The coronavirus (SARS-CoV-2) was reported to have emerged from the city of Wuhan in Hubei province in China and later reported to spread rapidly in different parts of the world within the following months. Its most common symptoms have been equated with flu, high fever, dry cough, sore throat, loss of taste, with frequent impact on the lungs and respiratory system creating breathing difficulties, and with some cases leading to death (1, 2). The speedy transmission, heavy upsurge of infections, and associated deaths have created a sense of panic across the world (3). As the pandemic wave(s) spread, most countries declared the novel corona virus to be a public health emergency and took precautionary measures such as social distancing, isolation, quarantines, and wearing masks (4) to reduce its dispersion (5) aiming to protect their citizens.

Other than physical health, implementation of lockdowns (restricting populations to stay in and work from home) along with inadequate information or uncertain measures to protect themselves or vulnerable loved ones have created varying types of psychological distress among people worldwide (6). Fears of being infected or isolated in quarantines have adversely affected many as they felt compelled to distance themselves from their peers, colleagues, families, and other social contacts (7). Seeking to deal with the uncertainties and possible implications of COVID-19 has impacted human psychology at many levels, including increasing fear, stress, anger (8), depression, anxiety, and in worst case scenarios, suicidal tendencies (9). It has also been reported that pandemic distress coupled with certain extreme preventive measures could trigger other pre-existing mental health diseases and even induce novel symptoms in those who previously did not have any mental health issues (10).

COVID-19 pandemic related studies across various regions have documented different psychological factors that directly and indirectly affect the mental health of almost every segment of the population (11). Special attention has been given to the impacts on medical workers around the world (12–15) as they were both directly exposed to COVID-19 patients and psychologically faced with additional self- and other-care challenges. Studies conducted in diverse cultural contexts such as, Israel, Turkey, Egypt, India, the United States, Saudi Arabia, China, Kuwait, Iran, Poland, and Bangladesh (16–26) have noted and examined the unique issues and implications facing medical staff during the COVID-19 pandemic. However, neither the context nor challenges facing doctors in Pakistan have been widely reported in recent literature especially during the fifth wave of COVID-19.

Pakistan presents an interesting and important case for a national context as a highly populated (220 million) under-developed country and one already facing the multiple challenges of an energy crisis, weak economy, and political instability. A health emergency was declared in Pakistan right after the initial infected COVID-19 cases gained momentum. Partial and smart lockdowns, vaccinations, and improved treatment policies have helped Pakistan to control the transmission of the virus to protect the general citizens of the country (27).

An earlier investigation about the COVID-19 pandemic on seven different Asian countries (including Pakistan) found that the people of Thailand and Pakistan scored very high on the depression anxiety stress scale (DASS-21) as compared to the other countries (28). A study on the Punjab province of Pakistan reported that 21.9% of depression and 21.4% of anxiety symptoms were witnessed among the health care workers (HCW) and that the most affected population was medical doctors (29). It is also found that 79.7% of the HCW in Pakistan were having very high levels of and severe anxiety issues concerning COVID-19 (7). Researchers interviewed thirteen young doctors and found that they were experiencing psychological distress in the form of increased stress, fear, and anxiety after the emergence of the COVID-19 pandemic in Pakistan (30). Another sample reported that 43% of anxiety/depression prevailed among the frontline doctors of Pakistan in 2020 (31). Clearly, HCW in Pakistan have been more exposed to COVID-19 as elsewhere, and as an important health service sector that every country looks to in such distressing pandemic situations, their responses, wellbeing, and mental health cannot be overlooked.

The abovementioned studies provide evidence that HCW and frontline doctors are among the most vulnerable populations at a higher risk who are also more exposed to COVID-19 cases on a frequent and long-term basis as compared to ordinary people (in Pakistan as in other nations). Unfortunately, most of previous studies were completed during the initial waves of COVID-19 and did not adopt a well-established scale (like the DASS-21) to document the levels of depression, anxiety, and stress specifically of doctors. DASS-21 is widely considered to effectively address the symptoms of depression, anxiety, and stress (32) which indicate the mental health of the general populace rather than a clinical population. Research gaps exist in not examining the fifth wave of COVID-19, application of DASS-21, and specifically not yet targeting the frontline doctors in Pakistan. Therefore, the current study aims to address and consider the connections between these previously unexplored areas by incorporating the DASS-21 to apply this instrument to the frontline doctors of Pakistan during fifth wave of COVID-19.

The study aimed to fill noted gaps to extend pandemic research to document the symptoms and levels of depression, anxiety, and stress among the frontline doctors in Pakistan during the fifth wave of COVID-19, and to validate DASS-21 in the context of Pakistan. Past research in Pakistan tended to focus mainly on HCW but could not be extrapolated to project the special case situation or psychological orientations faced by frontline doctors who had to actively deal with a pandemic that lasted several years and face the unabating needs of COVID-19 patients. Most of the previous research had been carried out during the initial waves of COVID-19 and though contributing much toward general understandings of the psychological effects of a pandemic, had not yet found ways to study the ongoing mental health of frontline doctors, especially during this late stage, in the fifth wave of COVID-19. Most importantly, a well-established scale (DASS-21) had not been previously considered or validated, either in Pakistan or tested for its effectiveness in determining which psychological symptoms arise more prominently in medical or para-medical staff. Therefore, connecting all the above-mentioned limitations, the current study is designed to fill the gaps in the existing literature.

