healthcare practitioners during COVID-19 Read online: Scan this QR code with your smart phone or mobile device to read online.

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[Find the meaning and references behind the names: Main]

Page 2 of 10 Original Research http://www.sajpsychiatry.org Open Access The COVID-19 presents a range of neuropsychiatric disorders during the acute and post-illness phases. Confusion, depressed mood, anxiety, impaired memory and insomnia, and steroid-induced mania and psychosis are encountered during the acute stages of COVID-19. 15 A recent meta-analysis indicated a high prevalence of post-traumatic stress disorder (PTSD) (32.2 % ), depression (14.9 % ) and anxiety disorders (14.8 % ) during the post-illness phase 15 An increased risk of incident anxiety, depressive stress, and adjustment and substance use disorders have also been reported at 1-year follow-up. 16 The increase in neuropsychiatric complications has led to an influx of psychiatric patients to the mental healthcare system, which may impact the coping abilities of mental healthcare practitioners 11 More people have needed mental health support since the pandemic, but disruptions and resource shortages have aggravated the mental healthcare system’s ability to administer care. 17 According to the World Health Organization, 17 more than 60 % of countries, including South Africa, reported disruptions in the delivery of mental health services. These included difficulties with delivering counselling and psychotherapy (67 % ), critical harm reduction (65 % ) and emergency interventions (35 % ). 17 In an online survey on mental health conducted by the South African Depression and Anxiety Group (SADAG), more than half of the 1214 respondents reported anxiety and panic as one of the main challenges during the lockdown and has since recorded an increase in the number of calls to their helplines. 18 Psychosocial responses, including coping strategies, are crucial in limiting adverse mental health outcomes in mental healthcare practitioners 1,9 Various coping strategies can be adopted to reduce psychological distress, with some variable efficacy, depending on the specific context 19 Contemporary coping mechanism analysis emphasises an avoidance and approach paradigm. 20 Individuals cope with a stressor by avoiding it or attempting to adapt to or change it. 20 Avoidant coping methods are considered dysfunctional and maladaptive and increase the risk of anxiety and depression. 20,21 Approach coping strategies that include emotionand problem-focused strategies are regarded as more adaptive and associated with better mental health outcomes 20,21,22,23,24,25 Avoidant or dysfunctional strategies include substance misuse, self-distraction, behavioural disengagement, denial, self-blame and venting 20 (Figure 1) Approach coping styles include problemand emotionfocused strategies and, in most studies, are associated with better mental health and lower anxiety. 22,23,24,25 Approach methods include active coping, planning, instrumental support (problem-focused), emotional support, positive reframing and acceptance. However, planning has previously been linked to higher psychological distress 26 The original Brief Coping Orientation to Problems Experienced (Brief- COPE) questionnaire included humour and religion as general coping factors. Later, their position became more ambiguous, with factor analysis indicating varying positions between approach and avoidant strategies. 27 Coping strategies associated with better mental health outcomes during the recent COVID-19 pandemic are slowly emerging. Research from previous infectious disease outbreaks and the recent COVID-19 pandemic suggests that positive emotion-focused coping strategies, including positive reframing, humour and acceptance, can mitigate the effects of stress during a pandemic 7,26,28 The increased resilience with religion to various stressors reported in earlier studies was not replicated in recent studies 26,29,30 Other researchers reported that approach-coping methods, including problem-solving, cognitive restructuring, and problem-focused approach-coping strategies, such as planning and active coping, improved mental health during epidemics 31,32,33,34 The objectives of the study were: (1) to explore possible relationships between depression, anxiety and coping styles among mental healthcare practitioners during the COVID-19 pandemic; (2) to measure the severity of depression, anxiety and stress; and (3) to identify avoidant and approach coping methods used Research methods and design Study design, population and sampling A quantitative, descriptive, cross-sectional study was conducted. All mental healthcare practitioners working at Optima, Bloemcare and Mondia Woodlands private hospitals and the Free State Psychiatric Complex (FSPC) public healthcare facility were invited to participate. Professional categories among those invited included psychiatrists, psychologists, occupational therapists, social workers and nursing staff. The estimated population size was 740, of which 506 were employed in the public sector and 234 in the private sector Data collection The first author collected data from 01 August until 30 September 2021 during adjusted COVID-19 alert levels 3 and 2. 35 A demographic questionnaire was designed to collect FIGURE 1: Brief-Coping Orientation to Problems Experienced inventory: Avoidant and approach coping styles. Coping styles Avoidant Approach Self-destruction Denial Substance use Behavioral disengagement Self-blame Venting Active coping Emotional support Informational support Positive reframing Planning Acceptance

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[Find the meaning and references behind the names: Low]

