Industrial Psychiatry Journal

: 2021  |  Volume : 30  |  Issue : 1  |  Page : 123--130

Postexposure psychological sequelae in frontline health workers to COVID-19 in Andhra Pradesh, India

Keya Das1, V S S. R. Ryali1, R Bhavyasree1, C Madhu Sekhar2,  
1 Department of Psychiatry, PESIMSR, Chittoor, Andhra Pradesh, India
2 Department of Psychiatry, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh, India

Correspondence Address:
Dr. Keya Das
G 02, Tuscan East Apartments, Lazar Road, Cox Town, Bengaluru - 560 042, Karnataka


Introduction: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 has engulfed the globe since December 2019. Healthcare workers remain at the forefront of this battle, and like prior pandemics face mental health challenges along with physical risks. We aimed to study the perceived stress and possible posttraumatic stress in the frontline workers exposed to active COVID-19 duties in the state of Andhra Pradesh, India. Methodology: A special voluntary, anonymous, survey-based Google questionnaire was designed with mandatory consent form and queries to clarify inclusion exclusion criteria. Tools included valid, reliable self-administered scales, namely General Health Questionnaire 12, Perceived Stress Scale and Impact of Events Scales-Revised. A purposive sampling method was adopted, by posting the survey questionnaire on WhatsApp groups of doctors, interns, and nurses working on active COVID-19 duty in Andhra Pradesh. Results: About 69.7% of the frontline workers recorded higher perceived stress and definitive posttraumatic stress disorder (PTSD) was found in 34.8%, with psychological distress recorded in 53%. Conclusion: The higher levels of perceived stress discovered in the vast majority with definitive PTSD features in a third of the sample indicates the need for provision of mental health support proactively among frontline workers on active COVID-19 duty.

How to cite this article:
Das K, Ryali V S, Bhavyasree R, Sekhar C M. Postexposure psychological sequelae in frontline health workers to COVID-19 in Andhra Pradesh, India.Ind Psychiatry J 2021;30:123-130

How to cite this URL:
Das K, Ryali V S, Bhavyasree R, Sekhar C M. Postexposure psychological sequelae in frontline health workers to COVID-19 in Andhra Pradesh, India. Ind Psychiatry J [serial online] 2021 [cited 2021 Oct 26 ];30:123-130
Available from:

Full Text

We witnessed history in the making, as news broke of a unique pneumonia in Wuhan, China as 2019 came to a close. The etiology was ascribed to coronavirus disease 2019 (COVID-19), unfurling across Chinese borders into international territories.[1] February 11, 2020, marked WHO designating the new coronavirus disease as COVID-19.[2]

Prior pandemics belonging to same virus family are Severe Acute Respiratory Syndrome (SARS) and Middle East respiratory syndrome (MERS) coronavirus.COVID-19 too was theorized to have zoonotic origins namely via snakes, bats, and pangolins at the Wuhan wet markets. Ever since late 2019, the virus has engulfed the globe resulting in millions afflicted, marked number of deaths particularly with increased affliction noted in vulnerable and elderly.[3] January 30, 2020, saw World Health Organization declare that the global COVID-19 outbreak was a public health emergency of international concern.[4]

Encountering this crisis, Frontline healthcare personnel directly participating in the evaluation, diagnosis, management of patients with COVID-19 stand the risk of suffering distress and could manifest other mental health symptoms.[5] Wu et al. studied the psychological impact of the SARS epidemic on hospital employees in China, reported that about 10% of the respondents reported having undergone increased levels of posttraumatic stress symptoms following the SARS outbreak. Healthcare workers quarantined, manning high risk wards, or friends/family contracting SARS exhibited a 2–3 manifold risk of posttraumatic stress (PTS) symptoms. Respondents' perceptions of SARS-related risks were significantly positively associated with PTS symptom levels and partially mediated the effects of exposure.[6]

Chong et al. evaluated the psychological impact of 2003 SARS outbreak in China, demonstrated that the stresses perceived and anticipated by the hospital workers were debilitating, thereby impacting work efficiency, behavior, and health. Greater than 2/3rd of the sample manifested psychiatric symptoms of stress.[7]

Over 28 million cases of COVID-19 reported throughout the world, and numbers increasing by the day,[8] puts healthcare professionals under tremendous pressures as they deal with many variables some of which are longer working hours, lack of personal protective equipment, lack of specific drugs and protocols, and being away from family apart from fear of contracting the illness themselves. Prior studies evaluating outbreaks of SARS and the MERS, found frontline medical staff had reported high levels of stress that resulted in posttraumatic stress disorder (PTSD).[9],[10]

Essential to the formulation of policies pertaining to health of frontline workers, it is imperative to fully grasp the psychological impact the COVID-19 has had on individuals at the frontline. This study is aimed at identifying the psychological distress, prevalence of stress reaction and PTS among the frontline healthcare workers working in COVID-19 areas. To our knowledge, this is the first study assessing Stress and eventual PTSD in frontline workers exposed to active COVID-19 duties in the state of Andhra Pradesh, India.


