Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

Jianbo Lai, Simeng Ma, Ying Wang, Zhongxiang Cai, Jianbo Hu, Ning Wei, Jiang Wu, Hui Du, Tingting Chen, Ruiting Li, Huawei Tan, Lijun Kang, Lihua Yao, Manli Huang, Huafen Wang, Gaohua Wang, Zhongchun Liu, Shaohua Hu · JAMA Network Open · 2020 · health-psychology · 10.1001/jamanetworkopen.2020.3976 · record lai2020-factors-associated-with-mental-hea
tag layer · index · concepts · authors · עברית
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Other fields define these differently the same word, defined another way in another discipline
anxiety 5 fields · COVID-19 4 fields · depression 3 fields

Tags on this paper

Every tag the record carries, each linking to every other paper in the corpus that carries it. A tag appears here whether or not its words occur in the article — the spans below are only the ones a sentence in this paper licenses. Of the 25 concept tags on this paper, all 25 are grounded in a quoted sentence.
frontline workers second-line workers nurses physicians depression anxiety insomnia distress PHQ-9 GAD-7 ISI IES-R COVID-19 SARS Wuhan Hubei province tertiary hospital secondary hospitals multivariable logistic regression odds ratios confounders 2-stage cluster sampling response bias comparator group longitudinal follow-up exposure intensity perceived personal danger resource shortage inexperience loss of control cutoff score survey
Method, as described: region-stratified 2-stage cluster sampling of 34 hospitals, four validated Chinese instruments (PHQ-9, GAD-7, ISI, IES-R), nonparametric group comparisons and multivariable logistic regression

Legend

relation to other workclaim_relationshow this paper stands to another: agrees, contradicts, extends, qualifies
claim typeclaim_typethe shape of the claim: existence, mechanism, method, critique, prediction, null
concept edgeconcept_edgesan asserted relation between two concepts, with the sentence asserting it
conceptconceptsan idea the paper works with, quoted where the paper uses it
content tagcontent_tagsa finding, definition, quantity, statistic or variable named in the paper
contributioncontributionwhat the paper claims to add
controlcontrolsan experiment run to eliminate a rival explanation
limitationlimitationswhat the paper says its evidence cannot support
mechanismmechanismshow the reported effect is said to come about
methodmethodhow the paper produced its evidence
object of studyobject_of_studywhat the paper is about — the thing it investigates
phenomenonphenomenonthe effect or regularity under study
research questionresearch_questionthe question the paper sets itself
sensesensesa distinct use of a term, quoted where the paper fixes it

The paper

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Every tag on this page

claim_relations 3 · claim_type 1 · concept_edges 12 · concepts 25 · content_tags 21 · contribution 1 · controls 9 · limitations 5 · mechanisms 5 · method 1 · object_of_study 1 · phenomenon 1 · research_question 1 · senses 5

Relations on this page carry a quotation for the claim. Where a relation was separately evidenced — and so tested against the vocabulary for its type — the row says so; none of 12 relations here carry that mark. The rest are the tagger’s reading of the sentence quoted beside them.

