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J Psychiatry Brain Sci. 2016; 1(1): 2; https://doi.org/10.20900/jpbs.20160002
1 Emergency Department, the Second Xiangya Hospital of Central South University, 139 Renmin (M) Rd, Changsha, Hunan, 410011, P.R. China
2 Mental Health Institute of the Second Xiangya Hospital, Central South University, China National Clinical Research Center for Mental Health Disorders, National Technology Institute of Psychiatry, Key Laboratory of Psychiatry and Mental Health of Hunan Province, 139 Renmin (M) Rd, Changsha, Hunan, 410011, P.R. China
Correspondence: Dr. Yanhui Liao, Dr. Jinsong Tang, 139 Renmin (M) Rd, Changsha Hunan P. R. China (410011).
Objectives: To evaluate life events, anxiety and depression levels among physicians and nurses in emergency department (ED).
Design: An anonymous, self-reporting survey was employed between January 2013 and April 2013 that included Life Event Scale (LES), Zung's Self-Rating Anxiety Scale (SAS), Zung's Self-Rating Depression Scale (SDS) and other Likert-style questions.
Participants: A total sample of 412 participants (124 physicians and 288 nurses) from the emergency department of eleven grade-3 and grade-2 general hospitals in Hunan Province, China.
Results: ED physicians and nurses both experienced more negative life events than positive life events (mean total score: 14.13 VS. 6.41). The high pressure of work as a negative life event was the most frequently reported of all life events. Suggestive anxiety symptoms were reported by 6.34 % (5.65 % in physicians and 6.60 % in nurses) and suggestive depression symptoms were reported by 17.73 % (14.5 % in physicians and 18.8 % in nurses). Negative, but not positive, life events correlated with symptoms of depression and anxiety. Physicians experienced many more work-related negative events than nurses. Nurses showed higher levels of anxiety and depression than physicians.
Conclusion: These findings suggest that emergency department physicians and nurses experienced many more negative life events than positive life events, and these negative life events, especially work-related negative events, may harmfully impact their mental health placing them at risk for depression and anxiety. Developing a range of coping strategies for decreasing the harmful effects of these negative life events and minimizing, or controlling, the occurrence of anxiety and depressive symptoms should be emphasized for physicians and nurses who work in a hospital’s emergency department.
The term stress, introduced into the health sciences in 1926 by Hans Selye, refers to a state characterized by a uniform response pattern, regardless of the particular stressor, that could lead to long-term pathologic changes . Chronic stressors, such as environmental and psychosocial stressors, are associated with physiological, psychological, and behavioral responses. Stress has often been conceptualized as major life events that disrupt normal activities, requiring adaptive responses, and also as daily life events (chronic stressors) which are defined as the problems, difficulties, and challenges that people experience during extended periods of time in their daily lives . Divorce could be recognized as a major life event and job dissatisfaction could be considered as a chronic stressor. Markers of daily life stress reactivity may increase the risk of mental disorders .
Depression  and anxiety  are two of the most prevalent and comorbid psychiatric illnesses. Depression and anxiety have been associated with low levels of physical function . Depression is one of the most important burdens of diseases  and causes of global disability-adjusted life year (DALY) (unipolar major depression is one of the thirty leading causes of worldwide DALYs for both sexes in 1990) . The National Co-Morbidity Replication Survey conducted between February 2001 and April 2003 estimated the lifetime prevalence of major depression to be 16.9 % overall with a higher prevalence in females (20.2 %) compared to males (13.2 %). The lifetime prevalence of anxiety disorders was 28.8 % . Stressful life events have been associated with the onset of generalized anxiety disorder  and number of episodes and depression severity . Spinhoven et al, found that specific adverse life events, both in early life and adulthood were associated with anxiety and depressive disorders, and have a high comorbidity of affective disorders .
Emergency departments are recognized as a stressful environment that often exert a negative effect on the physical health and psychosocial well-being of physicians and nurses. A line of research have indicated a direct relationship between stress and illness in general . It has been generally accepted that major life events, such as a broken marriage and the deaths of family members or friends, are associated with physical and mental health impairments in individuals. The underlying assumption is that such events serve as precipitating factors, influencing the timing, but not the type of, illness episodes . Studies found that work-related, personal and family-related stressful life events contribute to the development and / or course of chronic diseases (Renzaho, Houng et al. 2013). Stressful life events have been associated with the onset of generalized anxiety disorder  and number of episodes and depression severity . Although there is a growing concern about mental health (such as stress, anxiety and depression) in the general population . There is a limitation in the research of life events and levels of depression and anxiety in physicians and nurses from emergency department whom have been daily exposed to intensive and stressful working environment. What is less clear, however, is whether accumulating daily life events are presenting sustained impact on them.
