Of fear, burnout, and stress: Comparison of psychological distress levels among frontline medicine residents during different COVID-19 pandemic waves in Pakistan


  • Taymmia Ejaz, MBBS
  • Syed Ahsan Ali, MBBS, FCPS
  • Sheema Saadia, MBBS
  • Saad Bin Zafar Mahmood, MBBS
  • Madiha Iqbal, MBBS
  • Aisha Fareed Siddiqui, MBBS




COVID-19, mental health, healthcare workers, psychological impact


Background: While studies have evaluated the impact of coronavirus disease 2019 (COVID-19) on the mental health of healthcare workers (HCW), to our knowledge, there are no studies in Pakistan, which have compared psychological distress levels during the first and second waves of the pandemic. This study was done to assess anxiety levels of Internal Medicine residents and identify risk factors for psychological distress.

Methodology: Cross-sectional study was conducted in the Aga Khan University Hospital, Karachi. A questionnaire comprising of demographic data and risk assessment tools, a seven-item Generalized Anxiety Disorder scale (GAD-7), and a nine-item Patient Health Questionnaire (PHQ) was used for data collection from Internal Medicine residents using nonprobability convenience sampling technique in May–June 2020 and April 2021.

Results: A total of 88 responses were recorded. Response rate was 75.7 percent (56/74) and 43.2 percent (32/74) during the first and second waves, respectively. Mean age was 27.9 ± 3.2 years and mean clinical career in years was 3.2 ± 2.1. Majority, 51.8 percent (29/56) and 68.8 percent (22/32), were not satisfied with community prevention measures and 75 percent (42/56) and 65.6 percent (21/32) considered interventions necessary in case of psychological distress during pandemic, during the first and second waves, respectively. A higher number of HCW reported their family not supporting their frontline work during the first wave (16.1 percent vs 3.1 percent; p value 0.023). There was a statistically significant difference in psychological distress levels as median GAD-7 scores were 5(IQR 2–8) vs 9.5(IQR 3.25–13) (p value 0.009) and median PHQ-9 scores were 4(IQR 2–11) vs. 7(IQR 4–s17) (p value 0.056) during the first and second waves, respectively.

Conclusion: There was a significant difference in anxiety levels during the first and second waves of COVID-19, and family support for frontline work was higher during the second wave. Further studies are required to assess these differences.

Author Biographies

Taymmia Ejaz, MBBS

Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan

Syed Ahsan Ali, MBBS, FCPS

Assistant Professor, Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan

Sheema Saadia, MBBS

Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan

Saad Bin Zafar Mahmood, MBBS

Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan

Madiha Iqbal, MBBS

Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan

Aisha Fareed Siddiqui, MBBS

Section of Internal Medicine, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan


Lima CKT, Carvalho PM de M, Lima I de AAS, et al.: The emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease). Psychiatry Res. 2020; 287: 112915. DOI:10.1016/j.psychres.2020.112915.

Qiu J, Shen B, Zhao M, et al.: A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatry. 2020; 33(2): e100213. DOI:10.1136/gpsych-2020-100213.

Adams JG, Walls RM: Supporting the health care workforce during the COVID-19 global epidemic. JAMA. 2020; 323(15): 1439-1440. DOI:10.1001/jama.2020.3972.

Chen Q, Liang M, Li Y, et al.: Mental health care for medical staff in China during the COVID-19 outbreak. Lancet. Psychiatry 2020; 7(4): e15-e16. DOI:10.1016/S2215-0366(20)30078-X.

Kang L, Li Y, Hu S, et al.: The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiat. 2020; 7(3): e14. DOI:10.1016/S2215-0366(20)30047-X.

Naushad VA, Bierens JJLM, Nishan KP, et al.: A systematic review of the impact of disaster on the mental health of medical responders. Prehosp Disaster Med. 2019; 34(6): 632-643. DOI:10.1017/S1049023X19004874.

Carvalho PM de M, Moreira MM, de Oliveira MNA, et al.: The psychiatric impact of the novel coronavirus outbreak. Psychiatry Res. 2020; 286: 112902. DOI:10.1016/j.psychres.2020.112902.

Xiang YT, Yang Y, Li W, et al.: Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiat. 2020; 7(3): 228-229. DOI:10.1016/S2215-0366(20)30046-8.

Saragih ID, Tonapa SI, Saragih IS, et al.: Global prevalence of mental health problems among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Int J Nurs Stud. 2021; 121: 104002. DOI:10.1016/j.ijnurstu.2021.104002.

Chua SE, Cheung V, Cheung C, et al.: Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers. Can J Psychiatry. 2004; 49(6): 391-393. DOI:10.1177/070674370404900609.

Liu X, Kakade M, Fuller CJ, et al.: Depression after exposure to stressful events: Lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry. 2012; 53(1): 15-23. DOI:10.1016/j.comppsych.2011.02.003.

Preti E, Di Mattei V, Perego G, et al.: The psychological impact of epidemic and pandemic outbreaks on healthcare workers: Rapid review of the evidence. Curr Psychiatry Rep. 2020; 22(8): 43. DOI:10.1007/s11920-020-01166-z.

