Psychosocial Morbidity Among Doctors Working in Intensive Care Unit in Tertiary Care Hospitals in Chennai - A Cross Sectional Study

Unit like caring extremely morbid patient, palliative care to debili-tated patient, exploring the poor condition of the patient to their attenders and revealing the deceased patient status into their attenders are all very challenging and difficult thing 5 . Doctors and other health care workers are all involving directly in diagnosing and treating the morbid patients, which leads to continuous stress and anxiety. Doctors are more risk of ABSTRACT Introduction : Intensivists routinely works in a demanding, highly complicated environment where mortality and morbidity are common events and it affects their own physical as well mental health. Objective : The aim was to assess psychological factors and the various influencing factors on psychological health among study participants. Methods: The list of tertiary care hospitals in Chennai were collected and Ten hospitals were selected randomly by lottery method and 15 doctors who were working in Intensive Care Units (ICU) were selected from each hospital by systematic random sampling to arrive at the calculated sample size of 150. The Data was collected using the Pretested semi structured questionnaire and validated DASS-21 Scale. Results : The prevalence of Depression, Anxiety and Stress was found to be 78.6%, 86% and 60.6% respectively among ICU doctors. It was found that, having a history of either diabetes or hypertension and working more than 8 hours per day was an important predictor for depression and stress respectively with statistically significant association (P<0.05). Conclusions : Routine screening of physical health and mental health for doctors involved in the diagnostic as well as treatment aspects of work towards patients in Intensive Care Unit (ICU) should be conducted periodically.

Working situation in Intensive Care Unit like caring extremely morbid patient, palliative care to debilitated patient, exploring the poor condition of the patient to their attenders and revealing the deceased patient status into their attenders are all very challenging and difficult thing 5 . Doctors and other health care workers are all involving directly in diagnosing and treating the morbid patients, which leads to continuous stress and anxiety. Doctors are more risk of getting infection from patient, and further it was carried to their family members, these are all some complicated situation where they have to work regularly 6 . Disease-related mortality, heavy workload, overtime duties and usage of personnel protection equipment (PPE) cause physical and psychological distress. Stress reaction symptoms such as anxiety, depression, feeling physically weak and antagonistic behaviour have been reported more among healthcare workers during and in the aftermath of previous outbreaks 7 . Before COVID-19, ICU doctors are already in a serious threat due to work pattern and stress in this environment, pandemic condition gave additional burden to ICU doctors 8,9 . Stress is an integral part of mental health and is probably one of the prominent issues in today's society. Anxiety is a disorder commonly associated with unease and fear, exhibiting symptoms such as fatigue, palpitations and restlessness 10 . While considering the causes we have to take into account, environmental, genetic, psychological, social and biological factors as well. Anyone who is exposed to anxiety and worry tend to lose their self-confidence and become depressed with the humiliation faced which in turn increase their occupational stress with degrading work performance. Reduced work performance by itself intensifies one's anxiety and this continued cycle of events eventually destroys people's mental and physical abilities leading to unstable neuropsychiatric disorders. Physicians and nurses are affected by a plethora of workplace stressors, because of their duty to provide proper and effective treatment to sick patients 11,12 .
The healthcare workers are facing a greater portion of violence from patient and caregiver that will affects their physical and psychological well-being and limits their work performance and job satisfaction 13 . Particularly doctors are being victims of verbal and physical violence in many occasions by patient and their relatives. Many studies reveal about workplace violence and its impact on psychological health among healthcare workers 14,15 .
Based on this perspective, we aimed to assess the psychosocial health of doctors working in the ICU and strengthen the mental wellbeing of the doctors.

METHODOLOGY
This was a descriptive cross-sectional study conducted among doctors working in Intensive Care Unit (ICU) in tertiary care hospitals in Chennai, Tamil Nadu during August 2021 to January 2022.
Sample size: From a study done by N.A. Uvais et al, Perceived Stress among Doctors Working in Intensive care Units was found to be 20.6% 16 . Taking this as P value and applying in the formula Z 2 PQ/L 2 where P= 20.6. Q= 79.4 and absolute precision (L) was taken as 7%, the required sample size was calculated as 134. Taking 10% as non-response the final sample size was calculated and rounded off to 150 (n=150).
Sampling technique: Multistage sampling method. The list of tertiary care hospitals in Chennai was collected. In the 1 st Stage, using simple random sampling by using lottery method, 10 hospitals were selected randomly and 15 doctors working in Intensive Care Units (ICU) were selected by systematic random sampling from each hospital till the required sample size of 150 is reached. The Data was collected using the pre-validated DASS-21 Scale for assessing depression, anxiety and stress after obtaining informed consent 17 . Pretested semi structured questionnaire was used to collect data regarding sociodemographic details, their work pattern, social relationships and psychological factors. The data was filled by the investigator himself using the interview schedule. Collected data were entered using MS EXCEL and analysed using SPSS-version 21 and chi-square value, p value and odds ratio were done to find out the association between depression, anxiety, stress and related variables.
Inclusion criteria: Doctors who had training in ICU patient management and had working experience at least 6 months in intensive care unit were included in the study.
Exclusion criteria: Doctors who were on drug therapy for psychiatric illness and medical interns were excluded from the study.
Data collection tools: A pretested semi structured questionnaire was utilized to obtain information about the socio demographic data and occupational details.
DASS-21 questionnaire was used to assess psychological aspect of the participants. It is divided into three subscales that assess depression, anxiety, and stress. On a 4-point Likert scale ranging from 0 (does not apply to me) to 3 (applies to me most of the time), the participants were asked to rate their experience with each symptom. The scores are summed up in each subscale and are categorized into mild, moderate, severe and extremely severe, According to DASS-21 scale a validated tool for use to measure depression, anxiety and stress among adult population 17 .
Human subject protection and ethical consideration: Approval from the Institutional Human ethics committee of Sree Balaji medical college and hospital was obtained. Patient's information was kept confidential and anonymous.