Page 3 of 10 Original Research http://www.sajpsychiatry.org Open Access information regarding occupation, gender, age and years of clinical experience. In addition, the Depression, Anxiety and Stress Scale (DASS-21) 36 and the Brief-COPE 37 inventory were completed by each respondent. Depression, Anxiety and Stress Scale-21 The DASS-21 36 measures psychological distress. Items on this scale describe negative emotional states experienced during the previous 7 days. It consists of 21 questions, with each scored on a four-point Likert scale from 0 (‘did not apply to me at all’) to 3 (‘applied to me very much’). Depression, anxiety and stress are measured by seven questions each. Depression, anxiety and stress were graded as normal, mild, moderate, severe or extremely severe during the calculation of participants’ Likert scores mentioned above (Table 2). The DASS-21 has previously been used in research on the COVID-19 pandemic 7,38 In a study conducted in Nigeria, Coker et al. 39 reported excellent reliability for the DASS-21 subscales of depression, anxiety and stress (Cronbach’s alpha values of 0.81, 0.89 and 0.78, respectively). Furthermore, excellent internal consistency and discriminative, concurrent and convergent validities were demonstrated 39 For this study, respondents with normal or mild depression DASS-21 scores ( ≤ 13) and anxiety DASS-21 scores ( ≤ 9) were regarded as having low levels of depression and anxiety. Respondents with moderate, severe or extremely severe DASS-21 scores for depression ( ≥ 14) or anxiety ( ≥ 10) were regarded as having high levels of depression and anxiety. Brief-Coping Orientation to Problems Experienced questionnaire For this study, the Brief-COPE 37 was used to measure coping methods utilised by respondents. Avoidant or approach coping styles were compared for depression and anxiety. The Brief-COPE 37 is a frequently used 28-item self-report questionnaire assessing theoretically derived coping mechanisms with 14 subscales. Each subscale consists of two items that are rated on a four-point Likert scale indicating 1 (‘I have not been doing this at all’), 2 (‘a little bit’), 3 (‘medium amount’) to 4 (‘I have been doing this a lot’). 9 The scale can also determine someone’s primary coping styles as avoidant or approach coping (Figure 1) The Brief-COPE has been used to evaluate coping strategies during previous infectious disease outbreaks. Hanfstingl et al 40 conducted a study during the COVID-19 pandemic on 529 respondents, of which the results supported the original hypothesised 14-factor structure of the Brief-COPE. Avoidant and approach coping styles Avoidance strategies are cognitive, emotional or behavioural attempts to detach oneself from potentially harmful situations. 38 These include efforts to deny, disengage emotionally or remove oneself physically from stressful situations. Brief- COPE avoidant coping domains include substance use, behavioural disengagement, self-distraction, self-blame, denial and venting (Figure 1). With approach coping strategies, individuals actively move towards stressors to alter the situation or seek alternatives. 38 Strategies may include seeking information, social support and planning. On the Brief-COPE questionnaire, approach strategies include active coping, positive reframing, planning, acceptance, emotional and informational support. Religion and humour were excluded from the approach or avoidant paradigm because of their ambiguous position, as reported by previous investigators with factor analysis indicating varying positions between approach and avoidant strategies. 27 Data analysis The Department of Biostatistics, Faculty of Health Sciences, University of the Free State analysed the data using SAS Version 9.4 and SPSS IBM Statistical software (SAS Institute Inc., Cary, NC, USA). Categorical variables were summarised as medians and percentiles as the distributions were skewed. Associations were calculated between health practitioners reporting low and high levels of depression and anxiety using Kruskal-Wallis for numerical variables and Chi-square or Fisher’s exact test for categorical variables Depression and anxiety were each compared with the variables of coping and stress. To evaluate the relationship between depression, anxiety and coping styles, we used an ordinal regression model that considered the hierarchical nature of coping strategies and how they might influence mental health outcomes. This model is particularly useful because it captures the hierarchy in coping strategies, analyses multiple mental health outcomes, provides increased statistical power, and permits context-specific analysis Ethical considerations Ethical clearance to conduct this study was obtained from the University of the Free State Health Sciences Research Ethics Committee (No. UFS-HSD 2021/0039/2004). All ethical standards as prescribed by the Declaration of Helsinki were adhered to. Permission to conduct the study was obtained from the clinical managers of each hospital and the Free State Province Department of Health. Once approval was obtained, the first author distributed the information leaflets, informed consent documents and questionnaires to individual practitioners and supervisors for distribution. Participants placed completed questionnaires in strategically placed collection boxes in each facility. Information remained confidential, and data were anonymised. Respondents placed completed questionnaires in a sealed collection box made available at each facility, collected by the first author. Respondents were provided with the principal investigator’s contact number. They were encouraged to contact the investigator or another mental healthcare practitioner of their choice if they experienced severe anxiety or depression during or after completing the questionnaire.

