Effects of Depression and Resilience of Public Workers on Work-related Stress and Anxiety in Response to the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19), which began in 2019, remains a concern today. As of March 30, 2021, the cumulative number of confirmed cases worldwide is 127,349,248 with 2,787,593 fatalities.1 Healthcare workers in the world have tried to manage infections and to prevent further spread, and numerous studies were conducted to explore the distress and burnout effect on healthcare workers.2, 3, 4, 5, 6, 7 However, officials working on plans for preventing the spread of the virus have also suffered from severe distress symptoms such as depression, anxiety, or burnout.6

Effective administration of the COVID-19 response depends on the effort and capacity of public workers, from the frontlines to the central administration.8 For many public workers, COVID-19 has fundamentally changed where and how they work, and the demands of their jobs.8 Frontline public workers such as local government officials are in charge of transporting confirmed COVID-19 patients to dedicated hospitals in each region, designating hospitals in the event of group infections, direct management of social distancing, working at selective clinics, and managing self-isolation subjects.

The response to COVID-19 has presented a meaningful and rewarding challenges for public workers. However, firefighters, emergency medical technicians, social workers, and local provincial or city government officials have been directly exposed to harsh, unpredictable work environments such as lengthy working hours, increasing demands, vague roles and responsibilities, and exposure to human suffering. As a result, some likely suffer from anxiety regarding getting infected while transferring patients to hospitals and physical, and mental exhaustion due to excessive workload and the stress of not being able to take care of their families. Nevertheless, the stress experienced by public workers is easy to be taken for granted or to be interpreted as a problem for the future.

As the Pandemic situation continues, several previous studies have reported an increase in the prevalence of depression. The prevalence rate of depression among healthcare workers during COVID-19 is 22.8%,9 whereas during the same period, it was reported as 16.5–48.3% for the general population.10, 11, 12, 13 In addition, the prevalence of anxiety is also rising to 22.6–36.3% in pandemic situations.10, 11, 12 Most of these studies are cross-sectional, and the effects of depression on anxiety responses to disease are unclear. It has been shown that depression and anxiety have worsened each other,14 and it is a foregone conclusion that cognitive negative distortion of depression affects individuals' anxiety response. They augment their anxieties by selective response and set up a vicious circle of anxiety, distorted perception, and increased anxiety.15 So, it would be very helpful for public workers to lower their anxiety responses to properly perform their duties in a pandemic situations.

In this context, the term resilience refers to one's ability to cope or adjust well to stressful events16. People are able to adapt well over time to stressful situations, adverse events, and trauma. Resilience has been defined in numerous ways. It is a concept relating to the ability to adjust quickly to the stressful events in one's life, and it includes personality, interpersonal relationships, and the temporal characteristics of the stressor.17, 18 It is also an ability to accept stress as an opportunity, recognize one's limits to control stress reaction, become self-efficient, strengthen one's resistance to it, adapt, and develop a sense of humor.19 Resilience is also patience, tolerance toward negative effects, and adaptability to change.20 Psychologically, resilience, as an adaptive coping strategy, may be helpful in reducing public workers' stress and psychiatric symptoms, still allowing them to work in this pandemic era.

We hypothesized that independent variables (public workers' depression) would have a negative direct effect on comorbid anxiety response to the viral epidemic, regarded as dependent variables, and that worker's resilience may serve as mediator of the relationship between independent and dependent variables. Therefore, to examine this hypothesis, we explored the clinical variables related to public workers' stress and anxiety during the epidemic as well as the mediating effect of resilience on the relationship between their depression and anxiety.

Of 938 participants who completed this online survey, 62.6% were male, 35.5% were junior employees (20 to 39 years old), and 20.9% were single, and their mean years of employment were 11.5 ± 9.6 years. Additionally, 15.5% had jobs involving work related to COVID-19. Only 7.0% had a history of depression, anxiety, or insomnia (Table 1).

