Brazilian physiotherapist anxiety and depression during the COVID-19 pandemic: a cross-sectional survey

Abstract This study investigated the prevalence and the potential risk factors for anxiety and depression among physiotherapists during the pandemic. Physiotherapists answered a web-based questionnaire including 1) sociodemographic, professional and clinical information; 2) psychosocial demands; and 3) two validated questionnaires to measure anxiety and depression. Binary logistic regression identified the risk factors by means of odds ratio (OR) and 95% confidence interval (CI). In 417 participants, there was a high prevalence of anxiety (48.2%) and depression (53.0%). The risk factors for anxiety were female sex (OR 2.07; 95%CI 1.01-4.24), worsening in sleep patterns (OR 3.78; 95%CI 1.92-7.44), moderate (OR 2.24; 95%CI 1.00-5.00) and extreme concern about financial issues (OR 3.47; 95%CI 1.57-7.65), and extreme loneliness (OR 3.47; 95%CI 1.71-7.07). The risk factors for depression were female sex (OR 2.16; 95%CI 1.03-4.55), low family income (OR 2.43; 95%CI 1.21-4.89), worsening in sleep patterns (OR 5.97; 95%CI 3.02-11.82), extreme concern about financial issues (OR 2.61; 95%CI 1.15-5.94), and extreme loneliness (OR 4.38; 95%CI 2.00-9.63). This study found a high prevalence of anxiety and depression in the studied population and identified risk factors for both.


Introduction
The coronavirus disease 2019 (COVID- 19) pandemic has a potential of dramatically affect the mental health and psychological well-been of healthcare professionals 1 .Healthcare workers had a high prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), probably due to the increased exposure to virus 2 .Since, in several countries, physiotherapists often perform aerosol-generating procedures, they are among the health workers most exposed to the virus [3][4][5] .Many of the infected professionals are asymptomatic, favoring silent transmission to co-workers, family members and other people in the community 2 .This situation can cause a great fear of contamination in these professionals and can result in psychological disorders 6 , increasing the risk of anxiety and depression development 7 .
The impact of the pandemic on the mental health of physiotherapists and other health professionals goes far beyond the fear of being infected, and probably also involves financial and other personal aspects.Due to the high transmissibility of coronavirus, once the pandemic started, public restraining measures were necessary, generating important socio-economic and psychological impacts 8 .Therefore, many physiotherapists and rehabilitation services had to interrupt or reduce their activities abruptly without prior planning, which probably caused an important economic impact, especially on self-employed professionals 9 .
However, other physiotherapists had to continue practicing, as they play an important role in the management of respiratory conditions in patients admitted to hospitals wards or intensive care units with suspected or confirmed COVID-19 5 .These professionals had to deal with an increase in workload 10 due to a lack of personnel and to a high number of patients to attend in a short time 10,11 .The work overload is described as workplace stressor and has been experienced by physiotherapists in their daily routine, even before the current pandemic 11 .To work in a front line of care, self-rated increases in workload, negative coping style, and fear of getting infected by the virus were identified as some risk factors for anxiety and depression in health professionals 10 .
During this pandemic, physiotherapists reported high levels of perceived stress 12 .However, we do not know to what extent the pandemic context is affecting the physiotherapists mental health, since we found only one study showing high levels of anxiety and depression on a small sample of South Korean physiotherapists 13 .Therefore, considering that physiotherapists are essential for both treatment of acute COVID-19 patients [3][4][5]14 and rehabilitation of patients presenting possible sequelae 15 , we believe that knowing the factors that affect the mental health of these professionals is of utmost importance for creating strategies to prevent and/or mitigate possible psychological disorders.
In view of this scenario, the objectives of this study were: 1) to quantify the prevalence and the magnitude of anxiety and depression among physiotherapists during the COVID-19 pandemic, 2) to verify whether sociodemographic, professional, clinical and psychosocial factors associate with anxiety and depression, and 3) to find out potential risk factors for anxiety and depression.