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Page 4 of 10 Original Research http://www.sajpsychiatry.org Open Access Results Demographic data A total of 212 (28.6 % ) of 740 mental healthcare practitioners in Bloemfontein’s private and public mental health sectors participated in the study (Table 1). The majority were women (81.1 % ), nursing staff (77.8 % ) and between the ages of 46–55 years (29.2 % ), followed by 36–45 years (26.4 % ) and 26–35 years (24.1 % ). Most respondents worked in the public sector (60.4 % ), followed by the private sector (28.3 % ), and had between 0 and 5 years (27.8 % ) or 5–10 years of experience (27.4 % ) Depression and anxiety Overall, 28.3 % and 40.6 % of respondents, primarily women, reported high levels of depression and anxiety, respectively (Table 1). Professional categories with high depression scores ( ≥ 14 on the DASS-21) mainly included nurses (31.5 % ). Depression, Anxiety and Stress Scale-21 anxiety scores ≥ 10 (moderate to extremely severe) were also high for 44.2 % of nurses, followed by psychologists (37.5 % ). Only 7.7 % of medical practitioners reported moderate or severe depression and anxiety Depression, anxiety and stress A significant association ( p < 0.0001) between depression, anxiety and stress severity was observed in our study population (Table 2). Respondents with high levels of depression and anxiety experienced high stress levels in 63.3 % and 55.9 % of cases, respectively. Most respondents (80.3 % ) with low DASS-21 depression scores ( ≤ 13) had normal stress levels (DASS-21 stress scores ≤ 14), while 10.5 % and 9.2 % regarded their stress as mild, or moderate to severe, respectively. Normal to mild anxiety was associated with normal (86.5 % ), mild (10.3 % ) or moderate (3.2 % ) stress exposure Avoidant versus approach coping styles in depression and anxiety Avoidant coping strategies predicted both depression ( p < 0.0001) and anxiety ( p < 0.0001), while approach coping strategies were associated with anxiety only ( p = 0.0068) (Table 3). Respondents with high depression or anxiety scores used avoidant coping strategies (‘little bit, medium, a lot’) in 91.7 % and 82.6 % of cases, respectively ( p < 0.0001) (Table 4). Most respondents with low levels of depression (62.5 % ) or anxiety (67.5 % ) did not use avoidant coping. Approximately 57 % of those with high anxiety levels used approach coping (47.7 % ‘medium’, 9.3 % ‘a lot’), while 48.5 % of respondents with low anxiety used approach coping moderately or frequently (31.8 % ‘medium’, 16.7 % ‘a lot’) ( p = 0.0068) (Table 5) Selected avoidant coping methods: Depression and anxiety Significant associations between depression, anxiety and all avoidant coping styles were identified in our study TABLE 1: Demographic characteristics of respondents with high depression and anxiety scores Demographic characteristics Total group ( N = 212) Depression * Anxiety ** Score ≥ 14 Score ≥ 10 n % n % n % Gender Male 40 19.0 8 20.0 13 32.0 Female 172 81.0 52 30.0 73 42.0 Age range (years) 18–25 10 5.0 4 40.0 8 80.0 26–35 51 24.0 20 39.0 25 49.0 36–45 56 26.0 14 25.0 21 37.0 46–55 62 29.0 15 24.0 19 31.0 56–65 27 13.0 5 18.0 9 33.0 > 65 6 3.0 2 33.0 4 67.0 Occupation Nursing 165 78.0 52 31.0 73 44.0 Social worker 3 1.0 1 33.0 1 33.0 Occupational therapist 15 7.0 2 13.0 5 33.0 Psychologist 16 7.0 4 25.0 6 37.0 Psychiatrist/medical practitioner 13 6.0 1 8.0 1 8.0 Years of experience (years) 0–5 59 28.0 23 39.0 32 54.0 5–10 58 27.0 16 28.0 24 41.0 10–20 32 15.0 5 16.0 10 31.0 20–30 32 15.0 8 25.0 9 28.0 30–40 23 11.0 6 26.0 7 30.0 > 40 8 4.0 2 25.0 4 50.0 Workplace Private sector 60 28.0 19 32.0 24 40.0 Public sector 128 60.0 34 27.0 51 40.0 Both private and public sector 24 11.0 7 29.0 11 46.0 * , DASS-21 depression scores: 0–13 = normal-mild; ≥ 14 = moderate, severe and extremely severe ** , DASS-21 anxiety scores: 0–9 = normal-mild, ≥ 10 = moderate, severe, and extremely severe.