The purpose of this study was to assess the timing and number of specific life events (including family and marriage, work and study, social and others life events) and to examine the impact of them on physicians and nurses who are working in an emergency department which is often considered as stressful working environment. Given that physicians and nurses in emergency departments are working under high stress, we hypothesized that negative life events from work (rather that family and social) would be the most frequently reported ones. Also, given that the timing and number of stressors are contributing to the risk for of depression and anxiety, we also hypothesized that high levels of life events are associated with negative outcomes, such as depression and anxiety.
A cross-sectional, descriptive, self-reported survey design was used to explore life events, levels of anxiety, and depression in a sample of emergency department physicians and nurses.2.2 Participants
The present study employed a self-reporting survey design. Entry into the study was between January 2013 and April 2013. A total of 412 participants (124 physicians and 288 nurses) from emergency departments of eleven grade-3 and grade-2 general hospitals in Hunan Province of China was involved in this study. Apart from working in the department of emergency as a physician or nurse, there were no exclusion criteria. Participation was voluntary and subjects could withdraw at any time of the study without prejudice or consequence to their work.2.3 Assessment measures
In addition to some demographic and functional variables, the following self-administered questionnaires were used: Life Event Scale (LES), Zung's Self-Rating Anxiety Scale (SAS) and Zung's Self-Rating Depression Scale (SDS). Fatigue Assessment Instrument (FAI), and Pittsburgh Sleep Quality Index (PSQI) were also included in the battery of measures. Details of FAI and PSQI will be discussed separately. All participants were invited to complete a battery of self-administered measures.2.3.1 Life Event Scale (LES) 
The LES is a 48-item self-report measure designed to assess positive and negative life events. It includes 28 family and marriage-related events, 13 work and study related events, and 7 socially related and other events. It has been widely used in assessing life events experienced by individuals with psychosocial stress and illness as well as general population in China. Participants were asked to rate which of the list of life events had occurred. They were then required to identify when it happened (score for 0 to 3 points: never happened, within the previous 6 months, more than 6 months, and long-term), to define the event as positive or negative, to rate the degree of its mental effect (score for 0 to 4 points: not at all, mild, moderate, severe, and extremely severe), and classify the duration of this mental effect (score for 1 to 4 points: within 3 months, within 6 months, within 1 year, and more than 1 year). Total scores of each happened event = scores of when it happened × score of degree of its mental effect × score of the duration of this mental effect; total negative scores = added scores of each negative event; total positive scores = added scores of each negative event. High negative scores could mean high stress, anxiety, and distress. LES is a Chinese version of the questionnaire and is widely used in China with high level of reliability and validity . It was used for heroin users in a previous study .2.3.2 Zung's Self-Rating Anxiety Scale (SAS) [19, 20]
The Rhe SAS is a 20-item (e.g., ‘ I feel more nervous and anxious than usual.’), self-reported rating scale designed to assess anxiety. Items are scored on a likert-scale ranging from 0 (not at all) to 4 (extremely) with scores ranging between 0 and 80. Higher scores indicate higher levels of anxiety.2.3.3 Zung's Self-Rating Depression Scale (SDS) [21,22]
The SDS is a 20-item questionnaire assessing mood symptoms over the past week (e.g., ‘I feel downhearted, blue, and sad’). Each item is scored on a likert-scale ranging from 1 (never) to 4 (always). Higher scores indicate higher levels of depression.2.4 Procedure
Prior to the survey, the protocol was approved by the University Ethics Committee (The Second Xiangya Hospital of Central South University Review Board, No. S101, 2011) and the studies were carried out in accordance with the Declaration of Helsinki. All clinical workers, i.e. physicians and nurses, in the emergency departments of eleven general hospiatls in Changsha City were invited to participate in the study during their free time. It was emphasized that participation in this study was completely voluntary and anonymous, and that participants were free to withdraw at any time. Participants were encouraged to answer all the questions independently within one hour. Participants were fully informed about the measurement in the study. Oral informed consent was given by all study participants.2.5 Statistical Analyses
Statistical analysis was performed using the SPSS for Windows (Version 22, SPSS Inc., Chicago, IL, USA) software package. To address missing data, 4 incomplete questionnaires were excluded. Descriptive statistics were used to explore the study population’s characteristics and pooled responses. Independent sample T-tests and Pearson’s chi-square test were used to determine differences between physicians and nurses in terms of life events, anxiety, and depression. Correlations between life events, and anxiety and depression symptoms were explored using the Pearson Correlation. An alpha level of 0.05 was set to determine statistical significance.