Design
A cross-sectional study was conducted from 22 May to 24 June 2020 (approximately 8 weeks after the implementation of the social distancing rules due to the COVID-19 pandemic in Brazil).A convenience sample of physiotherapists participated in an online survey.The Regional Physiotherapy Council sent an e-mail for all physiotherapists registered on it.The e-mail had a link to a questionnaire built on the Survey Monkey platform.A 3-step e-mailing process was implemented to optimize the response rate, with seven days apart among each step.Multiple entries from the same individual were prevented by the electronic survey system through e-mail addresses.

Participants
Physiotherapists registered on Regional Physiotherapy Council, who practice in Espírito Santo (ES), a Southeastern Brazilian state, and who agreed with the informed consent term, were included in this survey.It is worth mentioning that registration on Regional Physiotherapy Council is mandatory for all physiotherapists who work in the ES state.The physiotherapists who did not complete the questionnaire were excluded from the study.According to Regional Physiotherapy Council, there were 4,173 physiotherapists registered on it in May 2020.Using this number, a confidence level of 0.95 with a margin of error of 5%, the sample size was estimated in 352 participants.
The clinical characteristics and information related to the COVID-19 pandemic looked on: 1) confirmed diagnosis of COVID-19 (yes; no), 2) previous diagnosis of depressive, anxiety or any psychological or psychiatric disorder (yes; no), 3) change in sleep patterns during the pandemic (improved a little; kept the same; worsened), 4) change in family income during the pandemic (no change; small reduction; large reduction; improvement), 5) practicing social distancing appropriately (yes; no), 6) COVID-19 infected or dead people in your social environment (no; yes for far people; yes for close people like family or friends), and 7) psychological treatment (yes, I am doing psychotherapy; I was doing psychotherapy, but I stopped it due to pandemic; nowadays no, but I already had done; I have never done).
The section about psychosocial demands asked physiotherapists an answer on a five-point Likert scale (not at all; slightly; moderately; very; extremely) to the question "In the past seven days, how much the factors below did affect you psychologically?": 1) housework, 2) care and relationship with children, 3) relationship with the partner, 4) excessive professional activities, 5) concern about financial issues, 6) concern about yourself being infected by coronavirus, 7) concern about close people/family members being infected or becoming ill by COVID-19, 8) restriction of leisure/social interaction, and 9) loneliness.
The GAD-7 is a self-reported scale used to screen for anxiety disorders and to assess its severity level 16 .The Brazilian version of GAD-7 was translated into the Portuguese language and was validated for the Brazilian population 17 .The GAD-7 consists of seven items about the frequency of symptoms over the last two weeks.The answer to each item is scored on a four-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day) 17 .The GAD-7 scores range from 0 to 21, and scores 5, 10, and 15 represent mild, moderate, and severe anxiety symptoms, respectively 18 .According to a systematic review, the GAD-7 had acceptable properties for identifying generalized anxiety disorders at cutoff scores from 7 to 10 19 .In the present study, a score of 10 was chosen as the cutoff.
The PHQ-9 is a brief self-administered tool widely used to screen for the signs and symptoms of major depression and to assess their severity 20 .It was translated into Brazilian Portuguese (Copyright© 2005 Pfizer Inc., New York, NY) and validated 20,21 .The PHQ-9 consists of nine questions assessing the rate of depressive symptoms and signs, in the last two weeks, with answers presented as a four-point Likert scale ranging from 0 (none) to 3 (almost every day) 20 .The final score ranges from 0 to 27.Scores from 0 to 4 indicate the absence of depressive disorders.The depressive symptoms may be classified as mild (5-9), moderated (10-14), moderately severe (15-19), and severe (≥ 20) 21 .In the present study, a cut-off score ≥ 10 was used because it has high sensitivity (88%) and specificity (88%) for major depression 21 , and it has proven to be the most suitable for depression screening 20 .

