Occupational stress and diminished levels of overall well-being among healthcare workers were issues of concern even prior to the coronavirus disease 2019 (COVID-19) pandemic, which exacerbated existing stressors and introduced new challenges to this workforce.^1,2 Mental health concerns that have been the focus of attention in this workforce include depression, anxiety, substance use disorders, post-traumatic stress disorder (PTSD), burnout, compassion fatigue, and suicide.

Healthcare workers have long faced a convergence of stressors that are less common in other types of work. These stressors include the emotional burden of dealing with individuals who are seriously ill or dying; witnessing traumatic events, which is associated with PTSD, particularly among first-responders;^3,4 secondary traumatic stress following exposure to traumatized patients, particularly in emergency rooms;^5,6 witnessing or being the target of workplace violence,⁷ which can result in adverse physical, psychological, social, and emotional effects;^7–10 and workplace bullying.^10–12 The prevalence of these problems has been reported to be particularly pronounced in emergency and psychiatry departments within hospitals, in the home health setting, and in nursing care facilities.^7,9,13 Among the additional stressors for many healthcare workers are poor job design, management challenges, suboptimal safety climate/safety culture, high caseloads, the effects of shift work and long work hours, and exposure to pathogens.

Most research on mental health in the healthcare workforce has focused on physicians (including physicians in training) and nurses. Problems noted among physicians include depression, anxiety, substance use disorders, burnout, and suicide.^13–17 As with the general public, estimated prevalences of depression among healthcare workers vary depending on the case definition and characteristics of the measurement instrument (e.g., criteria met for depressive disorder versus presence of sub-clinical depressive symptoms; self-reported symptoms versus provider-diagnosed depression; current depressive symptomatology versus incidence in the last 12 months), as well as demographic characteristics of the respondents (e.g., variation by age).^{14–16,18,19} Depression has also been reported among physicians in training; a systematic review noted estimates of the prevalence of depression or depressive symptoms among residents ranging from 21% to 43%, depending on the case ascertainment variables listed above,¹⁶ while a prospective study found an increase in depression based on PHQ-9 scores from 3.9% prior to the internship year to more than 20% during each quarter of the internship.²⁰ As with depression, suicide risk appears to accelerate during the physician training period.¹⁹ Beyond the training period, female physicians have been found to have higher rates of completed suicide, at 1.4–2.3 times the rate in the general population,¹⁸ although a recently-published analysis suggests the overall suicide risk among physicians is not significantly different from that of the general population.²¹ Identified risk factors for mental health issues among physicians are both individual and occupational, with the latter including the stress of patient interactions and expectations, easy access to medication, heavy workload, adverse work schedules, and problematic or limited social interaction in the workplace.¹³

A high prevalence of depression has been noted among registered nurses (RNs).²² A survey of nurses employed by hospitals reported rates of depressive symptomatology of 18%, approximately twice that of the U.S. population, with job satisfaction, body mass index, number of health problems, mental well-being, and health-related productivity significantly associated with depression scores.²³ The prevalence of depression among RNs is reported to be highest among those who are young, female, or working in intensive care or psychiatric units.²² Nurses appear to be at higher risk for suicide than both physicians and the general public.^24,25

Mental health concerns in the healthcare workforce are not restricted to physicians and nurses. However, information about the prevalence of mental health problems among other healthcare occupations is more limited. Rates of depression, stress, and PTSD have been reported for emergency services personnel, but estimates vary widely.²⁶ The scant literature on healthcare support workers (e.g., patient care aides; occupational, physical, and dental aides; phlebotomists) has found that care and support workers have worse mental health than the general working population²⁷ and that patient care aides are more likely to report depression than nurses.²⁸ Female healthcare support workers have also been found to have elevated rates of suicide.²⁵ Janitors across all industries have a higher prevalence of depression than other workers.²⁹ Although ancillary healthcare workers such as housekeeping staff do not have direct patient care responsibilities, they frequently work in patient care areas.

Mental health is also a concern for social workers, counselors, psychologists, and others who are tasked with directly addressing the mental health needs of others.^30,31 Male human service workers have been found to have higher levels of antidepressant use than other workers at the same skill level.³² Elevated suicide rates have been reported among male welfare support workers, social workers, and female welfare support workers.³³

Although the pandemic has led to new mental health challenges for workers globally, healthcare workers have been particularly at risk due to increased emotional, physical, and organizational demands, as well as increased risk of infection with SARS-CoV-2, the virus that causes COVID-19. However, fully addressing the long-term mental health needs of this workforce also requires understanding the levels of baseline, pre-pandemic mental health issues. To assess baseline mental health and well-being among healthcare workers in different occupations, we examined 2017–2019 data from the Behavioral Risk Factor Surveillance System (BRFSS). While BRFSS does not include prevalence data on the full range of mental health conditions and is limited to self-reported conditions and diagnoses, it does sample from a wide range of healthcare (and other) industries and occupations.