There were 450 subjects invited to participate. There were 408 participants (90.67 % response rate) returned completed questionnaire including 124 physicians (30.39 %) and 284 nurses (69.61 %). The detailed socio-demographic characteristics appear in Table 1. Nationality: 383 (93.0 %) Han Chinese, 29 (7.0 %) minorities. Marital status: 225 (54.6 %) married, 187 (45.4 %) unmarried. Educational level: 352 (85.4 %) Nursing school or college, 60 (14.6 %) above college.
Detailed life events reported by 408 participants appear in Tables 2. and 3. According to the LES responses, the most frequently reported (17.40 %, 71 participants) life events were the experience of high pressure at work having a negative impact on them. Falling in love, engagement, marriage, to start an employment, gaining a new family member, I am, or my wife, is pregnant, getting a promotion and significant economic improvement are the frequently reported positive life events; high pressure at work, dissatisfaction with current job, significant lifestyle pattern changes (dietary and sleep), withheld bonus or penalty, failure in love, work required separation from spouse, debt, housing shortage, be misunderstood, unjustly being blamed, falsely charged and discussed, parents-in-law conflict, family financial problems, significant economic improvement, poor relationship with spouse or partner, family member with serious illness, or injury are frequently reported negative life events. Four participants reported being in a foreign country as positive life events while one subject reported it as negative life event (see Table 2.).
Compared with total scores of positive life events, participants reported higher scores for negative life events, and physicians experienced more positive and negative life events than nurses (see Table 3.).
High aggregate mean scores were observed suggesting high levels of anxiety. Twenty-six (6.37 %, 6 males, all physicians, and 20 females, 1 physician and 19 nurses) participants obtained SAS scores ≥ 50 and 72 (17.65 %, 15 males (13 physicians and 2 nurses) and 57 females (5 physicians and 52 nurses)) participants obtained SDS scores ≥ 50 indicative of high anxiety and depression symptoms respectively for these participants (Table 4.). Three (0.73 %) participants obtained scores ≥ 60, 23 (5.61 %) participants obtained scores between < 60 and ≥ 50, and 31 (7.56 %) participants obtained scores between < 50 and ≥ 45 on the SAS which are indicative of severe, moderate, and mild anxiety respectively. A similar pattern obtained for SDS, high aggregate mean scores were observed suggesting high levels of depression. Seven (1.72 %) participants obtained SDS scores in the very upper ranges ( ≥ 60 scores) indicating very high level of depression symptoms while 65 (16.01 %) participants obtained scores between < 60 and ≥ 50 and 57 (14.04 %) participants obtained scores between < 50 and ≥ 45 on the SDS which are indicative higher depression symptoms in these participants. No significant gender or occupational (nurses and physicians) differences were found on the SDS ( p = 0.751, p = 0.720) and only one the SAS (p = 0.577, p = 0.331).
Pearson correlation analyses were conducted between the total positive score, total negative score, and SAS (anxiety), SDS (depression). Total negative LES score correlated with both anxiety (rp = 0.311, p < 0.000) and depression (rp = 0.200, p < 0.000), while total positive LES score did not correlate with anxiety (rp = 0.039, p = 0.427) and (rp = - 0.041, p = 0.406).
To our knowledge, this study is the first to investigate details of family and marriage, work and study, social and other life events, and their association with symptoms of anxiety and depression among physicians and nurses from emergency departments in Hunan Province, China.
The frequently reported positive life events were falling in love or engagement, marriage, starting new employment, and gaining a new family member. Negative life events were high work pressures, dissatisfaction with current employment, significant lifestyle pattern changes (dietary and sleep) (Table 2.). Participants reported more negative life events (14.1) than positive life (6.4) and physicians experienced more negative and positive life events than nurses did (Table 3.). A total of 17.40 % (71 participants) reported high pressures of work as negative impacts. It was the most frequently reported life event (Table 2.) and is consistent with our first hypothesis. In China, health care staffs often suffer from heavily physical and psychological burdens, especially emergency health care providers . In addition to the pressures of clinical work, Chinese physicians often face pressures to publish, which is one the critical requirements for promotion . This may partly explain why physicians experienced more negative life events than nurses. The question of why physicians experienced more negative and positive life events than nurses arises. A possible explanation is that physicians and nurses have different experience levels and sources of stress and they have different coping strategies for stress. For example, Goodfellow et al. found that nursing staffs have different sources of stress than physicians and individuals with partners, or children, are relatively protected from stress . As for work-related life events, physicians may have greater commitment to their work compared to nurses , which may expose physicians to higher working pressures.
