Edited by: Biljana Filipovic, University of Applied Health Sciences, Croatia
Reviewed by: Adriano Friganovic, University of Rijeka, Croatia
Biserka Bergman Markovic, Academy of Medical Sciences of Croatia, Croatia
†These authors have contributed equally to this work and share first authorship
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The COVID-19 pandemic has significantly impacted general medical practice by altering work structures and increasing teamwork while also adversely affecting the mental health of general practitioners and family medicine specialists. This study assesses depression, anxiety, and fear levels among general practitioners and family medicine specialists in Europe 2 years after the COVID-19 pandemic’s onset, and it explores influencing factors.
This observational cross-sectional study included participants from 13 European countries. Data was collected from May to August 2022 with an anonymous online survey incorporating validated questionnaires for depression (PHQ-9), anxiety (GAD-7), and fear of COVID-19 (FCV-19S). Data analysis involved descriptive statistics, correlation tests, and linear regression.
A total of 1,723 participants completed the survey. Findings indicated an overall mild to moderate levels of anxiety (GAD-7: 5.4 ± 4.76) and depression (PHQ-9: 6.33 ± 5.43), and moderate fear of COVID-19 (FCV-19: 12.84 ± 5.29). Key determinants of anxiety, fear, and depression included country, at-risk status, patient non-compliance, and mental health history. Sex influenced anxiety and fear, losing co-workers to COVID-19 influenced anxiety and depression, while losing relatives or friends influenced fear.
Two years into the pandemic, European general practitioners and family medicine specialists showed mild to moderate levels of anxiety, depression, and fear. Country, at-risk status, mental health history, and work-related challenges significantly affected mental health. Crucial interventions are needed to support healthcare workers during pandemics, focusing on protective measures, stable work environments, and coping strategies for anxiety and depression.
Epidemics and pandemics have been associated with increased rates of psychological distress, particularly among healthcare workers (HCWs), who are frequently exposed to high-risk environments and intense workloads (
The COVID-19 pandemic has placed an unprecedented strain on global healthcare systems, significantly affecting the well-being of primary care providers. While the pandemic has prompted beneficial changes such as enhanced teamwork and modified work systems, these benefits have been counterbalanced by increased workloads, psychological distress, and workplace stressors, including patient non-compliance, lack of social support, and exposure to misinformation and harassment from COVID-19 deniers (
This study aims to fill this research gap by providing a comprehensive analysis of depression, anxiety, and fear of COVID-19 among European GPs and FMSs 2 years into the pandemic. Unlike previous studies that focused primarily on hospital-based HCWs, our research provides new insights into how various demographic, professional, and personal factors influence mental health outcomes within primary care settings. By offering a cross-national perspective, this research provides valuable insights into the psychological well-being of primary care physicians and informs policy recommendations for mitigating future mental health burdens during public health crises.
This anonymous online observational cross-sectional survey was conducted across 13 European countries: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Germany, Italy, Latvia, Macedonia, Montenegro, Romania, Serbia, Slovenia, and Turkey. The target population was GPs and FMSs in the member-countries. Convenience sampling was used to recruit participants through various national organizations of GPs and/or FMSs in each country.
The initial questionnaire, based on an extensive literature review, was developed in English by the core team (MZ, JD, AZ, KC, LŠ), and piloted in February–March 2022. Following revisions, it was translated, back-translated, and adapted for 13 languages. The questionnaire included several sections, including sociodemographic questions, questions addressing professional and personal experiences during COVID-19, and scales for assessing depression, anxiety, and fear of COVID-19.
The primary endpoints included depression levels using the nine-item Patient Health Questionnaire (PHQ-9) scale, anxiety levels using the seven-item Generalized Anxiety Disorder (GAD-7) scale and the fear levels using the Fear of COVID-19 scale (FCV-19S). The PHQ-9 is a validated nine-item tool used for screening, diagnosing, monitoring and measuring the severity of depression, with a sensitivity and specificity of 88% for Major Depressive Disorder at a cut point of ≥10 (
Participants from Germany were exempted from the “number of registered patients” metric, due to different registration practices, and a surrogate parameter was used for workload comparison, which is the “number of patients treated quarterly.”
The survey was conducted on the Qualtrics platform, which complies with GDPR regulations and ensures data security. No identifiable personal data, such as names, surnames, or addresses, were collected, guaranteeing participant anonymity. The survey was launched on the 23rd of May 2022 and closed on the 10th of August 2022. Our target sample size was a minimum of 50 participants per country. In total 1723 people participated in the survey. The statistical analysis was performed using the R Statistical software (version 4.0.5), with continuous variables reported as mean ± SD and categorical variables as percentages. All tests were two-tailed and a
To explore associations, four different tests were performed: (1) Pearson’s correlation for two continuous variables; (2) Spearman’s correlation for ordinal and continuous variables; (3) Point biserial correlation for dichotomous and continuous variables; (4) Kruskal Wallis test for categorical and continuous variables. The Kruskal-Wallis test is a non-parametric equivalent of ANOVA which shows that there are differences, e.g., between countries, without assessing how strong these differences are. Linear regression models examined factors influencing depression, anxiety, and fear. Covariates were selected using stepwise AIC (bi-directional) method.