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Page 5 of 10 Original Research http://www.sajpsychiatry.org Open Access population (Table 6). Six avoidant coping strategies were used significantly more by depressed and anxious respondents independently. The associations were particularly robust for self-blame, behavioural disengagement and substance use ( p < 0.0001). The other avoidant styles included denial, selfdistraction and venting. Respondents with high depression scores used self-distraction (91.7 % ), self-blame (76.7 % ), denial (61.6 % ) and substance use (45 % ) more often as coping strategies. Most respondents (80.9 % ) with low depression scores did not disengage behaviourally ( p < 0.0001) as a means of coping. Similarly, those with high anxiety scores used denial (52.3 % ), self-blame (68.6 % ), substance use (38.4 % ) and venting (76.8 % ) significantly more than those with normal or mild anxiety. In contrast, significantly fewer with normal or mild anxiety used avoidance mechanisms such as denial (77.0 % ‘a lot’), self-blame (70.6 % ‘a lot’), substance use (84.9 % ‘a lot’) or behavioural disengagement (82.5 % ‘a lot’) as coping strategies Approach coping subscales: Depression and anxiety Of all the different approach coping styles investigated in this study, active coping ( p = 0.0045), informational support ( p = 0.0321), and planning ( p = 0.0025) were associated with anxiety. Planning and acceptance were also associated with depression ( p = 0.0037 and 0.0065, respectively) (Table 5). No significant differences in other approach coping strategies, including seeking emotional support, informational support and positive reframing, were found among respondents with and without depression or anxiety Other coping methods: Anxiety and depression Respondents with high anxiety levels used humour and religion more (65.5 % and 88.4 % , respectively) than those with low anxiety (46.8 % and 75.4 % , respectively) ( p = 0.0087 and 0.0188, respectively). Respondents with high depression scores used humour more (66.7 % ) than those with low depression scores (49.3 % ) ( p = 0.0226). Using religion to cope was similar across the range of DASS-21 depression scores. Respondents who did not use humour or religion for coping reported significantly less anxiety ( p < 0.0001) and depression ( p < 0.0001). The differences remained significant for primarily avoidant or approach coping styles (Table 7) Discussion The study demonstrated satisfactory reliability and validity for the DASS-21 ( α = 0.95) and the Brief-COPE ( α = 0.92). TABLE 2: Depression, Anxiety and Stress Scale-21 depression and anxiety scores by stress severity Distribution of scores DASS-21 stress severity scores p Normal (0–14) Mild (15–18) Moderate (19–25) S evere (26–33) Extremely severe (34–42) n % n % n % n % n % Depression * < 0.0001# ≤ 13 ( n = 152) 122 80.3 16 10.0 12 8.0 2 1.0 0 0.0 ≥ 14 ( n = 60) 9 15.0 13 22.0 17 28.0 12 20.0 9 15.0 Anxiety ** < 0.0001# ≤ 9 ( n = 126) 109 86.0 13 10.0 4 3.2 0 0.0 0 0.0 ≥ 10 ( n = 86) 22 26.0 16 19.0 25 29.0 14 16.0 9 10.0 DASS, Depression, Anxiety and Stress Scale. #, Fisher’s exact test was used to determine the p -value because of small expected counts * , DASS-21 depression scores: 0–13 = normal-mild, ≥ 14 = moderate, severe and extremely severe; ** , DASS-21 anxiety scores: 0–9 = normal-mild, ≥ 10 = moderate, severe, and extremely severe TABLE 3: Depression, Anxiety and Stress Scale-21 depression and anxiety scores by avoidant and approach coping style DASS-21 scores Coping style p Not at all Little bit Medium amount A lot n % n % n % n % Avoidant coping style Depression * < 0.0001# ≤ 13 ( n = 152) 95 62.0 48 32.0 9 6.0 0 0.0 ≥ 14 ( n = 60) 5 8.0 42 78.0 11 18.0 1 2.0 Anxiety ** < 0.0001# ≤ 9 ( n = 126) 85 67.0 34 27.0 7 6.0 0 0.0 ≥ 10 ( n = 86) 15 17.0 57 66.3 13 15.0 1 1.0 Depression * 0.1195 ≤ 13 ( n = 152) 39 26.0 36 24.0 54 35.0 23 15.0 ≥ 14 ( n = 60) 8 13.0 19 32.0 27 45.0 6 10.0 Anxiety ** 0.0068 ≤ 9 ( n = 126) 36 29.0 29 23.0 40 32.0 21 17.0 ≥ 10 ( n = 86) 11 13.0 26 30.0 41 48.0 8 9.0 DASS, Depression, Anxiety and Stress Scale. #, Fisher’s exact test was used to determine the p -value because of small expected counts * , DASS-21 depression scores: 0–13 = normal-mild, ≥ 14 = moderate, severe and extremely severe ** , DASS-21 anxiety scores: 0–9 = normal-mild, ≥ 10 = moderate, severe and extremely severe.

