Human behavior worldwide changed after the lockdown measures in response to the COVID-19 pandemic [1]. Believably, environmental and social changes introduced by the pandemic were shown to affect sleep timing and duration in recent studies among different populations and have resulted in an unprecedented psychological impact on healthcare workers, who were already working under stressful conditions [2, 8,9,10,11]. Growing reports highlighted the impact of the COVID-19 pandemic on sleep quality, anxiety, insomnia, and other neuropsychiatric influences among the frontline healthcare workers as being on fire, facing the new enemy, and exposed to infection and severe complications up to death. This is a rich research point as the relationship looks bidirectional; improvement in mental health and sleep efficiency may reduce the negative impact of the current pandemic and vice versa [12,13,14].

On the other hand, to the best of our knowledge, no reports focusing on the second-line HCWs who are not in the direct battle with the new enemy and the implications of the pandemic on their mental health, quality of life with a suspected negative impact on their work performance, are still not studied efficiently. So, we conducted the current work to assess anxiety, insomnia, and poor sleep among second-line HCWs during the COVID-19 pandemic.

The main results in the current work are as follows: although being a second-line HCWs, there was a high prevalence of anxiety, insomnia, and poor sleep, during the COVID-19 era. There was a significant change in anxiety, insomnia, and poor sleep in participants after the current pandemic. Also, among participants without prior condition before the COVID-19 pandemic, 43.4% developed anxiety, 58.5% developed insomnia, and 65.1% developed poor sleep.

Moreover, the cumulative effect of the COVID-19 pandemic on the study participants without prior condition revealed that three conditions (anxiety, insomnia, & poor sleep) were de novo experienced in 19.8%, while 12.3% still are not affected by the pandemic. Among 106 participants without prior condition, participants that had been following daily pandemic updates, being infected with, or having a friend/colleague who died with COVID-19 developed higher frequencies of de novo combined anxiety, insomnia, and poor sleep compared to those who do not.

A wide variety of studies worldwide focused on frontline HCWs and the effect of the current pandemic on mental health issues. In a recent Jordanian study, approximately 1/3 of the studied frontline HCWs who engaged in direct management of COVID-19 patients reported severe symptoms of anxiety (29.5%), depression (34.5%), and insomnia (31.9%) [15].

Mental health outcomes among frontline and second-line HCWs during the COVID-19 pandemic were studied in Italy by Rossi and colleagues in 2020 [16]. And reported 49.38% of the respondents endorsed post-traumatic stress, 24.73% reported symptoms of depression, 19.80% had symptoms of anxiety, and 8.27% had insomnia.

In another study from Kuwait, the reported prevalence of poor sleep during the current pandemic was 78.8 [14].

In China, a considerable percent of participants reported symptoms of anxiety (560 [44.6%]) and insomnia (427 [34.0%])). Median [IQR] Insomnia Severity Index scores among frontline vs second-line workers were 6.0 [2.0–11.0] vs 4.0 [1.0–8.0]; P < 0.001. Multivariate regression analysis showed that frontline HCWs engaged in close contact and management care of COVID-19 patients were associated with an increased risk of anxiety (OR, 1.57; 95% CI, 1.22–2.02; P < 0.001) and insomnia (OR, 2.97; 95% CI, 1.92–4.60; P < 0.001) [17].

There was an association between female sex with development of anxiety. Moreover, being married to a HCW was linked with anxiety and insomnia. Also, there was a trend of increasing frequency of anxiety, insomnia, and poor sleep with those whose experience was ≤ 5 years, while age and unchanged working hours were not associated with any mental health problems.

Oteir et al. in their study reported a mean age of participants was 32.1 (± 5.8) years, and the majority were males (80.3%), with no observed differences based on gender, job title, marital status, or educational level. Moreover, in the multivariate linear regression, none of the independent factors was associated with various neuropsychiatric scores, and the only exception was increased severity of insomnia among paramedics [15].

In a Chinese cross-sectional study of 1257 HCWs from 34 hospitals concerning with COVID-19 management, a considerable association was reported between depression, anxiety, and insomnia in frontline female nurses who particularly worked in Wuhan [17].

