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Cited by 600COVID-19 and Mental HealthHealthcare professionals’ stress and burnoutOccupational Health and Burnout

Impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis

Open access
Serrano-Ripoll, Maria J., Meneses-Echavez, Jose F., Ricci-Cabello, Ignacio, Fraile-Navarro, David, Fiol-deRoque, Maria A., Pastor-Moreno, Guadalupe, Castro, Adoración, Ruiz-Pérez, Isabel +2 more·2020·Journal of Affective Disorders
DOI 10.1016/j.jad.2020.08.034PMC PMC7443314

Published version of a preprint

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Abstract

Background This study aimed at examining the impact of providing healthcare during health emergencies caused by viral epidemic outbreaks on healthcare workers' (HCWs) mental health; to identify factors associated with worse impact, and; to assess the available evidence base regarding interventions to reduce such impact.Method Rapid systematic review. We searched MEDLINE, Embase, and PsycINFO (inception to August 2020). We pooled data using random-effects meta-analyses to estimate the prevalence of specific mental health problems, and used GRADE to ascertain the certainty of evidence.Results We included 117 studies. The pooled prevalence was higher for acute stress disorder (40% (95%CI 39 to 41%)), followed by anxiety (30%, (30 to 31%)), burnout (28% (26 to 31%)), depression (24% (24 to 25%)), and post-traumatic stress disorder (13% (13 to 14%)). We identified factors associated with the likelihood of developing those problems, including sociodemographic (younger age and female gender), social (lack of social support, stigmatization), and occupational (working in a high-risk environment, specific occupational roles, and lower levels of specialised training and job experience) factors. Four studies reported interventions for frontline HCW: two educational interventions increased confidence in pandemic self-efficacy and in interpersonal problems solving (very low certainty), whereas one multifaceted intervention improved anxiety, depression, and sleep quality (very low certainty).Limitations We only searched three databases, and the initial screening was undertaken by a single reviewer.Conclusion Given the very limited evidence regarding the impact of interventions to tackle mental health problems in HCWs, the risk factors identified represent important targets for future interventions.

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Crossref · 10.1016/j.jad.2020.08.034

Cites

190 of 190 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 87 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    Resident pulmonologists were at higher risk of burnout during viral outbreaks.

    “whereas one study (Austria-Corrales et al., 2011) reported that resident pulmonologists were at higher risk of burnout.”
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    • cites Austria-Corrales et al., 2011

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  • Findingcitation

    Higher perception of threat and risk was associated with depression among healthcare workers during viral outbreaks.

    “higher perception of threat and risk was also associated with a higher prevalence of a number of different mental health problems, including depression (Liu et al., 2012)”
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    • cites Liu et al., 2012 source

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  • Findingown data

    The prevalence of depression was higher after outbreaks (46%, 95% CI 43-48%) than during outbreaks (24%, 95% CI 24-24%).

    “Subgroup analyses showed higher prevalence of depression (46%, 95%CI 43 to 48%) and of anxiety (30%, 95% 29 to 30%) after the outbreaks than during the outbreaks (24%, 95%CI 24 to 24%, and 30%, 95%CI 29 to 30%, respectively).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The classification of studies as during versus after the outbreak, based on each study's own definition, is valid for subgroup comparisons.
  • Findingown data

    The pooled prevalence of burnout among healthcare workers during or after viral epidemic outbreaks was 28% (95% CI 26-31%; 3 studies, 1,168 participants).

    “burnout (28%, 95%CI 26 to 31%, 3 studies, 1,168 participants))”
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    • Rests on an assumption: The mental health conditions measured by different instruments across the included studies are sufficiently comparable to be combined in meta-analyses.
  • Findingown data

    The pooled prevalence of post-traumatic stress disorder among healthcare workers during or after viral epidemic outbreaks was 13% (95% CI 13-14%, I2 0%; 16 studies, 24,540 participants).

    “post-traumatic stress disorder (13%, 95%CI 13 to 14%, I2 0%; 16 studies, 24,540 participants))”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The mental health conditions measured by different instruments across the included studies are sufficiently comparable to be combined in meta-analyses.
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    Findingcitation

    Nurses were more likely to develop burnout than other healthcare workers during viral outbreaks.