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Page 6 of 10 Original Research http://www.sajpsychiatry.org Open Access This study replicated previous findings of a relationship between depression or anxiety and stress 41 In the context of personal protective equipment (PPE) shortages, fear of contracting COVID-19, a high workload, being confronted by moral and difficult ethical decisions, and reliance on effective coping strategies became paramount for limiting mental distress among medical personnel during the pandemic. 42 Practitioners in mental healthcare settings are particularly vulnerable as they are expected to function outside their usual scope of practice. Furthermore, managing highly infectious diseases, often in crowded wards where the implementation of social distancing and other preventative measures are unfeasible, may significantly contribute to stress among mental healthcare practitioners 43 Mental healthcare practitioners in Bloemfontein demonstrated a range of psychological responses to the COVID-19 outbreak. Salari et al. 42 reported high prevalence rates for depression (33.7 % ) and anxiety (31.9 % ) in the general population during the COVID-19 pandemic. Similar prevalence rates were reported among healthcare practitioners, ranging between 25.8 % and 28.3 % for depression and 24.9 % and 36 % for anxiety. 44,45 Respondents in this study reported comparable rates of depression (28.3 % ). However, the prevalence of anxiety exceeded those reported in previous similar studies (40.6 % ). 42,44,45 In this study, female gender, age 26–35 years and fewer years of professional experience were associated with depression and anxiety. These findings confirm previous reports that identified female gender, younger age and less professional experience as independent risk factors for depression and anxiety. 3,46 A lack of experience, fear of expressing challenges, higher error rates, and higher incidences of unhealthy behaviour may contribute towards the vulnerability of younger staff to the adverse mental effects of stress 47 Nurses (77.8 % ) were the largest participating professional group in this study and presented the highest risk for depression and anxiety. Our finding confirms previous reports of nursing staff as the professional category most at risk of mental illness during a pandemic 47,48 Nurses are frontline workers who experience the direct impact when healthcare systems are strained, thus making them more vulnerable to depression, anxiety and stress. 48 Previous research highlighted the association between high core competencies and a lower prevalence of psychological distress among healthcare professionals during COVID-19 49 TABLE 4: Avoidant coping in depression and anxiety Types of avoidant coping DASS-21 depression scores DASS-21 anxiety scores Normal-mild (≤ 13) Moderate-extremely severe (≥ 14) p Normal-mild (≤ 9) Moderate-extremely severe (≥ 10) p N = 152 N = 60 N = 126 N = 86 n % n % n % n % Self-distraction 0.0031# 0.0003# Not at all 48 32.0 5 8.0 45 36.8 9 10.0 Little bit 57 37.0 42 72.0 47 37.0 37 43.0 Medium amount 38 25.0 11 18.0 30 24.0 33 38.0 A lot 9 6.0 1 2.0 4 3.0 7 8.0 Denial < 0.0001# 0.0002# Not at all 115 76.0 23 38.0 97 77.0 41 48.0 Little bit 24 16.0 20 33.0 18 14.0 26 30.0 Medium amount 9 6.0 12 20.0 8 6.0 13 15.0 A lot 4 3.0 5 8.0 3 2.0 6 7.0 Substance use < 0.0001# < 0.0001# Not at all 127 84.0 33 55.0 107 85.0 53 62.0 Little bit 20 13.0 15 25.0 15 12.0 20 23.0 Medium amount 3 2.0 9 15.0 1 1.0 11 13.0 A lot 2 1.32 3 5.0 3 2.0 2 2.0 Behavioural disengagement < 0.0001# < 0.0001# Not at all 123 81.0 26 43.0 104 82.0 45 52.0 Little bit 25 16.0 22 37.0 20 16.0 27 31.0 Medium amount 3 2.0 10 17.0 2 2.0 11 13.0 A lot 1 1.0 2 3.0 0 0 3 3.0 Self-blame < 0.0001# < 0.0001# Not at all 102 67.0 14 23.0 89 71.0 27 31.0 Little bit 39 26.0 19 32.0 28 22.0 30 35.0 Medium amount 10 7.0 20 33.0 8 6.0 22 26.0 A lot 1 1.0 7 12.0 1 1.0 7 8.0 Venting 0.0054# 0.0007# Not at all 70 46.0 13 22.0 63 50.0 20 23.0 Little bit 54 35.0 34 57.0 42 33.0 46 53.0 Medium amount 21 14.0 11 18.0 15 12.0 17 20.0 A lot 7 5.0 2 3.3 6 5.0 3 3.0 DASS-21, Depression, Anxiety and Stress Scale-21. #, Fisher’s exact test was used to determine the p -value because of small expected counts.