Younger age and female sex were associated with all investigated outcomes except insomnia (e.g., anxiety for standardized age: odds ratio [OR], 0.60; 95% CI, 0.44–0.82; P = 0.001; perceived stress for standardized age: OR, 0.63; 95% CI, 0.46–0.85; P = 0.002; post-traumatic stress among women: OR, 2.31; 95% CI, 1.76–3.05; P < 0.001; depression among women: OR, 2.03; 95% CI, 1.44–2.87; P < 0.001). Being a frontline HCW was associated with PTSS (OR, 1.37; 95% CI, 1.05–1.80; P = 0.03) [16].

Among 106 participants without prior condition, 22.4% of those who followed updates about COVID-19 on a daily basis developed de novo combined anxiety, insomnia, and poor sleep compared to only 9.5% of those who were not following updates. A total of 38.5% of the participants that had been infected with COVID-19 developed de novo combined anxiety, insomnia, and poor sleep compared to only 17.2% of those who had not been infected. A total of 50% of the participants who had a colleague/friend who died with COVID-19 developed de novo combined anxiety, insomnia, and poor sleep compared to only 16.7% of those who had not.

In an Italian study, nurses and healthcare assistants were more likely to endorse severe insomnia (nurses: OR, 2.03; 95% CI, 1.14–3.59; P = 0.02; healthcare assistants: OR, 2.34; 95% CI, 1.06–5.18; P = 0.04). Having a colleague who died was associated with post-traumatic stress (OR, 2.60; 95% CI, 1.30–5.19; P = 0.007) and symptoms of depression (OR, 2.07; 95% CI, 1.05–4.07; P = 0.04) and insomnia (OR, 2.94; 95% CI, 1.21–7.18; P = 0.02); having a colleague hospitalized was associated with PTSS (OR, 1.54; 95% CI, 1.10–2.16; P = 0.01) and higher perceived stress (OR, 1.93; 95% CI, 1.30–2.85; P = 0.001); and having a colleague in quarantine was associated with PTSS (OR, 1.59; 95% CI, 1.21–2.09; P = 0.001), symptoms of depression (OR, 1.38; 95% CI, 1.00–1.90; P = 0.047), and higher perceived stress (OR, 1.66; 95% CI, 1.19–2.32; P = 0.002). Being exposed to contagion was associated with symptoms of depression (OR, 1.54; 95% CI, 1.11–2.14; P = 0.01 [16].

Frontline HCWs are the leading group affected by different mental health issues than before the current pandemic because of the higher chance of getting the infection with the unavailability of adequate personal protective equipment, high-stress level, and heavy daily workloads [14].

There had been strict lockdown measures to prevent the spread of the disease as guided by the WHO. As COVID-19 is highly contagious, social distancing and self-isolation were the best preventive measures to minimize the risk of spreading the infection. However, these precautionary strategies have a deleterious impact on emotional and mental health, such as the development of chronic insomnia. It can vary from simple mood changes, depression, and minor anxiety to very severe forms of mental issues such as severe depression and even suicide [18,19,20].

The home isolation itself is a psychological burden, and even the individual does not have clinical symptoms and remains physically well, they often suffer from adverse psychological effects [21].

Not only the frontline HCWs are at increased risk of sleep disturbances and mental health affection. In addition to the factors mentioned above, the second-line HCWS have other unique risks: first, the preexisting sleep and mental health issues before the pandemic due to heavy work schedules and frequent night shifts. This fragility makes them more susceptible to the deterioration or addition of a new health issue. Second, the second-line HCWs have a very likely chance to move forward to be a frontline one as a part of rotatory strategies or the need for more fighters in times of the pandemic peaks. Third, they are more interested in daily updates of disease and death rates, developing and failing many promising therapeutics supposed to achieve successful treatment.

To the best of our knowledge, this is the first study focusing on the second-line HCWs and the effects of the new pandemic on their mental health that can negatively affect health system quality. This can be a nucleus for further studies and planning for future therapeutic strategies.

This study’s limitations include the cross-sectional design; therefore, mental health affection was not evaluated during different time intervals. Moreover, it could be affected by the peak of COVID-19 cases. Finally, other variables that could affect mental health, e.g., depression and burnout, were not assessed. 

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