    “and burnout (Tolomiczenko et al., 2005)”
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    Findingcitation

    In a cross-sectional evaluation of an educational intervention for healthcare workers during the SARS epidemic, 35% felt prepared to deal confidently with the pandemic before the session and 76% felt better able to cope after the session.

    “While most participants did not feel prepared to deal confidently with the pandemic before the session (35%), there was a higher proportion of participants who felt better able to cope after the session (76%).”
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    Findingcitation

    Feelings of social rejection or isolation and higher impact of the outbreak on daily life increased the likelihood of anxiety among healthcare workers during viral outbreaks.

    “and anxiety (Que et al., 2020).”
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    • cites Que et al., 2020

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    Findingcitation

    Feelings of social rejection or isolation and higher impact of the outbreak on daily life increased the likelihood of stress among healthcare workers during viral outbreaks.

    “stress (Zhu et al., 2020)”
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    Findingcitation

    Feelings of social rejection or isolation and higher impact of the outbreak on daily life increased the likelihood of PTSD among healthcare workers during viral outbreaks.

    “Feelings of social rejection or isolation and higher impact of the outbreak on daily life (Styra et al., 2008) increased the likelihood of developing PTSD”
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    Findingcitation

    Feelings of social rejection or isolation and higher impact of the outbreak on daily life increased the likelihood of depression among healthcare workers during viral outbreaks.

    “depression (Chatterjee et al., 2020)”
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    Findingcitation

    A computer-assisted resilience training for healthcare workers improved confidence in support and training, pandemic self-efficacy, and interpersonal problems (p<0.05).

    “The intervention improved confidence in support and training, pandemic self-efficacy and interpersonal problems (p<0.05).”
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    Findingcitation

    Female gender was associated with higher levels of burnout among healthcare workers during viral outbreaks.

    “and burnout (Tolomiczenko et al., 2005)”
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    Findingcitation

    Stigmatisation, social rejection, and lower levels of social support were risk factors for stress among healthcare workers during viral outbreaks.

    “In addition, stigmatisation (Koh et al., 2005), social rejection (Park et al., 2018), and lower levels of social support were identified as risk factors for stress (Xiao et al., 2020).”
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    • cites Xiao et al., 2020

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    Findingown data

    Four studies described interventions to reduce the mental health impact of viral epidemic outbreaks in healthcare workers, and none used an experimental design.

    “Four studies (Aiello et al., 2011; Maunder et al., 2010; Chen et al., 2006; Wu and Wei, 2020) described four different interventions to reduce the mental health impact of viral epidemic outbreaks in HCWs (Online Appendix 6). None of them used an experimental design.”
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    Findingcitation

    In a cross-sectional study of exercise interventions for frontline medical staff during COVID-19, the intervention group had higher anxiety (45.89±1.12 vs 41.02±1.15; p=0.056), depression (50.13±1.81 vs 36.11±2.06; p=0.04), and PTSD (50.13±1.813 vs 29.89±1.97; p=0.03) than the control group.

    “In comparison with the control group, participants in the intervention group experienced higher levels of anxiety (45.89±1.12 vs 41.02±1.15; p=0.056), depression (50.13±1.81 vs 36.11±2.06; p=0.04), and PTSD (50.13±1.813 vs 29.89 ±1.97; p=0.03).”
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    • cites Wu and Wei, 2020

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    Findingown data

    Main risks of bias in the 106 cross-sectional studies were low response rate (high risk in 10%) and selection bias (10%).

    “In general, main risks of bias in the 106 cross-sectional studies were low response rate (high risk of bias in 10% of the studies) and selection bias (10%).”
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    Findingown data

    91% of studies used a cross-sectional design.

    “The majority followed a cross-sectional design (91%).”
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    Findingown data

    52% of studies examined COVID-19 and 35% examined SARS.

    “Around half of the studies (52%) examined the impact of COVID-19, followed by Severe Acute Respiratory Syndrome (SARS epidemic) (35%).”
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    Findingown data

    84% of studies used validated instruments to evaluate mental health.

    “84% did use validated instruments to evaluate mental health.”
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    Findingown data

    Most studies (65%) were conducted in Asian countries excluding the Middle East.

    “Most of the studies (65%) were conducted in Asian countries (excluding Middle East countries), including China (43%), Taiwan (8%), and Singapore (7%), among others.”
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    Findingown data

    74% of studies were conducted during viral epidemic outbreaks.