Maunder RG, Lancee WJ, Balderson KE, et al: Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis. 2006; 12(12): 1924-1932. DOI:10.3201/eid1212.060584.

Murphy J, Spikol E, McBride O, et al.: The psychological wellbeing of frontline workers in the United Kingdom during the COVID-19 pandemic: First and second wave findings from the COVID-19 Psychological Research Consortium (C19PRC) Study. 2020; 44: 1-27. DOI:10.31234/osf.io/dcynw.

Sasaki N, Kuroda R, Tsuno K, et al.: The deterioration of mental health among healthcare workers during the COVID-19 outbreak: A population-based cohort study of workers in Japan. Scand J Work Environ Heal. 2020; 46(6): 639-644. DOI:10.5271/sjweh.3922.

Mosolova E, Sosin D, Mosolov S: Stress, anxiety, depression and burnout in frontline healthcare workers during two peaks of COVID-19 pandemic in Russia. Psychiatry Res. 2021; 306: 114226. DOI:10.1016/j.psychres.2021.114226.

López Steinmetz LC, Herrera CR, Fong SB, et al.: A longitudinal study on the changes in mental health of healthcare workers during the COVID-19 pandemic. Psychiatry (New York). 2022 Spring; 85(1): 56-71. DOI:10.1080/00332747.2021.1940469.

Bhanja A, Kerrissey MJ, Peabody C, et al.: 9 managing burnout in a prolonged crisis: A 2-wave cross-sectional analysis of emergency department personnel over 6 months of the COVID-19 pandemic. Ann Emerg Med. 2021; 78(2): S5-S6. DOI:10.1016/j.annemergmed.2021.07.010.

Gündoğmuş İ, Ünsal C, Bolu A, et al.: The comparison of anxiety, depression and stress symptoms levels of healthcare workers between the first and second COVID-19 peaks. Psychiatry Res. 2021; 301: 113976. DOI:10.1016/j.psychres.2021.113976.

Hines SE, Chin KH, Glick DR, et al.: Trends in moral injury, distress, and resilience factors among healthcare workers at the beginning of the COVID-19 pandemic. Int J Environ Res Public Health. 2021; 18(2): 488. DOI:10.3390/ijerph18020488.

Chew QH, Chia FL-A, Ng WK, et al.: Perceived stress, stigma, traumatic stress levels and coping responses amongst residents in training across multiple specialties during COVID-19 pandemic—A longitudinal study. Int J Environ Res Public Health. 2020; 17(18): 6572. DOI:10.3390/ijerph17186572.

Dreher A, Flake F, Pietrowsky R, et al.: Attitudes and stressors related to the SARS-CoV-2 pandemic among emergency medical services workers in Germany: A cross-sectional study. BMC Health Serv Res. 2021; 21(1): 851. DOI:10.1186/s12913-021-06779-5.

Baumann BM, Cooper RJ, Medak AJ, et al.: Emergency physician stressors, concerns, and behavioral changes during COVID-19: A longitudinal study. Acad Emerg Med. 2021; 28(3): 314-324. DOI:10.1111/acem.14219.

Van Steenkiste E, Schoofs J, Gilis S, et al.: Mental health impact of COVID-19 in frontline healthcare workers in a Belgian Tertiary care hospital: A prospective longitudinal study. Acta Clin Belgica Int J Clin Lab Med. 2021; 77(3): 533-540. DOI:10.1080/17843286. 2021.1903660.

Magnavita N, Soave PM, Antonelli M: Prolonged stress causes depression in frontline workers facing the COVID-19 pandemic—A repeated cross-sectional study in a COVID-19 hub-hospital in Central Italy. Int J Environ Res Public Health. 2021; 18(14): 7316. DOI:10.3390/ijerph18147316.

Vitale E: Anxiety, depression and insomnia conditions in Italian nurses during the first and the second waves of the COVID-19 pandemic. J Evidence-Based Psychother. 2021; 21(1): 69-82. DOI:10.24193/jebp.2021.1.5.

Quintana-Domeque C, Lee I, Zhang A, et al.: Anxiety and depression among medical doctors in Catalonia, Italy, and the UK during the COVID-19 pandemic. PLoS One. 2021; 16(11): e0259213. DOI:10.1371/journal.pone.0259213.

Spitzer RL, Kroenke K, Williams JBW, et al.: A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006; 166(10): 1092-1097. DOI:10.1001/archinte.166.10.1092.

Kroenke K, Spitzer RL, Williams JBW: The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001; 16(9): 606-613. DOI:10.1046/j.1525-1497.2001.016009606.x.

McFadden P, Neill RD, Moriarty J, et al.: A cross-sectional examination of the mental wellbeing, coping and quality of working life in health and social care workers in the UK at two time points of the COVID-19 pandemic. Epidemiologia. 2021; 2(3): 227-242. DOI:10.3390/epidemiologia2030017.

Vagni M, Maiorano T, Giostra V, et al.: Protective factors against emergency stress and burnout in healthcare and emergency workers during second wave of COVID-19. Soc Sci. 2021; 10(5):178. DOI:10.3390/socsci10050178.