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[Find the meaning and references behind the names: Lopes]

Page 7 of 10 Original Research http://www.sajpsychiatry.org Open Access These findings are supported by the second-highest rates of depression and anxiety reported by social workers and clinical psychologists in this study. Working directly with highly infectious patients does not form part of the core competencies of social workers or clinical psychologists. Psychiatrists and medical practitioners presented the lowest risk for depression and anxiety. Stress Evidence suggests a critical role for stress in the structure of negative mood states, including depression and anxiety. 41 Interventions mitigating the negative effects of stress may be particularly effective in reducing depression and anxiety symptoms 41 Coping strategies play a significant role in determining outcomes during exposure to stressful events and are important determinants of psychological well-being, functioning and the development of medical and psychiatric illnesses 41,50 In this study, a small percentage of respondents (10.9 % ) reported experiencing severe to extremely severe stress on the DASS-21. Most respondents (80.3 % ) with low depression scores reported normal stress. Similarly, 86.5 % of respondents with low anxiety scores experienced normal stress. Although associations between stress and depression and stress and anxiety were demonstrated in the study population, the possible moderating role of effective coping strategies on stress is unclear. Avoidant coping Similar to previous studies, avoidant coping styles correlated independently with higher DASS-21 depression and anxiety scores in our study population 27,51,52 In particular, substance use, behavioural disengagement, and self-blame were highly significant for both depression and anxiety. Avoidant coping strategies were never utilised, or to a limited extent, by respondents with low depression (94 % ) and anxiety (94.5 % ). This suggests that avoidant coping may be a risk factor for anxiety, as reported previously 27,51 Bistricky 51 and Lopes et al. 52 reported similar associations between depression, anxiety, behavioural disengagement, denial, self-blame, selfdistraction and substance use during disasters Approach coping An intriguing finding in this study was that significantly more ( p = 0.0068) respondents with high anxiety scores (57.0 % ) TABLE 5: Approach coping with depression and anxiety Brief-COPE approach coping styles DASS-21 depression scores DASS-21 anxiety scores Normal-mild (≤ 13) Moderate-extremely severe (≥ 14) p Normal-mild (≤ 9) Moderate-extremely severe (≥ 10) p N = 152 N = 60 N = 126 N = 86 n % n % n % n % Active coping 0.0553 0.0045 * Not at all 41 27.0 9 15.0 38 30.0 12 14.0 Little bit 50 33.0 28 47.0 39 31.0 39 45.0 Medium amount 42 28.0 20 33.0 32 25.0 30 35.0 A lot 19 12.0 3 5.0 17 13.0 5 6.0 Emotional support Not at all 44 29.0 12 20.0 0.1597 39 31.0 17 20.0 0.1630 Little bit 52 34.0 25 42.0 43 34.0 34 39.0 Medium amount 32 21.0 18 30.0 25 20.0 25 29.0 A lot 24 16.0 5 8.0 19 15.0 10 12.0 Informational support Not at all 46 30.0 14 23.0 0.7748 43 34.0 17 20.0 0.0321 * Little bit 53 35.0 24 40.0 43 34.0 34 39.0 Medium amount 40 26.0 17 28.0 27 21.0 30 35.0 A lot 13 7.0 5 8.0 13 10.0 5 6.0 Positive reframing Not at all 40 26.0 10 17.0 0.0845 37 29.0 13 15.0 0.0677 Little bit 63 41.0 20 33.0 49 39.0 34 39.0 Medium amount 34 22.0 23 38.0 28 22.0 29 34.0 A lot 15 10.0 7 12.0 12 9.0 10 12.0 Planning Not at all 47 31.0 10 17.0 0.0037 * 44 34.9 13 15.0 0.0025 * Little bit 35 23.0 19 32.0 25 19.8 29 34.0 Medium amount 44 29.0 28 47.0 37 29.4 35 41.0 A lot 26 17.0 3 5.0 20 15.9 9 10.0 Acceptance Not at all 40 26.0 6 10.0 0.0065 * 37 29.0 9 10.0 0.0059 * Little bit 42 28.0 28 30.0 29 23.0 31 36.0 Medium amount 44 29.0 30 50.0 40 32.0 34 39.0 A lot 26 17.0 6 10.0 20 16.0 12 14.0 DASS-21, Depression, Anxiety and Stress Scale-21; COPE, Coping Orientation to Problems Experienced * , Statistically significant.