facettagfieldconf.whose words
object_of_studythe mental health of 1257 physicians and nurses in 34 Chinese hospitals with fever clinics or COVID-19 wards, surveyed over six days at the start of the outbreak
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object_of_studythe paper's words
research_questionwhat is the magnitude of depression, anxiety, insomnia and distress among health care workers treating patients with COVID-19, and which occupational and geographic factors are associated with it
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research_questionthe paper's words
contributiona prevalence-and-risk-factor survey filling a gap the authors name: psychological assistance was already being deployed nationally while evidence-based evaluation of frontline workers was scarce
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contributionthe paper's words
claim_typeexistence
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claim_typethe paper's words
phenomenonpsychological burden in health care workers during an epidemic: 50.4% reported symptoms of depression, 44.6% anxiety, 34.0% insomnia and 71.5% distress
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phenomenonthe paper's words
methodsurvey
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also in: survey
methodthe paper's words
mechanismsthe authors' account of why frontline nurses fare worst - close, frequent contact and longer hours than usual, which is exposure to the hazard and exposure to the workload at once
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mechanisms[0]0.95the tagger's words
mechanismshuman-to-human transmissibility and potential fatality are offered as intensifying the perception of personal danger - a belief about the disease rather than a dose of it
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mechanisms[1]0.95the tagger's words
mechanismspredictable shortages of supplies together with rising case influx are named as contributors to pressure, separately from contact with patients
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mechanisms[2]0.95the tagger's words
mechanisms71.5% of nurses held junior titles, which the authors read as fewer years of work experience - offered as why the most exposed group is also the least practised
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also in: inexperience
mechanisms[3]0.9the tagger's words
mechanismsa list of distress sources taken from the SARS literature: vulnerability or loss of control, concern for self and family, changed work, isolation
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mechanisms[4]0.9the tagger's words
limitationslimited in scope - 81.2% of participants were from Hubei province, so the findings do not generalise to less affected regions
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limitations[0]0.95the tagger's words
limitationssix days of collection and no longitudinal follow-up, so nothing here speaks to how the symptoms developed or resolved; the authors expect they worsened
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limitations[1]0.95the tagger's words
limitationsNO COMPARATOR GROUP. The study cannot separate being a clinician in the region from living in the region, and cannot separate preexisting symptoms from new ones
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limitations[2]0.95the tagger's words
limitationsresponse bias may remain at a 68.7% response rate, in either direction - the nonrespondents may have been too stressed to answer or not stressed enough to care
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limitations[3]0.95the tagger's words
limitationsthe headline prevalences and the stated detection cutoffs are two different thresholds and the paper does not reconcile them in the abstract, where only the lower one appears
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limitations[4]0.85the tagger's words
controlsmultivariable logistic regression adjusting for sex, age, marital status, educational level, technical title, place of residence, working position and type of hospital
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eliminates: the crude frontline-versus-second-line difference being an artefact of the front line's composition - sex, age, marital status, education, technical title, residence and hospital type are each held fixed, and those are the ones this quote names · outcome: held
controls[0]0.95the tagger's words
controlsall tests two-tailed at a significance level fixed in the Statistical Analysis section
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eliminates: a one-tailed test chosen after the direction of an effect was already visible · outcome: held
controls[1]0.95the tagger's words
controlsnonparametric tests (Mann-Whitney U, Kruskal-Wallis) after checking that none of the four score distributions was normal
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eliminates: a normality assumption the data do not meet - the authors report the check and then choose the test that does not need it · outcome: held
controls[2]0.95the tagger's words
controlsfour previously validated Chinese-language instruments with published band boundaries and cutoffs, rather than questions written for this study
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eliminates: instrument novelty as the source of the prevalence figures, and makes the numbers comparable with other studies using the same scales · outcome: held
controls[3]0.95the tagger's words
controlsoccupational and geographic data of the nonrespondents compared with those of respondents