Waage S, Pallesen S, Vedaa Ø, et al.: Sleep patterns among Norwegian nurses between the first and second wave of the COVID-19 pandemic. BMC Nurs. 2021; 20(1): 105. DOI:10.1186/s12912-021-00628-w.

Hasan SR, Hamid Z, Jawaid MT, et al.: Anxiety among doctors during COVID-19 pandemic in secondary and tertiary care hospitals. 2020; 36(6): 1360-1365. DOI:10.12669/pjms.36.6.3113.

Arshad AR, Islam F: COVID-19 and anxiety amongst doctors: A Pakistani perspective. J Coll Physicians Surg Pakistan. 2020; 30(10): 106-109. DOI:10.29271/jcpsp.2020.Supp2.106.

Imran N, Masood HMU, Ayub M, et al.: Psychological impact of COVID-19 pandemic on postgraduate trainees: A cross-sectional survey. Postgrad Med J. 2020; 97(1152): 632-637. DOI:10.1136/postgradmedj-2020-138364.

Amin F, Sharif S, Saeed R, et al.: COVID-19 pandemic-Knowledge, perception, anxiety and depression among frontline doctors of Pakistan. BMC Psychiatry. 2020; 20(1): 459. DOI:10.1186/s12888-020-02864-x.

Sandesh R, Shahid W, Dev K, et al.: Impact of COVID-19 on the mental health of healthcare professionals in Pakistan. Cureus. 2020; 12(7): 3-7. DOI:10.7759/cureus.8974.

Arshad MS, Hussain I, Nafees M, et al.: Assessing the impact of COVID-19 on the mental health of healthcare workers in three metropolitan cities of Pakistan. Psychol Res Behav Manag. 2020; 13: 1047-1055. DOI:10.2147/PRBM.S282069.

Asghar MS, Yasmin F, Alvi H, et al.: Assessing the mental impact and burnout among physicians during the COVID-19 pandemic : A developing country single-center experience. Am J Trop Med Hyg. 2021; 104(6): 2185-2189. DOI:10.4269/ajtmh.21-0141.

Shahbaz S, Ashraf MZ, Zakar R, et al.: Psychosocial, emotional and professional challenges faced by female healthcare professionals during the COVID-19 outbreak in Lahore, Pakistan: A qualitative study. BMC Womens Health. 2021; 21(1): 197. DOI:10.1186/s12905-021-01344-y.

Hussain M, Amjad M Bin, Ahsan J, et al.: Implementation of National Institute of Health Guidelines and other factors contributing to work-related burnout in COVID isolation ward and ICU physicians. J Ayub Med Coll Abbottabad. 2021; 33: 283-288.

Shahil Feroz A, Pradhan NA, Hussain Ahmed Z, et al.: Perceptions and experiences of healthcare providers during COVID-19 pandemic in Karachi, Pakistan: An exploratory qualitative study. BMJ Open. 2021; 11(8): e048984. DOI:10.1136/bmjopen-2021-048984.

Raza A, Matloob S, Abdul Rahim NF, et al.: Factors impeding health-care professionals to effectively treat coronavirus disease 2019 patients in Pakistan: A qualitative investigation.

Front Psychol. 2020; 11: 572450. DOI:10.3389/fpsyg.2020.572450.

Noreen K, Umar M, Sabir SA, et al.: Outbreak of coronavirus disease 2019 (COVID‑19) in Pakistan: Psychological impact and coping strategies of health care professionals. Pakistan J Med Sci. 2020; 36(7): 1478-1483. DOI:10.12669/pjms.36.7.2988.

Bhatti OA, Rauf H, Aziz N, et al.: Violence against healthcare workers during the COVID-19 pandemic: A review of incidents from a lower-middle-income country. Ann Glob Heal. 2021; 87(1): 41. DOI:10.5334/AOGH.3203.

Rashid A, Faisal K: Pandemic anxiety and its correlates among young doctors working frontline in Pakistan. Glob Ment Heal. 2020; 7: e27. DOI:10.1017/gmh.2020.22.

Haq MIU, Shafiq F, Sheikh H: Potential barriers amongst health care professionals (HCPs) of Pakistan in managing COVID-19 patients. Pakistan J Med Sci. 2020; 36(COVID19-S4): S17-S21. DOI:10.12669/pjms.36.COVID19-S4.2753.

Saadatjoo S, Miri M, Hassanipour S, et al.: Knowledge, attitudes, and practices of the general population about coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis with policy recommendations. Public Health. 2021;194:185-195. DOI:10.1016/j.puhe.2021.03.005.



How to Cite

Ejaz, T., S. A. Ali, S. Saadia, S. B. Z. Mahmood, M. Iqbal, and A. F. Siddiqui. “Of Fear, Burnout, and Stress: Comparison of Psychological Distress Levels Among Frontline Medicine Residents During Different COVID-19 Pandemic Waves in Pakistan”. Journal of Emergency Management, vol. 21, no. 3, June 2023, pp. 253-64, doi:10.5055/jem.0736.