Table 1
Demographic characteristics of participants (n = 938)

• Click for larger image
• Click for full table
• Download as Excel file

In the pandemic era, stress and anxiety levels were compared to the viral epidemic (Table 2), and it was observed that female (vs. male, P < 0.001), junior employees (vs. senior, P = 0.028), and married (vs. single, P = 0.030) reported the highest SAVE-9 scores. However, there was no significant difference in stress and anxiety levels between participant whose jobs involved or did not involve work related to COVID-19. Participants who were rated as having depression (PHQ-9 ≥ 10, P < 0.001) or generalized anxiety (GAD-7 ≥ 10, P < 0.001) reported higher SAVE-9 scores.

Table 2
Group characteristics relating to stress and anxiety responses to COVID-19 based on SAVE-9 scores

• Click for larger image
• Click for full table
• Download as Excel file

Spearman's correlation analysis showed that a high SAVE-9 score was significantly correlated with PHQ-9 (r = 0.43, P < 0.01) and GAD-7 scores (r = 0.49, P < 0.01), and PHQ-9 was significantly correlated with GAD-7 score as well (r = 0.78, P < 0.01). The level of resilience (CD-RISC scores) was positively correlated with longer values of years of employment (r = 0.12, P < 0.01) and negatively correlated with PHQ-9 (r = −0.26), SAVE-9 (r = −0.22), and GAD-7 (r = −0.28, all P < 0.01). The results are shown in Table 3.

Table 3
Spearman's correlation coefficients of each variables

• Click for larger image
• Click for full table
• Download as Excel file

Logistic regression analysis with forward selection was done and adjusted for age (junior vs senior), gender (male vs. female), marital status (single vs. married), jobs involving work related to COVID-19 (yes vs. no), past psychiatric history (yes vs. no), and years of employment (Table 4). Logistic regression analysis showed high PHQ-9 scores (adjusted odds ratio [aOR], 1.07; 95% CI, 1.01–1.14), high GAD-7 scores (aOR, 1.22; 95% CI, 1.13–1.31), and low resilience (aOR, 0.92; 95% CI, 0.86–0.98).

Table 4
Logistic regression analysis to explore the SAVE-9 variables expected in public workers (SAVE-9 ≥ 21)

• Click for larger image
• Click for full table
• Download as Excel file

In mediation analysis, the complete pathway from depression (independent variable) to resilience (mediator) to stress and anxiety in response to the epidemic (dependent variable) was significant (z = 11.83, P < 0.001), as shown in Table 5; thus indicating that resilience partially mediates the effects of depression on stress and anxiety regarding the epidemic (Fig. 1, Table 5).

Table 5
The direct, indirect, and total effects on mediation analysis

• Click for larger image
• Click for full table
• Download as Excel file

Fig. 1
Mediation model showing that the effect of depression (independent variables) on stress and anxiety to viral epidemic (outcome) is mediated by resilience (mediator).
PHQ-9 = Patient Health Questionnaire-9, SAVE-9 = Stress and Anxiety to Viral Epidemics-9.

• Click for larger image
• Download as PowerPoint slide

This study investigated clinical variables related to stress and anxiety regarding the viral epidemic among public workers, with focus on the mediating effects of resilience. Public workers who were female, junior, or married reported significantly higher SAVE-9 scores. High levels of stress and anxiety to the viral epidemic are defined by high PHQ-9, high GAD-7, and low CD-RISC 2 scores. As resilience mediates depression, stress, and anxiety regarding the epidemic, these findings suggest that psychological resilience may be an essential target for effective psychological interventions for public workers during this period.