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eliminates: nonresponse being concentrated in one occupation or one region - but NOT response bias itself, which the authors say may still exist because the two things it would turn on, stress and interest, are exactly what was not measured in the people who declined · outcome: partial
controls[4]0.95the tagger's words
controlstarget sample size set from a stated formula, a stated margin of error and a 35% prior from the SARS literature, then amplified by 50% for subgroup analysis
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eliminates: the subgroup comparisons being underpowered by accident - the amplification is declared in advance and for that purpose · outcome: held
controls[5]0.95the tagger's words
controlsreporting followed the AAPOR guideline for survey research
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eliminates: selective reporting of how the survey was conducted - a reporting standard is named in advance, which fixes the disclosures rather than leaving them to the authors' choice after the fact · outcome: held
controls[6]0.85the tagger's words
controlsa comparator group of people living in the same regions who were not clinicians
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eliminates: living in the region rather than working in it as a clinician - the paper says plainly there was no comparator group, so the two cannot be separated · outcome: absent-declared-unreported · would have ruled out, had it been run: nothing - THE CONTROL WAS NOT AVAILABLE. The authors state they cannot separate being a clinician in this region from simply living in it, so the entire prevalence finding is uncontrolled against the background rate in Wuhan at the same moment
controls[7]0.95the tagger's words
controlsethics committee approval, verbal informed consent, the right to terminate at any time, anonymity and assured confidentiality
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
eliminates: responses given under professional pressure during an outbreak being treated as freely given, when the respondents are staff of the reporting institution's own hospitals · outcome: held
controls[8]0.95the tagger's words
conceptsfrontline workers
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concepts[0]0.95the paper's words
conceptssecond-line workers
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concepts[1]0.95the paper's words
conceptsnurses
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: nurses
concepts[2]0.95the paper's words
conceptsphysicians
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: physicians
concepts[3]0.95the paper's words
conceptsdepression
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: depression
concepts[4]0.95the paper's words
conceptsanxiety
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: anxiety
concepts[5]0.95the paper's words
conceptsinsomnia
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: insomnia
concepts[6]0.95the paper's words
conceptsdistress
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: distress
concepts[7]0.95the paper's words
conceptsPHQ-9
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: PHQ-9
concepts[8]0.95the paper's words
conceptsGAD-7
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: GAD-7
concepts[9]0.95the paper's words
conceptsISI
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: ISI
concepts[10]0.95the paper's words
conceptsIES-R
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: IES-R
concepts[11]0.95the paper's words
conceptsCOVID-19
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: COVID-19
concepts[12]0.95the paper's words
conceptsSARS
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also in: SARS
concepts[13]0.95the paper's words
conceptsWuhan
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: Wuhan
concepts[14]0.95the paper's words
conceptsHubei province
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
concepts[15]0.95the paper's words
conceptstertiary hospital
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
concepts[16]0.95the paper's words
conceptssecondary hospitals
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
concepts[17]0.95the paper's words
conceptsmultivariable logistic regression
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
concepts[18]0.95the paper's words
conceptsodds ratios
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also in: odds ratios
concepts[19]0.95the paper's words
conceptsconfounders
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
also in: confounders
concepts[20]0.95the paper's words
concepts2-stage cluster sampling
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
concepts[21]0.95the paper's words
conceptsresponse bias
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also in: response bias
concepts[22]0.95the paper's words
conceptscomparator group
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
concepts[23]0.95the paper's words
conceptslongitudinal follow-up
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concepts[24]0.95the paper's words
sensessymptoms of depression / anxiety / insomnia / distress, AS USED IN THE FOUR HEADLINE PREVALENCES - a count of everyone scoring above NORMAL on each scale, which is a far lower bar than the cutoff the same paper defines for detecting each disorder. Read this figure with the band boundaries tagged under definitions and with the two statistics rows that quote Table 2's own band counts; the number is right and the sense is milder than the words suggest
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
senses[0]0.85the tagger's words