Data analysis
The Statistical Package for the Social Sciences (SPSS), version 22 (IBM, Armonk, NY, United States), was used for data analysis.The normality was evaluated by the Kolmogorov-Smirnov test.Categorical data are presented as absolute and relative frequencies.Continuous variables are shown as median and interquartile range (IQR).Chi-square test for independence was used to explore the relationship between each dependent variable (GAD-7 and PHQ-9) with each independent (sociodemographic, professional, clinical and psychosocial factors).Some sociodemographic and professional characteristics were not considered as independent variables and were used only for sample characterization.The independent variables that were associated with each outcome in these previous univariate analyses entered in binary logistic regression models, being the results presented as odds ratio (OR) and 95% confidence interval (95%CI).The assumptions of multicollinearity and outliers were evaluated.A significance level of 5% was adopted in all statistical steps.

Participants
A total of 533 individuals accessed the link sent by Regional Physiotherapy Council.Among them, five people did not accept to participate, and six did not meet the inclusion criteria.Therefore, 522 physiotherapists started filling the questionnaire and 417 subjects fully answered it, yielding a completion rate of 79.9%. Regarding

Prevalence and magnitude of anxiety and depression
The prevalence of anxiety and depression among the physiotherapists in this study were 48.2% and 53.0%, respectively.The medians of GAD-7 and PHQ-9 scores were 9 and 10, respectively.More details about prevalence and magnitude of anxiety and depression can be seen in Table 1.

Factors associated with anxiety and depression
Table 2 shows the associations between sociodemographic and professional characteristics and the outcomes -anxiety and depression.Anxiety and depression were significantly associated with sex and professional rolling before COVID-19.Depression was also significantly associated with marital status, children and family income.
Table 3 demonstrates the associations between clinical characteristics and information related to the COVID-19 pandemic and the outcomes -anxiety and depression.Anxiety and depression were significantly associated with previous diagnosis of depressive, anxiety or any psychological or psychiatric disorder, change in sleep patterns, change in family income, COVID-19 infected or dead people in social environment, and psychological treatment.
Table 4 presents the associations between psychosocial demands and the outcomes -anxiety and depression.Depression was significantly associated with all psychosocial demands.Anxiety did not associate only with care and relationship with children.

Risk factors for anxiety and depression
After the multiple binary logistic regression results, controlling for confounders, the risk factors for anxiety were female sex, worsening in sleep patterns, moderate and very/extreme concern about financial issues, and very/extreme loneliness.Similarly, the risk factors for depression were female sex, family income < 3 minimum wage, worsening in sleep patterns, very/ extreme concern about financial issues, and very/ extreme loneliness.Among all these risk factors, the worsening in sleep patterns was the strongest one, increasing 3.78 and 5.97 times the risk for anxiety and depression, respectively, in comparison to those that kept the same sleep pattern (Table 5).