    “Most studies were conducted during the viral epidemic outbreaks (74%).”
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    Findingown data

    Anxiety (62%) and depression (54%) were the most frequently examined mental health conditions, followed by acute stress disorder (33%) and PTSD (31%).

    “Anxiety (62%) and depression (54%) were the mental health conditions most frequently examined, followed by acute stress disorder (33%) and PTSD (31%).”
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    Study design and conductown data

    Subgroup analyses by age could not be conducted because data were not reported in a homogeneous format.

    “Similarly, we could not conduct subgroups analyses to explore differences according to HCWs' age due to the lack of available data reported in a homogeneous format (e.g. age quartiles).”
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    Interpretationown data

    Healthcare workers commonly present high levels of anxiety, depression, and PTSD both during and after viral epidemic outbreaks.

    “Results showed that HCWs commonly present high levels of anxiety, depression, and PTSD, both during and after the outbreaks.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Risk of bias of observational studies was assessed with Evidence Partners tools, and ROBINS I was applied to uncontrolled trials.

    “We assessed the risk of bias of observational studies (i.e., cross-sectional, case-control, and cohort studies) by using the set of tools developed by Evidence Partners (McMaster University) (Partners, 2020); whereas ROBINS I (Sterne et al., 2016) was applied to uncontrolled trials.”
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    Study design and conductnone given

    Two reviewers independently and blinded assessed full-text eligibility.

    “Two reviewers (of those aforementioned) independently and blinded against the others’ judgements assessed full-text eligibility.”
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    Interpretationcitation

    Working in a high-risk environment is a non-modifiable risk factor that increases the risk of clinically significant depression, anxiety, PTSD, and burnout among healthcare workers during viral outbreaks.

    “Some of the risk factors associated with mental health problems while providing frontline care during viral epidemic outbreaks cannot be modified. In this way, working in a high risk environment increases the risk of developing clinically significant symptoms, namely depression”
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    Study design and conductcitation

    The review followed Cochrane's recommendations for Rapid Reviews in response to COVID-19.

    “We conducted a rapid systematic review following WHO guidelines (Tricco et al., 2017) and Cochrane's recommendations for Rapid Reviews in response to COVID-19 (Cochrane, 2020).”
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    Study design and conductcitation

    The review followed WHO guidelines for rapid systematic reviews.

    “We conducted a rapid systematic review following WHO guidelines (Tricco et al., 2017) and Cochrane's recommendations for Rapid Reviews in response to COVID-19 (Cochrane, 2020).”
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    Interpretationcitation

    Specific healthcare worker cadres are more likely to report mental health problems, namely PTSD and burnout.

    “Likewise, it seems like specific cadres are more likely to report mental health problems, namely PTSD (Tang et al., 2017), and burnout (Austria-Corrales et al., 2011; Tolomiczenko et al., 2005).”
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    Study design and conductnone given

    One reviewer extracted data and assessed risk of bias, and a second reviewer cross-checked for accuracy and completeness.

    “For all studies one reviewer (of MJSR, MAFR, AC, DF, JM, GP, RZC) extracted all the data and assessed the risk of bias, while a second reviewer cross-checked the information for accuracy and completeness.”
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    Interpretationown data

    There is limited evidence on the impact of interventions to reduce mental health problems in healthcare workers during viral outbreaks, and its overall certainty is very low, mainly due to study design and serious risk of bias.

    “In contrast with the high number of studies examining impact on mental health, there is limited evidence regarding the impact of interventions to reduce mental health problems in this particularly vulnerable population, and overall its certainty is very low, mainly due to study design and serious risk of bias.”
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    Study design and conductcitation

    The review followed PRISMA guidelines for planning, conducting, and reporting.

    “We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for planning, conducting and reporting this study (Moher et al., 2009).”
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    Interpretationcitation

    Lack of specialized training and higher perception of threat and risk are modifiable factors that can be addressed in advance to mitigate mental health risks among healthcare workers during viral outbreaks.

    “However, this review also identified specific modifiable factors that can be addressed in advance and mitigate the risk brought by the aforementioned factors. Lack of specialized training was associated with anxiety, PTSD (Tang et al., 2017), and burnout (Maunder et al., 2004), and higher perception of threat and risk was associated with depression (Liu et al., 2012), anxiety (Alsubaie et al., 201”
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    Study design and conductcitation

    Publication bias was examined with funnel plots and Begg and Egger tests.