Among the 1723 participants, the majority were female (76.09%), and the average age was 47 ± 12 years (See Appendix 1, Table 1). Most of the participants worked in urban areas (74.29%). There were 913 FMSs and 711 GPs. The mean years of experience were 17.04 ± 10.98. The mean number of registered patients per GP, across countries, was 1865.02 ± 871.5, while the number of patients treated quarterly by German GPs was 1251.25 ± 399.08. Over two thirds of the participants were in a relationship/married and cohabitating (67.09%; See Appendix 1, Table 1).
The PHQ-9 scores had a mean of 6.33 ± 5.43, with a median of 5, indicating an overall mild to moderate depression. The GAD-7 scores had a mean of 5.4 ± 4.76, with a median of 4, indicating an overall mild to moderate anxiety. The FCV-19S scores had a mean of 12.84 ± 5.29, with a median of 12, suggesting an overall moderate fear related to COVID-19. The statement “It makes me uncomfortable to think about Corona” had the highest mean score of 2.35, followed by “When I watch news and stories about Corona on social media, I become nervous or anxious” with a mean score of 2.19. The statement “I cannot sleep because I’m worrying about getting Corona” had the lowest mean score of 1.48.
There was a significant association between country of origin and depression (
Closing practices during COVID-19 significantly increased depression levels, although the effect was small (
Participants categorized as “at-risk” (e.g., advanced cancer, severe asthma/COPD, pregnancy, age over 70) were more likely to experience depression (
Statistically significant factors associated with depression levels included country, losing co-workers to COVID-19, work-related challenges, falling within the at-risk category, and pre-existing mental health disorders (See Appendix 1, Table 4). Being from Serbia and not experiencing any mental health disorders before and during the pandemic significantly lowered depression levels. Conversely, being from Turkey, falling within the at-risk category, and experiencing mental health disorders before and during the pandemic significantly increased depression levels. Work-related challenges such as staff shortage, patient non-compliance, lack of clear guidance/protocols, and problems with prescribing medicine and medical devices to chronic patients significantly increased depression levels.
Statistically significant factors associated with anxiety levels included country, sex, losing co-workers to COVID-19, work-related challenges, falling within the at-risk category, and pre-existing mental health disorders (See Appendix 1, Table 5). Being male and from Serbia significantly lowered anxiety levels. Conversely, being from Germany, losing co-workers to COVID-19, falling within the at-risk category, having pre-existing mental health disorders, as well as staff shortages, patient non-compliance, and reduced methods of communication with the secondary/tertiary level of healthcare significantly increased anxiety levels.
Statistically significant factors associated with fear of COVID-19 levels included country, sex, work-related challenges, falling within the at-risk category, experiencing loss of relatives or friends to COVID-19, and pre-existing mental health disorders (See Appendix 1, Table 6). Males and participants from all countries except Turkey showed lower fear levels, while, falling within the “at-risk category,” patient non-compliance, and experiencing mental health disorders before and during the pandemic increased fear levels.
This survey study explored the levels of depression, anxiety and fear of COVID-19 among GPs and FMSs in Europe, 2 years after the COVID-19 pandemic’s onset, and it explored influencing factors. Our findings revealed mild to moderate levels of anxiety and depression, and a moderate level of fear of COVID-19 among the European GPs and FMSs. The three models we developed uncovered various demographic, professional and personal factors influencing these assessed levels. Overall, country, falling within the at-risk category, patient non-compliance and mental health history were key determinants across anxiety, fear, and depression models. Sex was an influencing factor in the anxiety and fear models. Losing co-workers to COVID-19 influenced anxiety and depression levels, while losing relatives or friends to COVID-19 influenced only fear levels.
While most COVID-19 mental health research focuses broadly on HCWs, we targeted GPs and FMSs, and this gave us nuanced insights. The main strength of our study lies in its multinational scope and large sample size, enhancing the generalizability of our findings and enabling cross-cultural comparisons.
On the other hand, participants were predominantly from Central and Eastern European countries, except for Italy and Turkey. Convenience sampling may have introduced selection bias, potentially excluding individuals with higher depression, anxiety, and fear levels. As an exploratory and observational study, multiple test corrections were not applied. The variables in the multivariate models included overlapping categories (e.g., ‘anxiety’ and ‘anxiety, depression’), which may introduce redundancy and complicate interpretation. While this reflects the real-world complexity of comorbid conditions, future studies could explore alternative categorizations to enhance clarity. Our approach aimed to preserve the richness of the data and participants’ experiences during the pandemic. Furthermore, the ‘N/A’ category for sex was included in the analysis but represents fewer than 0.5% of the total sample, which may contribute to computational instabilities and affect the stability of the results. Despite these limitations, the present study provides interesting research directions for future studies, especially to further explore the impact of many categorical variables that were found to be significant such as country, workplace sector, and marital status on the mental health status of GPs and FMS.
