Journal Pre-proof

Psychological distress and trauma during the COVID-19 pandemic: a survey of

doctors practising in anaesthesia, intensive care medicine and emergency medicine
in the United Kingdom and Republic of Ireland

Tom Roberts, Robert Hirst, Camilla Sammut-Powell, Charles Reynard, Jo Daniels,

Daniel Horner, Mark D. Lyttle, Katie Samuel, Blair Graham, Michael J. Barrett, James
Foley, John Cronin, Etimbuk Umana, Joao Vinagre, Edward Carlton, on behalf of the
collaborators of TERN, RAFT, PERUKI, ITERN, TRIC, and SATARN
PII: S0007-0912(21)00310-X
DOI: https://doi.org/10.1016/j.bja.2021.05.017
Reference: BJA 1730

To appear in: British Journal of Anaesthesia

Received Date: 12 May 2021

Revised Date: 16 May 2021
Accepted Date: 17 May 2021

Please cite this article as: Roberts T, Hirst R, Sammut-Powell C, Reynard C, Daniels J, Horner D, Lyttle
MD, Samuel K, Graham B, Barrett MJ, Foley J, Cronin J, Umana E, Vinagre J, Carlton E, on behalf of
the collaborators of TERN, RAFT, PERUKI, ITERN, TRIC, and SATARN, Psychological distress and
trauma during the COVID-19 pandemic: a survey of doctors practising in anaesthesia, intensive care
medicine and emergency medicine in the United Kingdom and Republic of Ireland, British Journal of
Anaesthesia, https://doi.org/10.1016/j.bja.2021.05.017.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
Psychological distress and trauma during the COVID-19 pandemic: a survey of doctors
practising in anaesthesia, intensive care medicine and emergency medicine in the United
Kingdom and Republic of Ireland

1, 2 * 1,3 4 5 6
Tom Roberts , Robert Hirst , Camilla Sammut-Powell , Charles Reynard , Jo Daniels , Daniel
1, 7 8,9 10 11,12 13, 14
Horner , Mark D Lyttle , Katie Samuel , Blair Graham , Michael J Barrett , James Foley
15 14, 16 17 18 1, 2
, John Cronin , Etimbuk Umana , Joao Vinagre and Edward Carlton on behalf of the
collaborators of TERN, RAFT, PERUKI, ITERN, TRIC, and SATARN

1) Royal College of Emergency Medicine, London, UK

2) Emergency Department, North Bristol NHS Trust, Bristol, UK
3) Emergency Department, Musgrove Park Hospital, Somerset NHS, Somerset, UK

of
4) Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health,
University of Manchester, Manchester, UK

ro
5) Department of Cardiovascular Sciences, University of Manchester, Manchester, UK
6) Department of Psychology, University of Bath, Bath, UK -p
7) Department of Intensive Care and Emergency Department, Salford Royal Hospital NHS
re
Foundation Trus, Salford, UKt
8) Bristol Royal Hospital for Children, Bristol, UK
lP

9) Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
10) Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
na

11) Faculty of Health, University of Plymouth, Plymouth, UK

12) Emergency Department, University Hospitals Plymouth, UK
ur

13) Department of Emergency Medicine, Children’s Health Ireland at Crumlin, Crumlin, Ireland
14) School of Medicine, Women’s and Children’s Health, University College Dublin, Dublin, Ireland
Jo

15) Emergency Department, University Hospital Waterford, Waterford, Ireland

16) Department of Emergency Medicine, St Vincent’s University Hospital, Dublin, Ireland
17) Emergency Department, Connolly Hospital Blanchardstown, Dublin, Ireland
18) College of Anaesthesiologists of Ireland, Dublin, Ireland

*Corresponding Author. Email: Tomkieranroberts@gmail.com

Keywords: anaesthesia; COVID-19; emergency medicine; intensive care; mental health;

psychological trauma

Editor - There have now been two major pandemic response phases in the UK and Ireland: one in the
spring of 2020 and one in the winter of 2020/21. This has placed an unprecedented strain on frontline
12
healthcare workers. Earlier research during the first pandemic response identified high rates of
2–5 5a, 5b
psychological distress and trauma in doctors and trainees. The impact of further pandemic
phases on mental health, workforce attrition and clinical care is yet to be established. As the
pandemic continues it is vital to track the psychological impact on acute care workers in order to
inform policy and service provision. Here we report the rate of psychological distress and trauma of
frontline doctors working in anaesthetics, intensive care medicine (ICM) and emergency medicine
(EM) during January 2021. We compared these to previous findings to quantify progressive
psychological impact.