Secondly, the study reveals the presence of suggestive anxiety symptoms in 6.37 % of the participants and suggestive depression symptoms in 17.65 % (Table 4.). Although the estimated prevalence of anxiety and depression found in this study is not higher than the general population [5, 27], close attention should be paid to symptoms such as self-treatment for mental illness is common in medical workers. It is reported that physicians do not seek the kind of professional help for themselves that they do for their patients . This appears to be especially true when they were suffering from mental health problems. Most would seek help for mental problems elsewhere than in the mental health care facilities located where they lived . Destigmatization of mental problems in physicians and interventions to improve the mental health care of physicians in ways that do not compromise their professional standing should receive more attention.
In addition, there were no statistical significances between nurses and physicians in terms of the prevalence of anxiety and depression (Table 4.). The mean SDS total scores in the current study were slightly higher than a university medical students sample from Changsha (39.0 VS. 37.4). The mean of SAS total scores was strikingly higher in this sample than medical students sample (36.0 VS. 24.8)  indicating that emergency department medical staff exhibit higher levels of anxiety compared to medical students.
We also found that nurses had higher total mean score of SAS (anxiety) and SDS (depression) than physicians (Table 4.). The majority (94.37 %) of nurses but only about a third (29.32 %) of physicians were female in this study, we speculated that these differences may due to the gender differences of depression and anxiety .
Finally, the correlation between total positive score, total negative score and SAS (anxiety), SDS (depression) was explored. Total negative LES scores were correlated with anxiety and depression. Total positive LES score did not correlate with either anxiety or depression. These findings were consistent with our second hypothesis i.e. that life events associate with depression and anxiety, and results from previous studies. Spinhoven et al. found that life events were significantly related to diagnostic and symptom course trajectories of depression and anxiety. Only negative life events have an independent effect on diagnostic and symptom course trajectories of depression . Fox et al. found that negative life events linked to greater depressive symptoms . The current study showed no association between positive life events and depression and anxiety, which does not agree with conclusions arrived at from the review of the literature on positive life events with depression and anxiety. Previous research indicated that positive life events would trigger recovery from depression and anxiety and predict better outcomes in depressed patients [34, 35]. The impacts of the positive life events on this sample and other general population requires further investigation. Further research is also required to better understand the impact of negative life events on chronic disease in high stressed emergency department physicians and nurses.
A significant strength of this study is that it assessed the incidence of positive and negative life events with reference to family and marriage, work and study, social and other aspects, and also asked participants to rate the severity and duration of the impact of these life events. To the best of our knowledge, no previous study had explored positive or negative, minor or major, life events and their association with anxiety and depression in Chinese medical workers, such as physicians and nurses, in a highly intensive work environment such as an emergency department. This study has several limitations. First, the data was collected using self-report measures which may have influenced the rates of at-risk depression and / or anxiety disorders observed. Studies using more costly and time-consuming interview-based methods would be superior to self-reporting methods in terms of detecting associations with depression and anxiety. Another weakness is the fact that the results of our observations were likely biased because of the less extensive sample (408 participants). It is noticeable that given the limitations of sample size and selectivity, the general yet specific life events were well measured. Finally, the sample was recruited only from emergency departments making it difficult to generalize beyond these relatively highly-stressed populations.
In conclusion, this study reported that physicians and nurses from emergency departments experience more negative life events than positive life events. The most frequently reported life event was high pressure on the job; Only negative (not positive) life events correlated with symptoms of depression and anxiety. Of the participants 6.37 % had suggestive anxiety symptoms and 17.65 % had suggestive depression symptoms. Since having a repertoire of strategies to employ leads to greater effectiveness than simply relying on one strategy . It suggests that developing a range of coping strategies for decreasing the harmful effects of these negative life events and minimizing or controlling the occurrence of anxiety and depressive symptoms should be emphasized for those in emergency departments and other populations. For example, psychological interventions such as cognitive behaviour therapy or meditation-based techniques might be indicated, as well as health education interventions and policy strategies could be applied for those emergency department physicians and nurses.
This work was supported by grants from the Specialized Research Fund for the Physician Program of Higher Education (20110162120013) and Hunan Provincial Natural Science Foundation of China (12JJ3112). The grants had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Authors Yanhui Liao and Jinsong Tang wrote the first draft of the manuscript. Author Yanhui Liao managed the literature searches. All authors contributed to and have approved the final manuscript.
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Li Y, Zhang H, Feng Z, Chen S, Liu T, Chen X, Tang J, Liao Y. Life Events, Anxiety, and Depression among Physicians and Nurses in the Emergency Departments of Eleven General Hospitals in Hunan, China. J Psychiatry Brain Sci. 2016; 1(1): 2; https://doi.org/10.20900/jpbs.20160002