Discussion
In the present study, 1) Brazilian physiotherapists presented a high prevalence of anxiety and depression; 2) female sex, worsening in sleep patterns, concern about financial issues, and loneliness were found as risk factors for both anxiety and depression, being the worsening in sleep patterns the strongest one; and 3) family income lower than 3 minimum wage was also found as a risk factor for depression.
When a score of 10 on the GAD-7 was used as a cutoff, the prevalence of anxiety among Brazilian physiotherapists was 48.2%, which was higher than 12.3% 7 and 12.9% 22 found in Chinese healthcare workers and 19% 23 reported in Israeli population.In addition, when 9, 8 and 5 were used as GAD-7 cutoff points, the anxiety prevalence rates were 35.1% 24 and 24.1% 25 in Chinese health professionals, and 32.3% in South Korean physiotherapists 13 , respectively.Regarding depression, when 10 was used as the cutoff score for PHQ-9, the prevalence among Brazilian physiotherapists was 53%, which was higher than 18.5% found in South Korean physiotherapists 13 , and 13.5% 25 , 14.8% 7 , and 17.2% 22 found in health professionals from other countries.
Professional characteristics could justify the high prevalence of anxiety and depression among physiotherapists.A recent systematic review showed that nurses had higher prevalence of anxiety and depression than physicians did, probably because nurses work closer to patients and are more exposed to contamination risk, suffering and death issues, and ethical dilemmas than physicians do 1 .It is worth mentioning that Physical Therapy practice demands close and long-term contact with patients and frequently includes aerosol-generating procedures, increasing the contamination risk 5 .However, comparing the findings of the present work with another study 13 , which are the only one research sampled exclusively by physiotherapists, Brazilian professionals still showed greater anxiety and depression prevalence rates than South Korean pairs.Beyond the enormous differences among Latin American and Asian culture, experience in previous pandemics, sociodemographic and economic aspects, South Korea was recognized for its precocious and proactive approach to prevent and treat pandemic related mental health diseases, including national policies on mental health 26,27 , which was not adopted in Brazil.Another possible explanation for the higher prevalence of anxiety and depression among Brazilian physiotherapists in comparison with health professionals from other countries might be the higher incidence of COVID-19 in Brazil compared to these countries 28 .A recent study found higher distress levels in healthcare workers who lives in the geographical areas with the highest incidence of COVID-19 29 .
Another factor that contributed to these high rates of anxiety and depression was the female predominance (81.3%) in the present sample, since the female sex emerged as a risk factor for anxiety and depression in the present study and in previous ones 7,30 .Moreover, even before COVID-19 context, the preponderance of anxiety 31,32 and depression 33,34 disorders among women was already well evidenced in the literature.Considering 1) the female sex as a risk factor for anxiety and depression; 2) the global tendency of higher proportion of female workers in the health workforce than in the general workforce 35 , which was also observed in the present study; 3) that women and men are exposed differently to the social and psychological consequences from a pandemic 36 ; and 4) the highest degree of gender equality has been related to low depression scores among men and women 33 ; future researches and mental health policies should pay attention to biological, psychological, social, environmental, and economic factors that contribute to this sex/ gender gap, especially in healthcare professionals during pandemic contexts 36,37 .In this sample, 69.5% of physiotherapists reported worsening in sleep patterns, which was identified as a risk factor for anxiety and depression.By the way, it appeared as the most potential risk factor, increasing in 3.78 and 5.97 times the probability of those who have worsening in sleep patterns to present anxiety and depression, respectively.Previous studies also described the sleep disorders-anxiety/depression association in healthcare workers during the COVID-19 outbreak 38,39 .Difficulty sleeping was one of the risk factors most strongly associated with anxiety in physicians 38 and positive correlation between depression and sleep disturbance was demonstrated in frontline medical staff from a designated hospital for COVID-19 infection 39 .Moreover, during the COVID-19 pandemic, health professionals have shown worse sleep quality when compared to other occupational groups 24,40 and the disruption of the circadian rhythm, due to the overwork imposed to health professionals during the pandemic, was pointed as a possible cause of insomnia and difficulty sleeping 38 .Sleep deprivation can impair cognitive domains such as attention, memory, decision making, as well as psychomotor speed, all of which can affect performance in more complex cognitive tasks 41 .Complex procedures, such as handling the mechanical ventilation, caring for artificial airways, weaning and extubation, demand high degree of attention and decision making by physiotherapists.In addition, physiotherapists need increased attention with personal and environmental protection measures to avoid aerosol particles exposure and themselves and team contamination 4 .Therefore, managers should guarantee adequate rest time for health workers in an attempt to minimize anxiety, depression, and negative impacts of worsening sleep on professional performance.
Concern about financial issues was also identified as a risk factor for anxiety and depression in Brazilian physiotherapists.It was already demonstrated that the economic situation plays a role in anxiety development during the pandemic 42 .The COVID-19 pandemic has globally increased fears of an impending economic crisis and recession, causing a reduction in workforce demand across most of the economic sectors and many jobs lost 43 .Although intensive care and inpatient units have faced unprecedented demand during pandemic, that increases the need for health pro-fessionals 44 , a distinct economic reality emerged in other health sectors due to elective surgeries cancel 44,45 , outpatient rehabilitation close 46,47 , patient office visits reduction, resulting in salaries decrease and many groups demission 45 .
Beyond the concern about financial issues, family income was associated with depression in the current study.Physiotherapists who had family income lower than three minimum wages had 2.43 more chances of having depression than those who had a family income higher than or equal to three and lower than or equal to five minimum wages.Previous studies in general population have been demonstrating this association [48][49][50] .A meta-analysis indicated that a 1 percent increase in relative ranking on income led to a 0.74 percent decrease in the log odds ratio of being depressed 50 .An Australian longitudinal cohort study showed that underemployment was associated with increased risk of depression and that inadequate remuneration associated with underemployment is a determinant of the poorer mental health 48 .Recently, a cross-sectional observational study done during COVID-19 pandemic also demonstrated the association between low- er income and depression 49 .Moreover, evidence has shown that the COVID-19 pandemic exacerbated previous inequalities and created others.While higher-income families could have a reduction in expenditure due to social distancing, since they spend a larger part of their total expenditure on services affected by the quarantine (i.e.leisure, holidays, restaurants, personal care), lower-income families spend a larger part of their income on primary necessities that are difficult to adjust to any earning reduction.In addition, lower-income workers are more likely to have their earnings reduced and are more likely to have lost their job 51 .Therefore, there is a need to protect the economically vulnerable people in times of financial crisis 52 .Another risk factor for anxiety and depression among Brazilian physiotherapists was loneliness.Similarly, loneliness, due to COVID-19 measures of social distancing, was the most prominent risk factor for anxiety and depression in Israeli general population 23 .Although social distancing and lockdown have shown efficacy in reducing viral transmission 53 , these control measures can trigger or increase lonely feelings 54 .Three months after the first case of COVID-19, 35.86% of 15,530 people in the United Kingdom reported that sometimes or often felt lonely 37 .A study performed during this pandemic in 50 states of the United States of America showed that loneliness was significantly higher than reported previously, and it was associated with higher levels of depression and ideation of suicide 55 .Although loneliness has been shown as an important risk factor for anxiety and/or depression during the pandemic in general population 23,37,55 , the role of loneliness in depression and anxiety among health professionals was fair investigated.It was demonstrated that loneliness was related to lower mental health in healthcare professionals 56 .Therefore, it is important to access feelings of loneliness among health professionals to plan strategies to increase social support for these professionals.
This study has some limitations.First, the cross-sectional design used does not allow address the long-term changes in anxiety and depression over the pandemic period.Second, answering all questions was mandatory to continue through the survey, which may have discouraged some participants from completion, reducing the sample size.However, the number of participants exceeded the estimated sample size to meet a 95% confidence level.Third, the convenience sample added to the fact that this survey was conducted in Brazil, where pandemic scenario was worse than in other countries, preclude the external generalization of the findings.On the other hand, it can help to strength evidence that urgent measures are needed in all scenarios when dealing with a global health issue.Finally, the self-reporting nature of the clinical variables, although using validated scales, may have less reliability than the assessment by mental health professionals.