The COVID-19 Emergency Response Assessment (CERA) study is an ongoing prospective

longitudinal survey study evaluating the psychological health of frontline doctors across the UK and
Ireland throughout the pandemic. All respondents of the original survey, delivered during the
2 6
acceleration phase of the first response, were invited to participate in the most recent iteration.
Participants repeated the original validated measures, the General Health Questionnaire-12 (GHQ-
12) for psychological distress and the Impact of Events Scale – Revised (IES-R) for trauma response.

of
78
Responses were collected from 28 January 2021 to 11 February 2021 (UK) and 01 February 2021

ro
to 15 February 2021 (Ireland), contemporaneous with peak hospital COVID-19 deaths in this
pandemic phase. Data were collected using REDCap (Research Electronic Data Capture) hosted at
-p
University Hospitals Bristol and Weston NHS Foundation Trust.
9 10
Ethical approval was obtained
from the University of Bath (UK) (ref: 20-218) and the Children’s Health Ethics Committee (Ireland)
re
(ref: GEN/806/20). Regulatory approval was obtained from the Health Regulation Authority (UK). All
lP

11
analyses and statistical outputs were produced using R.

In total 1719 participants responded to all CERA surveys, with response rates outlined in
na

supplementary-1. This latest cohort comprised 701 (40.8%) participants from Anaesthesia, 778
(45.3%) from EM, and 164 (9.5%) from ICM; some worked across two specialties. Demographic and
ur

professional characteristics are summarised in supplementary-2. The cohort was 51.0% female, had
Jo

a median age of 36-40 yr, and was representative of all professional grades. Respondents were
66.2% ‘White British’, 7.1% ‘Irish’ and 26.1% ‘Ethnic Minority’.

The prevalence of psychological distress, as defined by a score >3 on the GHQ-12 0-0-1-1 scoring
2
method, was 53.2% (n=801), an increase from 44.7% (n=1334) during the first pandemic response.
3
The median GHQ-12 score was 15.0 (Q1-Q3 11.0-20.0), higher than all previous surveys. The
average distress score was highest in the ICM cohort (supplementary-3).

The prevalence of psychological trauma (IES-R >24) was higher during January 2021 compared to
3
the peak of the first response, at 28.4% and 23.7%, respectively (supplementary-3). The prevalence
3
of ‘probable PTSD’ (IES-R >33) also increased to 17.2% (n=225) from 12.6% (n=343). Prevalence
of trauma (>24) increased in all speciality groups. This was highest in ICM at 31.1% (n=44) followed
by EM (28.9%, n=176) and Anaesthetics (27.7%, n=142). Across all surveys the median IES-R was
15 (Q1-Q3, 6-27), highest in the ICM cohort at 18 (Q1-Q3, 9-29) (supplementary-3).
Rates of distress and trauma during January 2021 are the highest they have been during this
pandemic. Figure 1 demonstrates the inter-survey change in GHQ-12 and IES-R for those that
completed all surveys. This highlights a cohort of individuals who have consistently scored high
distress and trauma scores across all time points, demonstrated as orange in figure 1.

Whilst there was a degree of recovery through the acceleration, peak, and deceleration phases of the
first pandemic response, this was reversed during the January 2021 peak. Almost 50% of those
scoring below the GHQ-12 distress threshold in the deceleration phase of the first response reported
scores above this threshold in the current survey. This resulted in the majority of all respondents
exceeding the distress threshold during January 2021 for the first time (figure 1).

Compared to previous surveys, there was an increase in the number of participants who reported

of
psychological trauma (> 24) and probable PTSD (> 33) in the IES-R. Proportionally fewer

ro
respondents demonstrated recovery compared to the number of participants with worsening trauma
symptoms between surveys 3 and 4 (figure 1). Further, 135/943 respondents who had never
-p
previously scored above 24 now reported a score above 24, and 60 (44.4%) of these were over 33.
re
These results may be subject to bias; only 31.6% of participants responded to all surveys. The GHQ-
lP

12 and IES-R were designed as screening rather than diagnostic tools; therefore, findings should be
interpreted as indicative. Formal diagnostic interviews offer a more definitive diagnosis; however, this
na

presents logistical challenges for large studies. As pre-pandemic data were not collected, we are
unable to compare to ‘usual’ levels of distress and quantify the influence of the pandemic on the
reported scores, yet due to the longitudinal nature of the study we can reliably report an increasing
ur

23
trend of distress and rates above normative data at each time point.
Jo

Our findings show that rates of psychological distress and trauma in doctors increased further during
January 2021 compared to the initial pandemic peak (April 2020). These findings raise significant
concerns regarding the psychological capacity of the acute care workforce for future pandemic
12
phases, which may exacerbate already existing workforce crises. Contrary to previous findings, we
found no evidence that the process of natural recovery, immersive pandemic working or increasing
therapeutic options for pandemic illness led to any mitigation in the prevalence of psychological
distress.