sensessevere symptoms - A SECOND AND HIGHER THRESHOLD IN THE SAME PAPER: a score greater than 10, 7, 15 or 26. For distress that cutoff of 26 falls at the boundary of the moderate band, while the 71.5% headline counts from the mild band up. SO `distress' IN THIS PAPER NAMES TWO DIFFERENT POPULATIONS DEPENDING ON WHICH SENTENCE YOU READ, and both are correct
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senses[1]0.85the tagger's words
sensesdistress - A SCORE ON THE IMPACT OF EVENT SCALE-REVISED, an instrument for the psychological impact of a specific event, not a clinical diagnosis and not general unhappiness. The same instrument carries the same sense in wang2020, where the label is `psychological impact` instead
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senses[2]0.95the tagger's words
sensesfrontline - SELF-REPORTED AND BINARY. It is a yes/no answer to whether the respondent was directly engaged in diagnosing, treating or nursing patients with fever or confirmed COVID-19; it carries no measure of hours, caseload or duration of exposure
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senses[3]0.95the tagger's words
sensesrisk factor / associated with - AN ADJUSTED CROSS-SECTIONAL ODDS RATIO. Confounders are named and controlled, which is more than wang2020's univariate analysis does, but the design still observes no temporal order: nobody was measured before becoming frontline
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senses[4]0.95the tagger's words
claim_relationsbuilds-on → the SARS-outbreak literature on health care workers (Maunder 2003, Bai 2004, Lee 2007, Chua 2004), which reported 89% with psychological symptoms in high-risk situations
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claim_relations[0]0.95the tagger's words
claim_relationsconfirms → the SARS emergency-department finding that nurses developed more distress and more behavioural disengagement than physicians
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note: the paper's own word is 'also showed', which is agreement reported after the fact and not a replication attempt - 'confirms' rather than 'replicates' for that reason
claim_relations[1]0.9the tagger's words
claim_relationsqualifies → the national deployment of psychological assistance hotlines and counselling during the outbreak, which this paper says ran ahead of any evidence base for frontline workers
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claim_relations[2]0.95the tagger's words
concept_edgesfrontline workers —causes→ insomnia
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direction on the measure: increases · strength of the relation: 0.85 · note: the paper's word is 'independent risk factor', which is an adjusted cross-sectional association and not a demonstrated cause; the weight is below 1.0 for that reason and the largest of the four odds ratios is this one Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span reports frontline work as an independent risk factor (odds ratio); an observational association typed as cause.
concept_edges[0]the tagger's words
concept_edgesfrontline workers —causes→ depression
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direction on the measure: increases · strength of the relation: 0.8 · note: adjusted association, CI lower bound 1.11 - the weakest of the four and the closest to no effect Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span reports frontline work as an independent risk factor (odds ratio); an observational association typed as cause.
concept_edges[1]the tagger's words
concept_edgesfrontline workers —causes→ anxiety
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direction on the measure: increases · strength of the relation: 0.8 Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span reports frontline work as an independent risk factor (odds ratio); an observational association typed as cause.
concept_edges[2]the tagger's words
concept_edgesfrontline workers —causes→ distress
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
direction on the measure: increases · strength of the relation: 0.8 Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span reports frontline work as an independent risk factor (odds ratio); an observational association typed as cause.
concept_edges[3]the tagger's words
concept_edgesdepression —operationalised-as→ PHQ-9
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strength of the relation: 1
also in: depression · PHQ-9
concept_edges[4]the tagger's words
concept_edgesanxiety —operationalised-as→ GAD-7
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strength of the relation: 1
also in: anxiety · GAD-7
concept_edges[5]the tagger's words
concept_edgesinsomnia —operationalised-as→ ISI
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strength of the relation: 1
also in: insomnia · ISI
concept_edges[6]the tagger's words
concept_edgesdistress —operationalised-as→ IES-R
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strength of the relation: 1 · note: the IES-R measures the psychological impact of a named event; 'distress' in this paper means nothing wider than that
also in: distress · IES-R
concept_edges[7]the tagger's words
concept_edgesfrontline workers —distinct-from→ second-line workers
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strength of the relation: 1 · note: the distinction is the paper's independent variable and it is a self-reported yes/no
concept_edges[8]the tagger's words
concept_edgesnurses —contrasted-with→ physicians
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strength of the relation: 0.95 Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but attributed: the span reports a SARS-outbreak study's finding about nurses and physicians.
also in: nurses · physicians
concept_edges[9]the tagger's words