    “Publication bias was examined with funnel plots and presence of asymmetry tested with Begg (Begg and Mazumdar, 1994) and Egger tests (Egger et al., 1997).”
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    Study design and conductreasoning

    The review applied GRADE to assess the certainty of evidence.

    “we used the GRADE approach to evaluate the certainty of the evidence, in order to facilitate evidence-informed decision making processes.”
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    Study design and conductnone given

    The review did not examine grey literature.

    “Despite searching three major databases and manually searching references of previously published systematic reviews, we did not examine grey literature.”
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    Premisecitation

    Managers are essential to mitigate stigmatization, especially among healthcare workers who have to be quarantined.

    “and stigmatization (Koh et al., 2005), especially among those HCWs who have to be quarantined.”
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    Interpretationown data

    During pandemics, healthcare workers experience a particularly heavy mental health burden, both while the outbreak is ongoing and afterward.

    “As observed in our review, the mental health burden for HCWs during pandemics is especially high both during and after the outbreak.”
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    A single reviewer performed the initial screening.

    “Moreover, the initial screening was undertaken by a single reviewer.”
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    Interpretationreasoning

    Online mobile-based technologies can also be used for informal contacts between quarantined healthcare workers.

    “and can also be used for informal contacts between HCWs who are quarantined.”
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    Study design and conductcitation

    Heterogeneity was quantified by the I2 statistic, with I2>50% deemed substantial.

    “Heterogeneity was quantified by the I 2 statistic, where I 2>50% was deemed as substantial heterogeneity (Deeks et al., 2019).”
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    Premisecitation

    Online mobile-based technologies may help foster connectedness and reduce isolation and stigmatization.

    “The proliferation of online mobile-based technologies could play an essential role in promoting connectedness and decrease the feelings of isolation and stigmatization (Gonçalves‐Bradley et al., 2018)”
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    Study design and conductcitation

    The GRADE approach was used to assess the quality of evidence for outcomes.

    “We used the GRADE approach (Schünemann et al., 2019) to assess the quality of evidence related to the outcomes included in this rapid review.”
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  • The paper relies on this without support.

    The mental health conditions measured by different instruments across the included studies are sufficiently comparable to be combined in meta-analyses.

    “We used the STATA command “metaprop” (Nyaga et al., 2014) to pool estimates of proportions with corresponding 95% confidence intervals.”
    “84% did use validated instruments to evaluate mental health.”

  • The paper relies on this without support.

    The classification of studies as during versus after the outbreak, based on each study's own definition, is valid for subgroup comparisons.

    “timing of data collection (i.e., before, during, or after the outbreak – based on the studies´ own definition)”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • In Spain, a high percentage of healthcare professionals experienced symptoms of anxiety, stress, depression, and sleep disorders; the prevalence of anxiety, depression, and stress was higher than that reported in previous studies on COVID-19.

    “In Spain, data revealed a high percentage of healthcare professionals experiencing symptoms of anxiety, stress, depression, and sleep disorders. The prevalence of anxiety, depression, and stress was higher than that reported in previous studies on COVID-19 [19,22].”

    From Mental Health in Healthcare Workers Post-COVID-19: A Latin American Review and Insights into Personalized Management Strategies (2024) · cites this paper as [22]

    Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • At the primary care level, morbidity and mortality have a significant impact; illnesses, absenteeism, shift changes, and excessive workloads directly affect the emotional state and mental health of professionals, with healthcare workers being the most affected.

    “At the primary care level, morbidity and mortality have a significant impact. Illnesses, absenteeism, shift changes, and excessive workloads directly affect the emotional state and mental health of professionals, with healthcare workers being the most affected [22].”

    From Mental Health in Healthcare Workers Post-COVID-19: A Latin American Review and Insights into Personalized Management Strategies (2024) · cites this paper as [22]

    Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • The effects of a stressor or trauma vary according to its intensity, duration, characteristics, and psychosocial context, and are influenced by gender and psychological characteristics of the individual or group affected.

    “From the perspective of grief and trauma theory, it is crucial to recognize that the effects of a stressor or trauma vary not only according to its intensity, duration, and characteristics but also according to the psychosocial context in which it occurs. Moreover, these effects are influenced by gender and psychological characteristics of the individual or group affected by trauma or stress.”