The study is a cross sectional, observational study designed at PESIMSR, Kuppam, Andhra Pradesh. Doctors, Interns and Nurses involved in COVID-19 Duties across the state of Andhra Pradesh who consented for the study and aged above 18 years were included in the study and those who were not on COVID-related duties were excluded.

The data were collected through an online semi-structured questionnaire which was developed using Google forms, with an electronic informed consent form appended to it. The consent form explains the study to be anonymous, voluntary, the participant being allowed to drop out at any point, and that the data will not be used commercially and is meant only for scientific publication. In addition, 3 other mandatory questions were: Are you a Doctor/Intern/Nurse?, Do you work in Andhra Pradesh?, Are you involved in active COVID-19 duties? Only if the above along with Consent being marked “Yes” mandatorily, did the form proceed to subsequent pages or would stop recording, ensuring exclusion criteria. Tools used to measure Psychological distress were The General Health Questionnaire (GHQ)-12. The GHQ-12 scale is used worldwide in different segments of practice and research – clinical, epidemiological, and psychological;[11],[12] the GHQ-12 showed high internal reliability (Cronbach's alpha of 0.82) and acceptable criterion validity.[13]

Perceived stress was measured using perceived stress scale-4 item (PSS-4). The PSS-4 is a brief tool derived from the PSS-10 with 4 items by Cohen, of which 2 items assess stress while 2 items measure coping strategy to stress.[14] Internal consistency for this scale was high and Cronbach's alphas ranged from 0.829 to 0.903.[15] Impact of event scale-revised (IES-R) was used to assess PTSD. The IES-R includes 22 items distributed over three subscales (intrusion items being 8, avoidance items being 8, and 6 hyperarousal items). Every item is rated on a likert scale of 0–4 (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, and 4 = extremely) experienced past 7 days. Total score on IES-R ranges between 0 and 88, and subscale scores can also be calculated.[16] Score is divided as <24, 24–32, 33–36 and >37 for no concern, clinical concern for PTSD, probable PTSD, and definitive PTSD, respectively, Cronbach's alpha = 0.85.[17]

The link of the Google form was distributed via Whatsapp groups/Facebook among general groups of Doctors/Interns/Nurses who are involved in active COVID-19 duties in Andhra Pradesh. The data was collected from the Google forms and method of sample collection was Purposive. Data collection began on August 15, 2020 and ended on September 15, 2020. The study received clearance by the Institutional Ethical research board. A total of 321 frontline health workers have filled the forms completely, 18 forms were incomplete and excluded.

Statistical analysis

The data were entered into MS excel 2007 version and further analyzed using IBM SPSS Statistics for windows, Version 21.0. Armonk, NY: IBM Corp..

Continuous variables were presented in descriptive statistics. Categorical data were presented using frequency and percentage. To test an association between attributes; Chi-square test, Fisher's exact test, Yate's correction have been applied as per the requirement of the cross tabulation tables.

The significance value was considered at the level of P ≤ 0.05.


[Table 1] elucidates out of 321 respondents 52.3% (n = 168) were male and 47.7% (n = 153) were female. Our sample was predominantly young with over 85% (n = 276) of frontline workers being <30 years. The mean age of the sample was 27.3 ± 4.7 years. Majority of the respondents (74.5%, n = 239) were unmarried. Education revealed, 40.2% (n = 129) to be MBBS graduates, 43% (n = 138) have completed PG degree (MD/MS), 8.7% (n = 28) have completed PG diploma, 2.5% (n = 8) have completed DNB plus PG diploma and 5.5% (n = 18) were nursing graduates. Predominant responders were Doctors, i.e., major portion being 39.3% (n = 126) post graduates and 36.4% (n = 117) Interns. 18.7% (n = 60) consisted of Consultant Doctors and Senior Residents. Only 5.6% (n = 18) consisted of nursing staff, being the smallest subgroup in our sample.{Table 1}

The number of days of COVID duty ranged from 0 to 60 days, with majority having done 7 days duty, i.e., 39.3% (n = 126) followed by 8–14 days duty being the next most common, i.e., 27.1% (n = 87). The mean number of COVID duty days was 14.7 ± 11.7. Most of our sample worked in screening area 31.5% (n = 101), followed by Isolation wards 24.3% (n = 78) and high risk wards 18.1% (n = 58). Minor portion of the sample worked intensive care unit (ICU) setting 4.4% (n = 14). Among them, 57% (n = 183) developed COVID-19 like symptoms and 43% (n = 138) did not.