To our knowledge, this is the first study to evaluate pre-pandemic mental health and well-being of the healthcare workforce using a broad definition of this workforce (healthcare industry workers who have patient care responsibilities or who work in patient care areas) and including low-wage healthcare workers. The purpose of this study was to identify segments of the healthcare workforce that had the highest pre-pandemic prevalences of selected adverse conditions related to mental health and well-being, as they might require additional services during and after the pandemic.

The 37,685 BRFSS respondents who worked in healthcare industries were the focus of the study (Table 2). Another 4,627 healthcare workers were employed in non-healthcare industries; results for this group are not further reported. The 219,871 non-healthcare workers comprised the comparison population. The largest subset of the 37,685 healthcare respondents were from the hospital industry (47%), followed by ambulatory care (29%), nursing care facilities (10%), home health (8%), dental offices (4%), and other healthcare industries (2%).

Although much of the research on adverse mental health conditions among healthcare workers has focused on physicians and nurses, our study assessed mental health and well-being among multiple healthcare industry workforces and found that healthcare support workers bore the greatest burden of these conditions before the COVID-19 pandemic. Among low-wage workers, patient and personal care aides were particularly at risk, with higher prevalences of adverse mental health conditions and poorer well-being compared to both other healthcare workers and the non-healthcare workforce. These findings by occupation were reflected in healthcare industry results: workers in the home health and nursing care facility industries, where the majority of patient and personal care aides work, had higher prevalences of adverse health conditions than their counterparts in hospitals and ambulatory care settings.

Workforces with either a very high prevalence of a single condition or many conditions with significantly elevated aPRs can be considered to have high mental health burdens. By these metrics, the occupations with the highest burdens have workforces that are largely female (nursing, psychiatric, and home health aides; counselors; personal care aides), have relatively high percentages of non-Hispanic African American workers (nursing, psychiatric, and home health aides; counselors; food preparation and serving), have low educational attainment (nursing, psychiatric, and home health aides; patient and personal care aides; janitors; food preparation and serving; trades), and/or have low household incomes (nursing, psychiatric, and home health aides; patient and personal care aides; janitors; food preparation and serving). Many workforces with these demographic characteristics are disproportionately subject to multiple stressors, including discrimination and restricted occupational options.^39,40

Previous literature has noted that self-reported health and the prevalence of mental health issues differ across demographic characteristics. Women report more mental health symptoms, both in general and in the workplace context,¹⁸ and they report more physical health repercussions from burnout.³¹ Socioeconomic status and race/ethnicity have been reported to affect self-rating of health in the general population, perhaps reflecting differing expectations⁴¹ or experiences.⁴² In an older study of mental health workers, non-White respondents reported lower levels of both emotional exhaustion and personal accomplishment, while higher education and salary were positively associated with both outcomes.³⁰ This observation may stem from different configurations of job demand and control, as well as other occupational and non-occupational stressors. Within the physician occupation, a recent study found no significant differences in prevalence of depressive symptoms by race/ethnicity.⁴³ Of interest is that our study did not observe significantly increased adverse health conditions for occupations with the highest prevalences of Hispanic workers. While Hispanic workers are disproportionately found in several low-wage healthcare occupations, they have a substantial presence in professional occupations (e.g. comprising 20% of dentists). Notably, the prevalence of depression in the general population is inversely related to income, with nearly 16% of adults with family income below the Federal Poverty Limit (FPL) reporting depression during the past two weeks, compared to 3.5% of adults from families with incomes at least four times the FPL.⁴⁴ All of the demographic and occupational findings in our study of mental health and well-being should be considered within the context of complex relations between discrimination, income, educational opportunities, and occupational opportunities, as well as reporting differences. While presentation of separate results by demographic group was beyond the scope of this scan of mental health outcomes by healthcare occupation, further research into demographic differences within specific occupations is warranted.

Mental health conditions among healthcare workers not only adversely affect the workers themselves and their families, they can also impact patient care.⁴⁵ A systematic review found that common mental disorders in nurses were strongly associated with multiple adverse work themes: general errors, medication errors, near misses, and decreased patient safety and satisfaction.⁴⁶ Self-reported exhaustion due to long-term stress has been associated with poor job performance and absence due to illness among healthcare and social insurance workers.⁴⁷ Depression among physicians is also associated with lower quality medical care;⁴⁸ although research on the effects of depression on care quality among low-wage healthcare workers is lacking, there is little reason to believe results would differ. The elevated burden of adverse health conditions observed among home health and nursing care facility industries in the current study may be linked to observed high staff turnover in these industries.