These findings provide contemporary evidence that there is a significant cohort of doctors who
continue to experience high levels of distress and trauma throughout every phase of the pandemic. It
is vital that those in distress are identified and fully supported via evidence-based therapies to prevent
long-term sequalae; the potential impact on workforce attrition and longer-term mental health is likely
to become unmanageable without imminent strategic action.
Authors’ contributions
The corresponding author attests that all listed authors meet authorship criteria and that no others
meeting the criteria have been omitted. TR conceived the idea for the study. All authors were
responsible for data collection and study design. CR and CSP conducted the data analysis. TR, RH,
JD, DH, EC and ML all contributed to drafts of the manuscript. All other authors critically reviewed the
manuscript and approved the final version.

Declaration of interests
Many of the authors have been working as frontline clinicians during the COVID-19 pandemic. They
have no competing interests to declare.

Funding

of
The Chief Investigator is directly funded as a research fellow by the Royal College of Emergency
Medicine. The GHQ-12 is being used under licence from GL assessments; the fee for use of this

ro
instrument within all three surveys has been waived. EC is a National Institute for Health Research

-p
Advanced Fellow. The study has direct funding from RCEM, grant code: G/2020/1.
re
Acknowledgements
The authors would like to acknowledge Mai Baquedano (University of Bristol) for her support with
lP

REDCap and GL Assessments for providing the licence for the GHQ-12 free of charge. We would like
to extend a special thanks to all contributors to this study (listed in supplementary-4), without whom it
na

would not have been possible.

ur

References
1. Deaths | Coronavirus in the UK [Internet]. [cited 2021 Apr 19]. Retrieved from:
Jo

https://coronavirus.data.gov.uk/details/deaths
2. Roberts T, Daniels J, Hulme W, et al. Psychological distress during the acceleration phase of
the COVID-19 pandemic: A survey of doctors practising in emergency medicine, anaesthesia
and intensive care medicine in the UK and Ireland. Emerg Med J; 2021; 0: 1–10
3. Roberts T, Daniels J, Hulme W, et al. Psychological Distress and Trauma in Doctors Providing
Frontline Care During the COVID-19 Pandemic in the United Kingdom and Ireland: A
Prospective Longitudinal Survey Cohort Study. SSRN Prepr [Internet] 2021 [cited 2021 Jan
25]; Retrieved from: https://papers.ssrn.com/abstract=3760472
4. Lee MCC, Thampi S, Chan HP, et al. Psychological distress during the COVID-19 pandemic
amongst anaesthesiologists and nurses. Br J Anaesth; 2020; 125: e384–6
5. ffrench-O’Carroll R, Feeley T, Tan MH, et al. Psychological impact of COVID-19 on staff
working in paediatric and adult critical care. Br J Anaesth; 2021; 126: e39–41
5a. Sneyd JR, Mathoulin SE, O'Sullivan EP, So VC, Roberts FR, Paul AA, Cortinez LI,
Ampofo RS, Miller CJ, Balkisson MA Impact of the COVID-19 pandemic on
anaesthesia trainees and their training. . Br J Anaesth 2020;125:450-455.
5b. Jotwani R, Cheung CA, Hoyler MM, Lin JY, Perlstein MD, Rubin JE, Chan JM,
Pryor KO, Brumberger ED. Trial under fire: one New York City
anaesthesiology residency programme'sredesign for the COVID-19 surge.
Br J Anaesth 2020;125:e386-e388.

6. Roberts T, Daniels J, Hulme W, et al. COVID-19 emergency response assessment study: a

prospective longitudinal survey of frontline doctors in the UK and Ireland: study protocol. BMJ
Open 2020; [update]
7. Goldberg DP, Gater R, Sartorius N, et al. The validity of two versions of the GHQ in the WHO

of
study of mental illness in general health care. Psychol Med 1997;
8. Weiss DS, Marmar CR. The Impact of Event Scale—Revised. Assess Psychol trauma PTSD

ro
New York, NY, US: The Guilford Press; 1997. p. 399–411
9. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international
-p
community of software platform partners. J Biomed Inform [Internet] Academic Press; 2019
re
[cited 2019 Oct 9]; 95: 103208 Retrieved from:
https://www.sciencedirect.com/science/article/pii/S1532046419301261
lP

10. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data
capture (REDCap)—A metadata-driven methodology and workflow process for providing
na

translational research informatics support. J Biomed Inform [Internet] Academic Press; 2009
[cited 2019 Oct 9]; 42: 377–81 Retrieved from:
ur

https://www.sciencedirect.com/science/article/pii/S1532046408001226
11. R Core Team. A Language and Environment for Statistical Computing. R Found. Stat.
Jo

Comput. 2018.
12. Kwanten LE. The UK anaesthesia workforce is in deepening crisis. Br J Anaesth 2021; 126:
e159–61
Jo
ur
na
lP
re
-p
ro
of