RESULT
A total of 150 doctors working in ICU had completed this study with consent. Out of all participants (n=150), 104 (69.3%) were aged below 30 years and doctors aged above 30 years are 46 (30.7%). Male participants are predominantly higher 84 (56%), when compared with females 66 (44%). Totally 89(59.3%) were unmarried and 61 (41.7%) were married. Out of all participants, 119 (79.3%) and 52 (34.9%) consumed tobacco in any form and alcohol in any form respectively. (Table 1)   Table 1 shows the association between depression and related variables. More than 87% of those who were more than 30 years of age suffered from depression. Around 90% of those who consume alcohol suffered from depression and the association between them was found to be statistically significant (P<0.05) with an odds ratio of 3.57. It was found that, persons suffering from depression had 3.17 times increased odds of having inadequate sleep. (OR = 3.17). Participants who are suffered from depression 2.2 times odds of had their social life affected due to ICU duties (95% CI -0.6-8.2). Among ICU doctors those who have Difficulty in taking lifesaving decisions were associated with depression with odds ratio of 3.1(95 CI -1.1-9.9). Other variables which had a statistically significant association (P<0.05) with depression were physical inactivity, working more than 8 hours per day and having a history of T2DM/HTN with an odds ratio of 2.48, 2.25 and 3.59 respectively.
On bivariate analysis, variables which were found to have statistically significant association with depression were analysed using multiple logistic regression analysis to eliminate the confounders. It was found that, having a history of either diabetes or hypertension was an important predictor for depression with an adjusted odds ratio of 3,48 (95% CI -1.3-8.8) ( Table 2).   The frequency of anxiety among ICU working doctors is shown in Table 3 along with its association with other related variables. Participants above the age of 30 were shown to have a higher level of anxiousness (87%). Anxiety was experienced by 90 percent of the female gender. Participants who were married had a higher level of anxiety (88.5%) than those who were not married (84.3%). In this study, it was discovered that there will be significant association between ICU doctors suffered from anxiety and difficulty in taking lifesaving decisions during duty hours which was statistically significant (P<0.05).
The association between stress and related variables shown in the table 4. It was found that more than 71% of those who were physically inactive suffered from stress which was found statistically significant with p value of 0.045*. Around 90% of those who consume tobacco in any form suffered from stress and the association between them was found to be statistically significant (P<0.05) with an odds ratio of 0.12. It was found that, persons suffering from stress had 3.03 times increased odds of having either Type 2 diabetes or hypertension (OR = 3.03). Among ICU doctors those who were had stress had 4.43 times odds of having difficulty in taking lifesaving decisions during their duties (OR = 4.43). Other variables which had a statistically significant association (P<0.05) with stress were working more than 8 hours per day and alcohol consumption with an odds ratio of 2.80 and 0.12 respectively.
On bivariate analysis, variables which were found to have statistically significant association with depression were analysed using multiple logistic regression analysis to eliminate the confounders. It was found that, having a history of either diabetes or hypertension and person who were working more than 8 hours per day was an important predictor for stress with an adjusted odds ratio of 3

DISCUSSION
The working environment in the intensive care units pose a lot of burden on the psychosocial wellbeing of the doctors. They may suffer from problems like depression, anxiety and stress which were screened among the ICU doctors in the present study. The study yielded interesting findings which are discussed below compared with studies done in India and elsewhere.
In the present study the prevalence of depression was found to be 78.6%. In a study done by Elhadi M et al in Libya, the prevalence of depression was found to be 48.5% among emergency physicians 18   Poor Sleep quality of the individual was found to be important factor which had significance association with depression and stress. Similar findings were obtained in a study done by Chen Y et al 26 . This show that individual with poor sleep quality have an increased odds of suffering from depression and stress.
Research shows that lack of adequate sleep could alter the mood status of the individual resulting in depression 26 which could have been the cause of the association between sleep and depression found in this study.
In present study, Participants with comorbidity(T2DM/Hypertension) having higher level of depression and stress. Similar results found in a study done by Chen Y et al shows that persons with history of hypertension had higher level of depression with p value 0.03(95% CI = 1.01-1.26) 26 . Prevention and counselling measures have to targeted towards those persons to reduce the psychological morbidity. In the present study, around 33% of the study participants suffered from sleep problems and statistically significant association was found between stress and sleep quality. Similar results were obtained in a study done by Sarcogultu KT et al, in which 40% of the study participants suffered from poor sleep quality 27 . Stress and sleep have a bidirectional relationship 28 which is evident from this study. Measures have to be taken to control the same.

CONCLUSION
The Doctors working in Intensive Care Unit are more prone for stress and other psychological health problems. Routine screening of doctors involved in the diagnostic as well as treatment aspect of work towards patients in Intensive Care Unit (ICU) should be conducted periodically and to ensure them about alternate cope-up strategy to cope-up the stress and anxiety. Some recommendation to cope up their stress and depression by doing relaxation exercise, connected with their family and outer world, looking after their physical health, challenging pressure situation and doing work out of their interest.