[Table 2] shows the mean GHQ scores were 15.0 ± 6.4. Among the respondents 53% (n = 170) scored higher on GHQ scale and 47% (n = 151) scored lower. The mean PSS score of the sample is 7.9 ± 1.9. Among the respondents 69.47% (n = 223) scored higher on PSS and 30.52% (n = 98) scored lower. The mean IES-R scores were 30.2 ± 19.6. Cut-offs considered for PSS was median 8, for GHQ 12 scale cut-off was median of 15 and for IES-R was 29.{Table 2}

Among the respondents 34.9% (n = 112) have definitive diagnosis of PTSD based on IES-R scale, 8.4% (n = 27) have probable PTSD diagnosis, 17.4% (n = 56) have clinical concern of PTSD and 39.3% (n = 126) did not have any PTSD concerns. The mean value of intrusion sub scale was 10.8 ± 7.1, for Avoidance scale was 12.4 ± 7.7 and for hyper arousal sub scale was 7.0 ± 6.0.

[Table 3] shows our study found no significant association between varied occupations and severity of perceived stress however, out of 321 frontline workers 69.5% (n = 223) scored higher on PSS scale and 30.5% (n = 98) scored lower on PSS scale. Among those that scored higher on PSS scale 52.9% (n = 118) were male and 47.1% (n = 105) were female with the association being not significant (P = 0.754). Majority of nursing staff in our sample revealed higher perceived stress (>8), i.e., 77.7% (14 out of 18), followed by postgraduates (89 out of 126) and interns (82 out of 117) 70%, respectively, than consultant doctors 65% (26 out of 40) and senior residents 60% (12 out of 20).{Table 3}

[Table 4] demonstrates our study found the duration of COVID duty to be significantly associated with perceived stress (P = 0.001). Frontline workers having worked 0–7 days and 15–30 days revealed more individuals having higher perceived stress than those having worked 30–60 days (66.4% vs. 8.5%).{Table 4}

[Table 5] shows our study found significant association between age ranges and grades of PTSD (P = 0.033). Predominantly frontline workers aged <30 years showed definitive PTSD scores 74.6% (103 out of 176) followed by those aged 31–35 years 26.9% (7 out of 26) as compared to older age groups. Similar findings were also witnessed for probable PTSD scores, with those aged <35 falling more in probable PTSD category.{Table 5}

[Table 6] presents our study found statistically significant association between development of COVID-like symptoms and grades of PTSD (P = 0.007). 112 frontline workers reported definitive PTSD scores, and majority among them 74 (66%) had experienced development of COVID-like symptoms. Similar findings were noted among the probable PTSD scorers', wherein a majority 66% (18 out of 27) reported having developed COVID-like symptoms.{Table 6}

[Table 7] shows our study found significant associations (P = 0.001) between varied occupations and PTSD scores. Highest definitive PTSD was recorded among junior physicians, i.e., Senior residents (50%) and interns (48%) than qualified nurses and consultant specialists. Similar findings were seen in probable PTSD, with senior residents and interns forming the majority.{Table 7}

Among those with definitive PTSD, majority worked 31.3% (n = 35) in screening area and 27.7% (n = 31) isolation ward, lesser numbers in 18.8% (n = 21) high risk ward with least sample in 4.5% (n = 5) ICU with association being not statistically significant (P = 0.065).