concept_edgessecondary hospitals —contrasted-with→ tertiary hospital
Quotation withheld — this record is not cleared for redistribution. The sentence is in the paper at the link above.
strength of the relation: 0.95
concept_edges[10]the tagger's words
concept_edgesWuhan —part-of→ Hubei province
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strength of the relation: 1 · note: and the paper's three strata are Wuhan, Hubei outside Wuhan, and outside Hubei, so the containment matters to how the comparison reads Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span compares working outside Hubei with working in Wuhan; part-of rests on world knowledge, not the span.
also in: Wuhan · Hubei province
concept_edges[11]the tagger's words
content_tags50.4% reported symptoms of depression, 44.6% anxiety, 34.0% insomnia, 71.5% distress
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content_tags.findings[0]0.95the tagger's words
content_tagsfrontline work was an independent risk factor for all four outcomes after adjustment; insomnia carried much the largest odds ratio at 2.97
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content_tags.findings[1]0.95the tagger's words
content_tagsbeing a woman and holding an intermediate professional title were associated with severe depression, anxiety and distress
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content_tags.findings[2]0.95the tagger's words
content_tagsWorking outside Hubei was associated with a lower risk of distress than working in Wuhan.
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content_tags.findings[3]0.95the tagger's words
content_tagssecondary-hospital staff reported more severe depression and anxiety than tertiary-hospital staff
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content_tags.findings[4]0.95the tagger's words
content_tagsbut frontline workers in secondary and tertiary hospitals scored equally high on all four scales - the hospital-type difference disappears at the front line
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content_tags.findings[5]0.95the tagger's words
content_tagsnurses, women, frontline workers and those in Wuhan reported more severe symptoms on every measurement
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content_tags.findings[6]0.95the tagger's words
content_tagsfrontline worker = answered yes to being directly engaged in diagnosing, treating or nursing patients with fever or confirmed COVID-19; everyone else is second-line
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content_tags.definitions[0]0.95the tagger's words
content_tagscutoffs for detecting major depression, anxiety, insomnia and distress: 10, 7, 15 and 26; above the cutoff is called severe
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also in: cutoff score
content_tags.definitions[2]0.95the tagger's words
content_tags1257 of 1830 contacted individuals completed the survey, a participation rate of 68.7%
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content_tags.quantities[0]0.95the tagger's words
content_tags1257 health care workers in 34 hospitals, over six days from 29 January to 3 February 2020
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content_tags.quantities[1]0.95the tagger's words
content_tags20 hospitals in Wuhan, 7 elsewhere in Hubei, 7 in other provinces - 34 in total
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content_tags.quantities[2]0.95the tagger's words
content_tagsmedian scores: PHQ-9 5.0, GAD-7 4.0, ISI 5.0, IES-R 20.0
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content_tags.quantities[3]0.95the tagger's words
content_tagstarget sample of at least 1070 completed questionnaires, from a 35% prior and a 50% amplification for subgroups
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content_tags.quantities[4]0.95the tagger's words
content_tagsfrontline vs second-line, adjusted: depression OR 1.52 (1.11-2.09), anxiety 1.57 (1.22-2.02), insomnia 2.97 (1.92-4.60), distress 1.60 (1.25-2.04)
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content_tags.statistics[0]0.95the tagger's words
content_tagsoutside Hubei vs Wuhan, distress OR 0.62 (0.43-0.88), P = .008
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content_tags.statistics[1]0.95the tagger's words
content_tagssecondary vs tertiary hospital: depression OR 1.65 (1.17-2.34), anxiety OR 1.43 (1.08-1.90)
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content_tags.statistics[2]0.95the tagger's words
content_tagssevere depression among women OR 1.94 (1.26-2.98); severe anxiety with an intermediate title OR 1.82 (1.38-2.39)
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content_tags.statistics[3]0.95the tagger's words
content_tagsTHE 71.5% DISTRESS FIGURE IS EVERY IES-R BAND ABOVE NORMAL: 459 mild + 308 moderate + 132 severe = 899 of 1257. The severe band alone is 132, or 10.5%, and the paper's own stated cutoff for detecting distress is 26 - the boundary of the moderate band, not of the mild one
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content_tags.statistics[4]0.95the tagger's words
content_tagsthe same shape on the PHQ-9: 448 mild + 108 moderate + 78 severe = 634 of 1257 = the reported 50.4%, while the stated cutoff for detecting major depression is 10
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content_tags.statistics[5]0.95the tagger's words
content_tagsall tests 2-tailed with the significance level fixed in advance; group comparisons by Mann-Whitney U and Kruskal-Wallis because none of the four distributions was normal
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content_tags.statistics[6]0.95the tagger's words

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