Conclusion
This research found a high prevalence of anxiety and depression among studied physiotherapists during the COVID-19 pandemic.Female sex, worsening in sleep patterns, concern about financial issues, and loneliness were identified as risk factors for both anxiety and depression.In addition, family income lower than 3 minimum wage also emerged as a risk factor for depression.Among all these risk factors, the worsening in sleep patterns appeared as the strongest one.Therefore, a proactive approach to prevent and treat physiotherapists mental burdens due to this and future pandemics should be implemented.

Collaborations
VK Capellini worked in design, data analysis and interpretation, writing, review and approval; FM aroP worked in conception and design, data collection, data interpretation, writing, review and approval; RD Vieira worked in conception and design, data collection, writing, review and approval; VL Wittmer worked in conception and design, data collection, writing, review and approval; MC Barbalho-Moulim worked in conception and design, data collection, writing, review and approval; SCS Soares worked in design, data analysis; writing, review and approval; CGT Oliveira worked in conception, writing, review and approval; H Duarte worked in conception and design, data collection coordination, data interpretation, writing, review and approval.The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

table 1 .
Prevalence and magnitude of anxiety and depression among physiotherapists during the COVID-19 pandemic.

table 2 .
Anxiety and depression according to sociodemographic and professional characteristics of physiotherapists.

table 3 .
Anxiety and depression according to clinical characteristics and information related to COVID-19 pandemic.

table 4 .
Anxiety and depression according to the intensity by which psychosocial demands affected the physiotherapists during the COVID-19 pandemic.

table 5 .
Risk factors for anxiety and depression in physiotherapists during the COVID-19 pandemic.