[Table 8] shows our study attempted to study the association between perceived stress and PTSD, with association being statistically not significant. However, majority of frontline workers revealed higher perceived stress 69.5% (n = 223) and majority of whom went on to show definitive PTSD scores 35.34% (79 out of 223).{Table 8}

[Table 9] shows the IES-R scale is categorized into three subscales. Our study found, 10.9% (n = 35), 18.4% (n = 59), and 13.7% (n = 44) rated higher on intrusion, avoidance and hyper arousal sub scales, respectively, out of 321 frontline workers. Predominantly, higher rating scores was found in the avoidance subscale followed by hyperarousal then intrusion.{Table 9}

[Table 10] demonstrates that in our study, among the 112 respondents with definitive PTSD, almost close to half the sample - 48.21% (n = 54) recorded high avoidance scores with the association being very significant. Similarly, the association between other subscales of hyperarousal, intrusion with PTSD had very significant associations with P = 0.0001.{Table 10}


This cross-sectional survey enrolled 321 respondents and revealed a high prevalence of PTSD and high levels of stress among health care workers exposed to COVID-19 duties. Our study has showed that the perceived stress levels were more in majority of the respondents 69.7% and definitive PTSD was found in 34.8%. Psychological distress as recorded on GHQ was higher in 53% of the respondents, in which 87% belong younger age group of <30 years and 51.2% were female. Females were more distressed psychologically than males. This finding was similar to a 2020 study done by Lai et al. in China, which studied 1257 healthcare workers and used PHQ9 and IES-R as tools.[5] We found perceived stress to be predominant in males (52.9%) as a contrast to psychological distress findings and definitive PTSD to occur more in females (55.4%).

Being actively involved in frontline COVID-19 care was an independent risk factor for poor mental health outcomes across all dimensions of interest. The perceived stress levels was lesser among various cadres of physicians -70.6% of the post graduates, 70.1% of the interns, 60% of the senior residents, 65% of the consultants as against 77.7% of the nursing staff. Front line nurses treating patients with COVID-19 are likely exposed to the highest risk of infection because of their close, frequent contact with patients and working longer hours than usual which leads to increased stress levels. Our results are in concordance with the recent study done by Khanam et al., India[18] assessing 133 healthcare workers using online self-report stress scale and IES-R scale which showed that when compared to doctors, the nurses experienced more stress in terms of feeling sad and pessimistic, feeling of being avoided by others, the burden of change in the quality of work, stress due to colleagues testing positive, and agonizing over the welfare of one's family in the event of succumbing to the illness themselves. Our results were not in concordance with the study done in 2020 by Lai et al. in China[5] reported that about one-third of the front-line workers manifested the lower moderate range in PTSD severity (IES-R) with the prevalence being significantly higher among the nursing staff (74.55) than the physicians (66.9). Our study found increased perceived stress in nurses but an increased PTSD among physicians.

Almost equal elevated stress was noted in 33.2% of the people who worked for <7 days and also 33.2% of the people who worked for 15–30 days indicating that the number of days of COVID duties are significantly associated with perceived stress scores.

In our study, 34.9% of the total people have definitive diagnosis of PTSD, 39.3% did not have PTSD, 17.4% and 8.4% have clinical concern and probable PTSD respectively. Our results are in concordance with a study done in 2009 by Wu et al. in Beijing,[6] China which evaluated 549 hospital employees selected by stratified random sampling exposed to SARS outbreak and used IES-R, 10-item semi-structured questionnaire for psychological impact, and 3-item semi-structured questionnaire for fear. The study found 10% of the hospital employees experiencing increased posttraumatic stress symptoms. Factors implicated were hospital employees being quarantined, working in areas of contamination such as SARS wards, family/friends suffering SARS, led to a 2–3 times increased likeliness of having high PTS symptom levels, than employees without these exposures.

57% reported “yes” to have had COVID like symptoms and 43% “No,” the individuals suffering the symptoms had higher levels of Perceived Stress and reported higher scores on IES-R. This could be likely given the fear of developing the illness themselves following exposure.

Majority of definitive PTSD workers (91.9%) belong to 21–30 years of age group indicating perhaps younger age group being larger population in the COVID work area, and hence more at risk of PTSD. Females (55.4%) had more definitive diagnosis of PTSD than Males, indicating gender role in stress. More unmarried people (68.8%) have definitive PTSD diagnosis than married people perhaps owing to greater sample being unmarried. Our findings were in contrast with a survey study done by Khanam et al. in Kashmir, India assessing 133 healthcare workers using online self-report stress scale and IES-R scale[18] showed that psychological impact was significantly more in males than females and in those who were married.

Definitive PTSD was noted more in people posted to screening area (31%) than compared to isolation ward (27.7%), high risk ward (18.8%), low risk ward (8%) and ICU (4.5%) which could be explained as larger of the study sample was assigned to screening area. In addition, the ambiguity of COVID status of patients presenting for screening, thereafter examining said patients, with limited protective safeguards may play a role. These findings were similar to the study done by Khanam et al. in 2020,[18] showed that the psychological impact was also significantly related to the place of posting and severe psychological impact was reported by those working in COVID clinics or the swab collection centers which seems to be a perceived high-risk work environment experienced by the front line health care workers.