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Page 8 of 10 Original Research http://www.sajpsychiatry.org Open Access regularly used approach coping methods (active coping, p = 0.0045 and planning, p = 0.0025) compared to those with low anxiety scores (48.5 % ) (Table 6). Active coping and planning were the two approach coping factors that reached the highest statistical differences between those with low and high anxiety scores. An intolerance of uncertainty could explain the unexpectedly high rate of approach coping in this subgroup, although it will require further investigation. Hoffman et al. 53 have argued that the level of anxiety determines the coping style, that is, those with low levels of anxiety do not require approach coping, which will support our previous statement. On the other hand, individuals who use approach coping may reduce anxiety through repeated exposure to anxiety-provoking stimuli that eventually result in extinction. Hesitant or inconsistent (intermediate) use of approach coping is, therefore, more likely to result in high levels of anxiety. It is also possible that the relative brevity of exposure during the pandemic could have been insufficient to result in extinction through exposure. Planning and acceptance were significantly associated with depression and anxiety among those with approach coping styles. Both planning and active coping positively correlated with anxiety, while planning and acceptance correlated with depression. These findings contradict previous research that reported planning and acceptance coping with being protective against depression and anxiety 7,26,28 A recent study conducted on the general population by Miola et al 54 during COVID-19 found that planning predicted low depression. It is reasonable to accept that, in a mental healthcare setting, too many complex and unpredictable factors can frustrate planning attempts and may instead increase stress. Savitsky et al 26 reported findings similar to ours, where planning was associated with more psychological distress among nursing students during the COVID-19 pandemic. Planning may form part of excessive worry, rumination, online research, and grieving during the pandemic. It is also possible that respondents could not choose or plan a safe approach but were required to continue managing patients under potentially life-threatening circumstances with uncertain outcomes for themselves and the patients. Exposure to overwhelming illness, trauma, and loss in the face of limited resources could also result in coping through acceptance as part of the grief process Humour and religion Low levels of anxiety and depression correlated significantly with never using religion or humour as a means of coping. Evidence suggests that the beneficial effects of humour as a coping style depend on the perceived availability of social support. Using humour in the context of a perceived lack of social support or self-denigrating humour (maladaptive use) has been linked to depression and anxiety 55 Healthcare practitioners reported a significant lack of and need for social support during the pandemic, which may explain the possible maladaptive effects of humour in our study population 56 Respondents with low DASS-21 anxiety scores used religion significantly more (regularly to very regularly) than those with high scores. Those with high anxiety scores used religion ‘a little bit’ (38.4 % ), ‘medium’ (20.9 % ) or ‘a lot’ (29.1 % ) Further analysis The study found that heightened anxiety was linked to an increased likelihood of transitioning to higher categories on the avoidant coping scale. Individuals with humour and religious attributes were less likely to transition to higher categories on the avoidant scale. Additionally, depression was associated with a reduced likelihood of moving to higher categories on both avoidant and approach coping scales. These findings highlight the complex interplay of emotional factors on coping strategies, emphasising the need for targeted interventions that address anxiety, depression, and psychosocial support among healthcare practitioners. Such interventions could enhance wellbeing, resilience, and coping strategies, ultimately contributing to the overall mental health of healthcare professionals on the frontlines of the pandemic response TABLE 7: Depression, Anxiety and Stress Scale-21 scores, religion and humour DASS-21 scores No humour Humour p No religion ( n = 29) Religion ( n = 12) No religion ( n = 68) Religion ( n = 103) Median IQR Range Median IQR Range Median IQR Range Median IQR