    From Mental Health in Healthcare Workers Post-COVID-19: A Latin American Review and Insights into Personalized Management Strategies (2024) · cites this paper as [22]

    The Results section on risk factors (page unavailable) links healthcare workers’ mental-health outcomes during viral outbreaks to perceived threat, gender, and social support or isolation. It does not establish that effects vary with a stressor’s duration or its characteristics generally, and its findings are limited to healthcare workers rather than any individual or group affected by trauma. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • HCWs are at particular risk of adverse psychological outcomes, including stress, anxiety, depression, distress, insomnia, emotional exhaustion, burnout, and post-traumatic stress disorder, during the COVID-19 pandemic.

    “Consistently with the results of many studies on the psychological impact of past pandemics on health professionals [14,15,16], the literature published until now about COVID-19 revealed that HCWs are at particular risk of adverse psychological outcomes, i.e., of developing more severe mental symptoms, including stress, anxiety, depression, distress, insomnia, emotional exhaustion, burnout, as wel”

    From Associations between Personality Traits, Intolerance of Uncertainty, Coping Strategies, and Stress in Italian Frontline and Non-Frontline HCWs during the COVID-19 Pandemic—A Multi-Group Path-Analysis (2021) · cites this paper as [20]

  • Very few studies have highlighted effective interventions that can improve the mental health of health care workers during infectious disease epidemics such as SARS, Ebola, and Middle East respiratory syndrome.

    “Very few studies have highlighted effective interventions that can improve the mental health of health care workers during infectious disease epidemics such as SARS, Ebola, and Middle East respiratory syndrome [3].”

    From Effectiveness of a Smartphone-Based Stress Management Program for Depression in Hospital Nurses During COVID-19 in Vietnam and Thailand: 2-Arm Parallel-Group Randomized Controlled Trial (2024) · cites this paper as [3]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Prose confuses study counts with percentages

    Minor

    The prose gives 62%, 54%, 33%, and 31% for the four conditions, but Table 1 lists those numbers as study counts. The table gives the corresponding percentages as 53%, 46%, 28%, and 26%.

  • Primary-care setting percentage is too high

    Minor

    Table 1 lists 3 primary-care studies among 117 studies, which is about 2.56%, not 5%.

    Reported 5 · recomputed 2.564103

  • Before-after studies are classified inconsistently

    Minor

    The intervention results say none of the four studies used an experimental design, whereas the methods explicitly classify non-controlled before-after studies as experimental. The results describe included interventions using that design.

3 of 3

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Authors
Serrano-Ripoll, M. J., Meneses-Echavez, J. F., Ricci-Cabello, I., Fraile-Navarro, D., Fiol-deRoque, M. A., Pastor-Moreno, G., Castro, A., Ruiz-Pérez, I., Zamanillo Campos, R., & Gonçalves-Bradley, D. C.
Affiliations
  • Norwegian Institute of Public Health (NO)
  • Health Research Institute of the Balearic Islands (ES)
ORCID
Venue
Journal of Affective Disorders
Publisher
Elsevier BV
Published
2020-12
Volume
277
Pages
347-357
ISSN
0165-0327 (ISSN-L)
DOI
10.1016/j.jad.2020.08.034
PMC
PMC7443314
OpenAlex
W3081088380
Semantic Scholar
45e353eacba1f376e269df9998854b053e8fe1c1
Cited by
592
References
199
Citations by year
2026: 26 · 2025: 28 · 2024: 83 · 2023: 113 · 2022: 153 · 2021: 150 · 2020: 39
FWCI
9.01
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Affective Disorders (publishedVersion)
  • medRxiv (acceptedVersion, cc-by-nd)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
  • RISalud Institutional Health Repository of Andalucía (submittedVersion, other-oa)
Topics
  • Social Sciences › Psychology › Clinical Psychology › COVID-19 and Mental Health
  • Health Sciences › Health Professions › General Health Professions › Healthcare professionals’ stress and burnout
  • Health Sciences › Health Professions › Occupational Therapy › Occupational Health and Burnout
Keywords
healthcare workers, mental health, acute stress disorder, anxiety, burnout, depression, post-traumatic stress disorder, risk factors, social support, stigma, occupational stress, self-efficacy, sleep quality, mental health interventions
MeSH terms
COVID-19, Health Personnel, Humans, Mental Health, Pneumonia, Viral, Stress Disorders, Post-Traumatic, Prevalence, Coronavirus Infections, Pandemics

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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