Multiple groups of healthcare workers reported insufficient sleep. The prevalence of insufficient sleep was elevated in the healthcare industry as a whole and specifically in the hospital and nursing care facility home industries, and among workers in specific healthcare occupations: RNs, patient care aides, personal care aides, medical assistants, phlebotomists, food preparation and serving workers, and workers in the trades. Whether insufficient sleep primarily reflects long working hours, shift work, or is a function of insomnia (from physical or mental health conditions) or mental health issues or conditions (e.g., anxiety, depression) likely varies by individual, as well as industry and occupation, and could not be determined in this cross-sectional study. Among all industries, shift work has been associated with increased risk of adverse mental health outcomes, with results varying by sex and shift type.⁴⁹ Shift work is associated with insufficient sleep,⁵⁰ which in turn has been associated with increased odds of poor self-rated health,⁵¹ burnout,⁵² and depressive symptoms.⁵³ The mechanisms of relations between insufficient sleep and some adverse effects may be complex: one study found that while long working hours appear to be linked to depression in physicians, the association disappeared after stratification for an occupational stress metric.⁵⁴ However, the high prevalence of insufficient sleep across the healthcare workforce is concerning.

This study has a number of limitations. Foremost is that BRFSS questions related to mental health are not comprehensive. While depression and “poor mental health days” are included, the survey does not specifically assess other common conditions such as anxiety. In addition, the “diagnosed depression” variable provides no specific information on severity or duration and is a single summary metric, with none of the detail included in survey instruments designed to ascertain symptoms or severity of depression. All information in BRFSS is self-reported and subject to social desirability and recall bias, with the former likely to lead to underestimated prevalences of adverse health conditions. Of the basic demographic characteristics, income was omitted most frequently (11%) for our study population. The results for several of the adverse health conditions we evaluated could also be affected by the stigma associated with mental health issues (resulting in underreporting); the level of stigma may differ by demographic and occupational group. Finally, as the BRFSS industry and occupation module is optional and is not administered by every locality, these results are not nationally representative. Despite these limitations, the current findings are useful for identifying groups within the healthcare workforce in most need of resources and interventions to address adverse mental health issues.

Prevention of the upstream (including organizational and structural) factors leading to mental health issues among healthcare workers, along with subsequent assessment, intervention, and treatment, is key. However, research on the efficacy of workplace mental health and well-being programs, practices, and policies (including those that are individually, group, and organizationally focused) has been characterized as sparse, methodologically weak, or failing to account adequately for differences in demographic or occupational groups.^30,31,55,56 The results of the current study highlight the need for understanding and improving working conditions that may impact healthcare workers’ mental health and well-being. Research on interventions among healthcare support staff and other low-wage healthcare workers, groups with the highest prevalences of adverse outcomes in this study, has been particularly limited. Such research is particularly important in light of the finding in previous research that the suicide rate in female healthcare support workers is significantly higher than that of all female workers.²⁵

Other barriers to addressing mental health issues include stigmatization of acknowledging and seeking help for mental health issues, as well as access to affordable care. Stigma has been noted particularly for physicians, who have concerns about the professional implications of accessing mental health care.¹³ The need for specialized service providers who are aware of these concerns has been noted.^13,18 Incorporating education about mental illness into medical training is recommended.⁴⁸ Another barrier, access to affordable care, is most salient for lower-wage workers, such as patient and personal care aides; low-wage workers are more likely to lack health insurance and to be unable to afford healthcare visits.²⁷

One potential approach to circumventing the stigma of seeking mental health assistance might be to focus on addressing burnout, a construct that is sometimes conflated with mental health concerns such as depression and anxiety. The nature of the relationship between burnout and mental health concerns is contested, with some research finding them indistinguishable⁵⁷ and other analyses suggesting that depression and anxiety are distinct from burnout⁵⁸ or that only specific characteristics of burnout are linked to depression⁵⁹ or anxiety.⁶⁰ Investigators have expressed concern that burnout is taken less seriously than the overlapping or coextensive diagnosis of depression.⁵⁷ However, the possibility that burnout may be less stigmatized and may thus present a more acceptable reason for seeking treatment should be explored. Unfortunately, interventions around burnout have limitations similar to those described for other mental health and well-being concerns. Public health and health delivery systems should strive to implement evidence-based programs that 1) meet the needs of specific workforces to support employee mental health and well-being, and 2) simultaneously address organizational impediments to the success of these programs through measures such as ensuring easy and affordable access, employee privacy, and supportive work cultures.

In these pre-pandemic survey data, elevated prevalences of the broadest range of mental health-related concerns were seen among low-wage healthcare workers. More recent work has documented the effects of both occupational and personal stressors associated with COVID-19 on a range of healthcare workers.^1,2,61,62 Among the general public, the prevalence of depression has increased markedly from pre-pandemic levels, particularly for more severe depression,⁶³ although whether this increase will be sustained is unclear. Regardless, the current emotional support needs of the healthcare workforce are likely greater than those indicated by this study. At the same time, mental health treatment resources have been heavily strained by the pandemic and its repercussions and are not available to all who would benefit from them. Moreover, many lower-income healthcare workers, such as the healthcare support group observed in this study to have high prevalences of multiple adverse health conditions, may not have access to affordable mental health treatment. A concerted effort to develop, implement, and evaluate occupation- and industry-specific, culturally competent prevention, intervention, and mitigation strategies addressing both organizational and personal conditions that lead to mental health issues is critical to ensuring a robust healthcare workforce.