Range Depression * 0 0–2.0 0–42.0 15.0 8.0–20.0 2.0–40.0 8.0 2.0–14.0 0–42.0 8.0 4.0–16.0 0–40.0 < 0.0001# Anxiety ** 0 0–2.0 0–38.0 12.0 5.0–17.0 0–40.0 6.0 2.0–14.0 0–38.0 8.0 4.0–16.0 0–34.0 < 0.0001# IQR, interquartile range; DASS-21, Depression, Anxiety and Stress Scale-21 * , DASS-21 depression scores: 0–13 = normal-mild, ≥ 14 = moderate, severe and extremely severe; ** , DASS-21 anxiety scores: 0–9 = normal-mild, ≥ 10 = moderate, severe and extremely severe #, Statistically significant TABLE 6: Brief-Coping Orientation to Problems Experienced factorial structure: clinically significant associations for depression and anxiety Coping mechanisms Depression (High vs. low) p -values Anxiety (High vs. low) p -values Avoidant coping < 0.0001 * < 0.0001 * Self-distraction 0.0031 * 0.0003 * Denial < 0.0001 * 0.0002 * Substance use < 0.0001 * < 0.0001 * Behavioural disengagement < 0.0001 * < 0.0001 * Self-blame < 0.0001 * < 0.0001 * Venting 0.0007 * 0.0054 * Approach coping 0.1195 0.0068 * Active coping 0.1195 0.0045 * Emotional support 0.1597 0.1630 Informational support 0.7748 0.0321 * Positive reframing 0.0845 0.0677 Planning 0.0037 * 0.0025 * Acceptance 0.0065 * 0.0059 * COPE, Coping Orientation to Problems Experienced * , Statistically significant.

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[Find the meaning and references behind the names: Diaz, Aly, Byrne, Xie, Sarfraz, Wang, Thomas, Long, Lawrence, Lai, Johnson, Grant, Med, Meng, Jones, Lim, Lin, Jackson]

Page 9 of 10 Original Research http://www.sajpsychiatry.org Open Access The cross-sectional study design may have limitations in predicting the long-term relationship between variables. Our research does not address the question of directionality or cause and effect. Do anxious or depressed mental healthcare practitioners engage in coping styles because they are anxious or depressed, or do specific coping mechanisms increase an individual’s risk of mental difficulties? Although it may be possible that the low response rate could have affected study results, potential respondents who were already emotionally overburdened may have chosen not to respond. In addition, the challenges imposed on mental healthcare practitioners during the pandemic and concerns about confidentiality and anonymity could have influenced decisions about participation. The sample was drawn from a limited geographic location in South Africa and the results may not be generalisable to other centres Conclusion Analysing coping strategies among mental healthcare practitioners during the COVID-19 pandemic revealed significant associations between psychological states and coping mechanisms. Our study confirms the significant psychological effects of COVID-19 on mental healthcare practitioners, especially nursing staff. Women and younger staff are at risk for depression and anxiety. Mental healthcare practitioners must be able to identify avoidant coping strategies that may increase the risk for depression and anxiety. Previous research suggests a protective role for approaching coping methods, but that finding was not replicated in this study Acknowledgements The authors wish to acknowledge Ms. Theanette Mulder and Dr. Daleen Struwig, medical writers or editors of the University of the Free State, Faculty of Health Sciences, for their technical and editorial preparation of the article Competing interests The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article Authors’ contributions Y.S. and E.d.P. formulated the research question, study design and methodology. Y.S. was responsible for data collection, project administration, presentation of results and writing the article’s first draft with assistance from E.d.P. and P.J.P. P.J.P. co-supervised the project, assisted with data interpretation, initiated additional statistical analyses, and authored subsequent draft versions. M.N. and A.B. performed the initial and additional statistical analyses and assisted with interpreting the results. All the authors approved the final article Funding information This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors Data availability Data are available from the corresponding author upon reasonable request Disclaimer The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings, and content References 1. Mbunge E. Effects of COVID-19 in South African health system and society: An explanatory study. Diabetes Metab Syndr. 2020;14(6):1809–1814. https://doi. org/10.1016/j.dsx.2020.09.016 2. Robertson LJ, Maposa I, Somaroo H, Johnson O. 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