Introduction

Ever since the initial outbreak of the ongoing COVID-19 pandemic, research has consistently shown high rates of symptoms of anxiety, depression, or post-traumatic stress disorder (PTSD) among healthcare workers (HCWs) [1, 2]. In Spain, one of the earliest pandemic hotspots worldwide, estimates showed that one in four HCWs had a probable major depressive disorder and one in five had a probable anxiety disorder or PTSD in 2020 [3, 4], and longitudinal analyses revealed that these problems either persist or get worse over time [5, 6]. This potentially threatens health systems with sick leaves due to mental health problems, including burnout.

Despite the prevalence and potential burden of mental health problems, HCWs rarely use mental health support. For instance, a representative study conducted in New York during the initial pandemic outbreak showed that only one in two HCWs seeking psychological support were actually receiving treatment [7]. In five Chinese regions including Hubei, only one in ten HCWs sought psychological support in February 2020 [8]. These findings suggest that, despite the early provision of mental health support to HCWs at the workplace during the pandemic [9], there are significant barriers to accessing psychological resources. Lack of trust in digital interventions was as a key barrier to psychological care in the general population, according to a recent umbrella review [10]. For HCWs, additional barriers included time constraints during the initial periods of the pandemic [11], internalized stigma [12], or the belief that HCWs never require psychological help [13]. In this study, we investigate the use of psychological support among HCWs in Spain over the two-year period following the initial outbreak of the pandemic and we explore the association between baseline workplace- and COVID-19-related factors and prospective use of psychological support.

Methods

Results and discussion

Table 1 summarizes the characteristics of the sample at the three time points. At baseline, participants had a median age of 43 years, and most were females (n = 242, 82%) and worked as nurses (n = 97, 33%) or physicians (n = 108, 37%). More than half had been exposed to COVID-19 patients (n = 154, 62%) and almost one in three scored above the threshold for probable depression on the PHQ-9 (n = 88, 30%).

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Table 1. Characteristics of the participants.

https://doi.org/10.1371/journal.pone.0292932.t001

The number and proportion of HCWs who had received psychological support during the previous three months increased over time from n = 44 (15%) at baseline to n = 51 (18%) in survey wave 2 and n = 59 (23%) in survey wave 3. Overall, workplace- and COVID-19-related variables at baseline were not associated with use of psychological support at follow-up (see Table 2): decision making on patient prioritization at baseline was associated with having received psychological support at survey wave 2 (OR 5.6, 95 percent CI 2.5, 12.6) and probable major depressive disorder at baseline was associated with psychological support at waves 2 (OR 1.1, 95 percent CI 1.1, 1.2) and 3 (OR 1.1, 95 percent CI 1.0, 1.2).

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Table 2. Association between workplace- and COVID-19-related variables at baseline and use of psychological support at follow-up.

https://doi.org/10.1371/journal.pone.0292932.t002

Roughly one in four HCWs who did not use psychological support reported symptoms compatible with major depressive disorder at follow up, suggesting barriers in access to psychological support among HCWs in need for it. Importantly, we found that the proportion of HCWs who received psychological support increased over time, consistent with the hypothesis that increased workload during the initial pandemic outbreak was a driver of barriers in access to psychological support [16]. In addition, this is the first study to examine the association between baseline workplace- and COVID-19-related variables and prospective use of psychological support among HCWs: Use of psychological support was overall not associated with job type, level of exposure to COVID-19 patients, or fear of infection—in spite of their link to worse mental health [3, 17]. HCWs involved in patient prioritization during the initial pandemic outbreak were more likely to receive psychological support one year later. While this result is not easy to interpret, a potential causal relationship between involvement in patient prioritization (especially in Spring 2020, when healthcare systems could not cope with increases in acute- and critical-care requirements), negative mental health outcomes, and subsequent need for psychological support seems plausible.

Our study has some limitations. First, we used non-probabilistic sampling techniques during recruitment, which increases the risk of self-selection bias. It is thus plausible that our sample is composed of HCWs who are likely to report mental health distress, and therefore underrepresents those without distress or not likely to report it. Second, because we were interested in longitudinal and prospective associations, we only included respondents to follow-up assessments. This may increase self-selection bias. Third, we did not collect any information on the specific type of psychological support, which would have been helpful to provide specific recommendations depending on the intervention providers, settings, or duration. Last, primary outcomes are self-reported, which may introduce additional bias (e.g., recall bias).

Our findings have implications for the design and implementation of mental health actions for HCWs in crisis settings which are in line with guidelines from the World Health Organization and the International Labour Organization [18]. First, we call for a generalised reduction of psychosocial risks at work that extend beyond the midst of initial pandemic crises, as the use of psychological support in 2021 and 2022 was at least as frequent as it was in 2020. Second, health promotion strategies at work should target barriers for accessing to psychological support among HCWs, which include not only contextual factors such as rotating shifts or work-life balance, but also internal factors, such as internalised stigma caused by seeking or using psychological support [12], or fear for the negative consequences of a mental health diagnosis [13]. Last, we found only a 10% increase of use of psychological support among people with probable major depressive disorder, compared with people without it. In light of this, we call for improving access to evidence-based scalable interventions at the workplace (see for example [19]).

Conclusions

Our results suggest that many HCWs may use psychological support in the 2-year period following the initial pandemic outbreak regardless of prior exposure to workplace- and COVID-19-related stressors. Specific mental health actions should focus on health promotion and primary prevention as well as on supporting people with mental health problems, such as depression symptoms.

Supporting information