It is evident in this study that 72.7% of doctors were having the symptoms of depression, 70.2% were having anxiety, and 58.3% were dealing with stress arising from the COVID-19 pandemic. The findings revealed that the psychological symptoms reported during the fifth wave of COVID-19 are much higher than the previously documented symptoms had been during the start of pandemic (29). This may be a logical finding from an ongoing pandemic, but has not been studied or confirmed previously, nor the impact expected to this hight degree. In addition, doctors rated moderate levels of depression and stress, but severe levels of anxiety specifically related to COVID-19 issues. The levels are in line with the findings of previous research which reported the severity of anxiety among the HCW in Pakistan (7). It has been reported that the symptoms and levels of depression, anxiety, and stress are more intense over time as compared to the earlier studies (30, 31). In comparison to the normal populace, it seems that mental health of the frontline doctors is seriously affected and considerably worse since the emergence of COVID-19 pandemic, suggesting that their needs may need to be recognized and better dealt with. Even though the treatment system has been improved and multiple vaccines are available and have been administered broadly, medical doctors are still facing psychological challenges.

In terms of the validation of DASS-21, the results of multiple statistical procedures essential for the attainment of reliability and validity of any measurement tool were fulfilled in the current study. There is abundant evidence available in the literature that has confirmed that DASS-21 is a reliable and valid scale for the assessment of depression, anxiety, and stress symptoms among various cultural contexts (32, 35). However, very few studies are available that confirm DASS-21 as a valid measurement tool in the cultural context of Pakistan, and if so, most have been applied to the general public (28) not specifically to the frontline doctors of Pakistan. The findings of this investigation revealed that DASS-21 is a valid and reliable measurement tool to document the depression, anxiety, and stress symptoms of frontline doctors during the fifth wave of COVID-19 on the cultural setting of Pakistan.

Though it has been established that mental health challenges are not limited to ordinary citizens or persons that have already been diagnosed as having mental health diseases, this study shows that those professionals that society relies on most during times of international health crises suffer at higher rates than might be expected. COVID-19 studies have already warned the world that the pandemic will likely have lasting impacts on the masses. The findings of the existing study have reconfirmed their predictions. Continuing in the line of studies that have examined HCW and the medical profession, this study shows even more clearly that even doctors, who are trained to deal with crises and have many such experiences, are not unaffected by its impacts, and in fact, perhaps suffer far more than expected. Pakistan has excellent medical doctor training, and its physicians are expected to perform an important role in the stability of society. Therefore, findings like these on the existence of serious levels of depression, anxiety, and stress among them even (or especially after dealing with several years of this pandemic) cannot be neglected due to the potential adverse effects on the society.

The pandemic may now have subsided, but more research is needed to determine if there are any long-term psychological syndromes that linger among medical professionals. Facing such facts, both policy makers and administrators need to ensure more support and assistance focused on frontline doctors. Their mental health can be improved or maintained primarily through two main bodies: the government and hospitals. The government should focus on providing certain seminars or training sessions for the counseling of their frontline doctors to secure and ensure their mental health. The hospitals and doctors' associations could regularly monitor their mental wellbeing and provide treatments to their HCW. Though effective strategies based on such research findings, Pakistan or other countries with similar conditions might be able to provide better medical conditions and staff support to effectively serve public health needs.

The mental wellbeing of the frontline doctors is a necessity for any country or nation during both normal and emergency situations like the COVID-19 pandemic. The current study has shed light on the alarming symptoms and higher-than-expected levels of depression, anxiety, and stress among the frontline doctors who have had to cope with the fifth wave of COVID-19 in Pakistan. Highlighting this issue warrants serious consideration from the government and both public and private hospitals' management. The policy makers in Pakistan or similar countries need to frame new polices to ensure their doctor's wellbeing which can ultimately influence the betterment of health in the society. The present study also validated the established DASS-21 instrument in the cultural context of Pakistan. Future research could seek to identify personality and situational factors that are directly influencing the depression, anxiety, and stress of doctors to consider correlations between factors or moderating variables. More studies targeting the long-term impacts of COVID-19 and the post-pandemic situation on the mental health of doctors or other health care populations will be beneficial for a greater understanding concerning the nature and influences of these past and future pandemics.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Institutional Ethics Review Committee of the SISU Intercultural Institute (SII), Shanghai International Studies University (SISU), China (2022-SII/IRB-0103). The patients/participants provided their written informed consent to participate in this study.

MN: investigation, conceptualization, methodology, validation, data collection, formal analysis, and writing—original draft preparation. SK: conceptualization, methodology, resources, and writing—review and editing. IB: conceptualization, formal analysis, and writing—review and editing. All authors contributed to the article and approved the submitted version.