Our study has probed into the subsymptoms of PTSD which has not been elaborated in other studies, namely intrusion, hyperarousal, avoidance. All of the above had significant association with definitive PTSD, implying need to clinically watch out for these sub-symptoms.

Our findings report that, 54 (48.12%) of those with definitive PTSD reported avoidance on higher levels indicate that avoidance as a sub-symptom may be more indicative of PTSD than hyperarousal and intrusion subsymptoms. We have not elaborated in detail the findings related to psychological distress as it goes beyond the scope of this paper and will be presented eventually.


Our study found frontline workers to COVID-19, had marked degree of perceived stress, and fell more in the categories of probable and definite PTSD. Younger age, female gender, being unmarried, and having experienced COVID like symptoms, equally working 7 days and 15–30 days in COVID areas were some of the associated factors with stress and PTSD.

Interestingly, nurses had increased levels of perceived stress, but physicians had increased PTSD. The subsymptom of avoidance was found to be a more significant indicator of existing PTSD.


This study was a cross-sectional, online survey type study with a purposive sampling method; hence the results may not be generalizable. Being an online survey, we were unable to delineate the attrition rate in sample owing to those who dropped out in the middle of completing survey, or refused consent. In addition, the survey being online could not account for those frontline workers without internet facilities. A longitudinal study, with detailed in person psychiatric evaluation would be more conclusive measure of PTSD in the healthcare workforce.


We thank our frontline healthcare worker colleagues who took the time to participate and volunteer for the study, and stand with them in solidarity. We also thank Dr. Aruna B. Patil, associate professor, Department of PSM, ESIC medical college and PGIMSR, Chennai for her valuable help in statistical details.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
2Mental Health and Psychosocial Considerations during the COVID-19 Outbreak. World Health Organization, Geneva, Switzerland. Available from: [Last accessed on 2020 Sep 13; Last updated on 2021 Mar 24].
3Usher K, Durkin J, Bhullar N. The COVID 19 pandemic and mental health impacts. Int J Ment Health Nurs 2020;29:315-8.
4World Health Organization. Statement on the Second Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus (2019-nCoV); January 30, 2020. Available from: [Last accessed on 2020 Feb 02].
5Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
6Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, et al. The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009;54:302-11.
7Chong MY, Wang WC, Hsieh WC, Lee CY, Chiu NM, Yeh WC, et al. Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. Br J Psychiatry 2004;185:127-33.
8Coronavirus Update (Live). COVID 19 Coronavirus Pandemic. Available from: [Last accessed on 2020 Sep 13; Last updated on 2021 Mar 24].
9Tam CW, Pang EP, Lam LC, Chiu HF. Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline healthcare workers. Psychol Med 2004;34:1197-204.
10Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry 2018;87:123-7.
11Zulkefly NS, Baharudin R. Using the 12-item general health questionnaire (GHQ-12) to assess the psychological health of Malaysian college students. Glob J Health Sci 2010;2:1.
12Kilic C, Rezaki M, Rezaki B, Kaplan I, Ozgen G, Sağduyu A, et al. General Health Questionnaire (GHQ12 & GHQ28): Psychometric properties and factor structure of the scales in a Turkish primary care sample. Soc Psychiatry Psychiatr Epidemiol 1997;32:327-31.
13Endsley P, Weobong B, Nadkarni A. The psychometric properties of GHQ for detecting common mental disorder among community dwelling men in Goa, India. Asian J Psychiatr 2017;28:106-10.
14Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
15Zanesco AP, Denkova E, Rogers SL, MacNulty WK, Jha AP. Mindfulness training as cognitive training in high-demand cohorts: An initial study in elite military servicemembers. Prog Brain Res 2019;244:323-54.
16Weiss DS, Marmar CR. The impact of event scale – Revised. In: Wilson J, Keane TM, editors. Assessing Psychological Trauma and PTSD. New York: Guilford; 1996. p. 399-411.
17Mystakidou K, Tsilika E, Parpa E, Galanos A, Vlahos L. Psychometric properties of the impact of event scale in Greek cancer patients. J Pain Symptom Manage 2007;33:454-61.
18Khanam A, Dar SA, Wani ZA, Shah NN, Haq I, Kousar S. Healthcare providers on the frontline: A quantitative investigation of the stress and recent onset psychological impact of delivering health care services during COVID-19 in Kashmir. Indian J Psychol Med 2020;42:359-67.