Consistent with previous studies among healthcare workers,2, 9 our findings show that female and junior public workers were more vulnerable to stress and anxiety during the pandemic. This implies that female and junior public workers may have more concerns about becoming infected and are more sensitive to minor physical symptoms. In Korea, public workers are a professional group that guarantees a stable employment situation, but even in the same working environment, there might exist differences between gender and age in terms of contracts and working conditions.30

Contrary to our expectations, married public workers reported a higher level of stress and anxiety in response to the epidemic. This result was inconsistent with prior research,31 which had suggested that marriage might serve as a protective factor against stressful experiences during the epidemic among nursing healthcare workers. However, in general, married people may worry not only about their own protection, but also about the safety of their family members, including children.32, 33 These findings indicate that the groups need psychological support, differences exist between occupational groups, and interventions are required accordingly. In this study there were no significant differences in the levels of stress and anxiety to viral epidemic between participants whose jobs did or did not involve work related to COVID-19. Further, we observed that there were no significant differences in the levels of stress and anxiety to the viral epidemic between participant who had experience or been treated depression, anxiety, or insomnia, and those who had not. Although we could not identify the reasons based on this study's data, we can hypothesize that the job itself did not have an influence on the anxiety levels, as this survey was conducted during May 2020 when the workers may have suffered from anxiety due to the viral epidemic, regardless of their work roles. Similarly, we can merely speculate that their past psychiatric history did not affect their anxiety level in this serious situation.

This study also found that depression not only contributes to resilience, but that this resilience may also help to explain the robust relationship between depression and stress and anxiety and the epidemic. According to previous studies about the effect of resilience among healthcare workers, resilience plays an important role in overcoming distress. Similarly, during the COVID-19 pandemic era, resilience and anxiety level have reportedly had inverse relationship among physicians,34 front-line nurses,35 and overall healthcare professionals.36, 37 Moreover, a recent study suggested that among general populations, more resilient adults experienced a lesser rate of burnout and distress during the pandemic, which is consistent with the previous finding that resilience had a reverse association with burnout among physicians.38, 39 However, although local public workers are working on the frontlines to prevent the spread of infectious diseases, research on their concerns about infection is still insufficient. Our findings add to the growing body of literature supporting the relationship between depression and anxiety and the viral pandemic. Furthermore, this study establishes that resilience serves as an important variable to mediate anxiety about infection and depression.

Finally, our results suggest that COVID-19 infection has had a significant impact on the mental health of Korean public workers. In particular, May 2020, when this study was conducted, was a period in which the number of infections in Korea was declining; however, since then, it has peaked again, and hence it was expected that public workers would continue to be exhausted. Therefore, the findings can be seen as a reflection of their burnout. The influence of resilience on depression and anxiety is a vicious cycle. Depression reduces resilience as an individual's psychological ability is exhausted, and if resilience is reduced, depression may worsen as an individual fails to cope with stress. In the systemic model of resilience proposed by Ungar and Theron,40 the ability of an individual to respond to stress is formed in a complex system in which the individual's biological and psychological systems and the social and ecological environment are influenced by one another. The social environment affects not only vulnerable individuals but also the general population, and this environment is created by all. During this period, a preventive intervention could be offered for public workers to increase their resilience, such as a program to improve positive emotions (including optimism and humor), cognitive flexibility (including positive explanatory style, positive appraisal, and acceptance), meaning (including religion, spirituality and altruism), social support (including role models), and an active coping style (including exercise and training).41 Such interventions could reduce the risk of developing mental disorders and experiencing other negative consequences by enhancing protective factors.42 In this context, psychological resilience is an essential target for psychological intervention for public workers.

The limitations of this study are as follows. First, the general population as a control group did not participate in this study, although we can assume that anxiety and stress levels of public workers are higher than those of the general population. Second, as a limitation of conducting a self-report survey study, fully detailed interviews were not conducted. However, during this pandemic, an online survey rather than face-to-face interviews was necessary to prevent the spread of the virus. Third, the application of the SAVE-9 scale that was specifically developed to assess work-related stress and anxiety of healthcare workers in response to the viral epidemic in this pandemic era might have been another limitation. However, the SAVE-9 scale was used in this study because we did not have any other rating scale for public workers. Further study is needed to validate the SAVE-9 scale for public workers.

In conclusion, female and junior public workers suffer more from work-related stress. Their stress and anxiety in response to the pandemic was related to their gender, regarding their workplace as dangerous, and experiencing depression. Thus, during the COVID-19 pandemic, it is necessary to closely observe the patterns of work-related stress and anxiety reactions among public workers and to devise a plan to reduce burnout.