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Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis

BMJ 2020; 369 doi: (Published 05 May 2020) Cite this as: BMJ 2020;369:m1642

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Linked Editorial

Covid-19: adverse mental health outcomes for healthcare workers

  1. Steve Kisely, professor1234,
  2. Nicola Warren, consultant psychiatrist13,
  3. Laura McMahon, medical student3,
  4. Christine Dalais, research librarian3,
  5. Irene Henry, psychiatry registrar1,
  6. Dan Siskind, associate professor125
  1. 1Metro South Mental Health and Addiction Services, Brisbane, Australia
  2. 2Metro South Public Health Unit, Coopers Plains, Australia
  3. 3School of Clinical Medicine, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, Australia
  4. 4Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Canada
  5. 5Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Australia
  1. Correspondence to: D Siskind PA-Southside Clinical Unit l School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia d.siskind{at}
  • Accepted 23 April 2020


Objective To examine the psychological effects on clinicians of working to manage novel viral outbreaks, and successful measures to manage stress and psychological distress.

Design Rapid review and meta-analysis.

Data sources Cochrane Central Register of Controlled Trials, PubMed/Medline, PsycInfo, Scopus, Web of Science, Embase, and Google Scholar, searched up to late March 2020.

Eligibility criteria for study selection Any study that described the psychological reactions of healthcare staff working with patients in an outbreak of any emerging virus in any clinical setting, irrespective of any comparison with other clinicians or the general population.

Results 59 papers met the inclusion criteria: 37 were of severe acute respiratory syndrome (SARS), eight of coronavirus disease 2019 (covid-19), seven of Middle East respiratory syndrome (MERS), three each of Ebola virus disease and influenza A virus subtype H1N1, and one of influenza A virus subtype H7N9. Of the 38 studies that compared psychological outcomes of healthcare workers in direct contact with affected patients, 25 contained data that could be combined in a pairwise meta-analysis comparing healthcare workers at high and low risk of exposure. Compared with lower risk controls, staff in contact with affected patients had greater levels of both acute or post-traumatic stress (odds ratio 1.71, 95% confidence interval 1.28 to 2.29) and psychological distress (1.74, 1.50 to 2.03), with similar results for continuous outcomes. These findings were the same as in the other studies not included in the meta-analysis. Risk factors for psychological distress included being younger, being more junior, being the parents of dependent children, or having an infected family member. Longer quarantine, lack of practical support, and stigma also contributed. Clear communication, access to adequate personal protection, adequate rest, and both practical and psychological support were associated with reduced morbidity.

Conclusions Effective interventions are available to help mitigate the psychological distress experienced by staff caring for patients in an emerging disease outbreak. These interventions were similar despite the wide range of settings and types of outbreaks covered in this review, and thus could be applicable to the current covid-19 outbreak.


  • Contributors: SK conceptualised the project with input from DS. CD devised the search with support from DS. LM, IH, and NW conducted the search. All authors were involved with data extraction and validation. SK conducted the data analysis with support from DS. SK and DS interpreted the data with support from NW and LM. SK wrote the first draft of the manuscript. All authors were involved in editing and approving the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. SK and DS act as guarantors.

  • Funding: No funding.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

  • Dissemination to participants and related patient and public communities: The authors intend to disseminate this research through social media, press releases to mainstream media, media interviews, and direct dissemination to hospital and health service directors in relevant jurisdictions.

  • The lead authors (SK and DS) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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