Various studies worldwide assessed depression, anxiety and fear in HCWs during COVID-19. In Italy, 28.1% of 139 GPs displayed moderate to severe depressive symptoms (mean PHQ-9 7.0 ± 4.8), while 31.7% displayed similar anxiety symptoms (mean GAD-7 7.4 ± 4.7) (
In our univariate analysis, males experienced lower levels of anxiety, depression and fear, while in the multivariate analysis, being male was associated with lower levels of fear and anxiety only. Previous studies revealed men were more prone to depression (
Our univariate analysis showed that GPs exhibited lower levels of depression, anxiety, and fear compared to FMSs, although this was not statistically significant in the multivariate models. Previous studies have found that GPs experience more depression, anxiety, and burnout than hospital staff (
A Greek study of 236 HCWs, including GPs, found rural work settings associated with a lower anxiety risk, although depression risk was not significantly affected by location (
A study of 1,040 Chinese GPs found anxiety associated with inadequate facilities and poor sleep, but mitigated by training and proper PPE (
These findings highlight the complex interplay of factors shaping mental health outcomes during the pandemic. The multivariate analysis revealed that being from Serbia significantly reduced depression and anxiety levels, yet no explanation for this effect was found in the data or existing literature. Conversely, higher anxiety levels in Germany and higher depression levels in Turkey may reflect distinct stressors, such as procedural changes or workload pressures specific to these healthcare systems. Differences in cultural norms, healthcare practices, or access to mental health resources could also contribute to these country-specific outcomes. Further research is needed to better understand these variations and their implications for supporting healthcare professionals.
The identified factors influencing anxiety, depression, and fear levels, including demographics, professional context, and personal history, highlight the multifaceted nature of mental health in this population. Our findings underscore the importance of tailored interventions and support mechanisms to address the unique challenges faced by GPs and FMSs. Policymakers and healthcare administrators should consider implementing strategies to mitigate work-related stressors and provide targeted mental health support. Future research should focus on longitudinal studies and comparative analyses across different healthcare systems and cultural contexts to further understand the pandemic’s global mental health impact.
GPs and FMSs in Europe experienced mild to moderate anxiety and depression levels, and moderate fear of COVID-19 levels 2 years into the pandemic. Various demographic, professional, and personal factors, such as country, at-risk status, and mental health history, influenced these levels across the three models developed. Comparison with previous studies demonstrated varying levels of anxiety, depression, and fear across different countries and professions during different stages of the pandemic, suggesting fluctuations possibly influenced by evolving understanding, policies, and vaccination efforts. Sex disparities and workplace challenges, like staff shortages and patient non-compliance, also impacted mental health. In future pandemics, actions should be taken to reduce the risks and increase the protective factors, including addressing GPs’ and FMSs’ needs, providing mental health support at the individual level, and combating stigma through awareness at the community-level.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The study was conducted in accordance with the Declaration of Helsinki. In Latvia, approval was given by the Riga Stradins University Research Ethics Committee (protocol code 2-PĒK-4/244/2022, approved on 325 20.04.2022). Ethical approval was not required in other participating countries, as confirmed by their respective regulatory bodies, since the study posed minimal risk and complied with national guidelines for anonymous survey research. Participants were informed about the study’s purpose, voluntary nature, and confidentiality of their responses.
MZ: Conceptualization, Data curation, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing. JD: Investigation, Methodology, Writing – original draft, Writing – review & editing. AZ: Investigation, Methodology, Writing – original draft, Writing – review & editing, Conceptualization. KC: Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing. HL: Investigation, Writing – review & editing. CF: Data curation, Formal analysis, Validation, Visualization, Writing – review & editing. MC: Investigation, Writing – review & editing. MS: Investigation, Writing – review & editing. CIB: Investigation, Writing – review & editing. NB: Investigation, Writing – review & editing. AS: Investigation, Writing – review & editing. CB: Investigation, Writing – review & editing. LK: Investigation, Writing – review & editing. ZJ: Investigation, Writing – review & editing. LR: Investigation, Writing – review & editing. MB: Investigation, Writing – review & editing. VL: Investigation, Writing – review & editing. EA: Investigation, Writing – review & editing. LŠ: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – review & editing.
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
We extend our sincere gratitude to Miloranka Petrov Kiurski, Mustafa Mümtaz Mazıcıoğlu, Mustafa Fevzi Dikici, Daniel Atijas, Hristo Dimitrov, Manon Richter, Fatbardha Skenderi, and Milena Kostić for their invaluable contributions to this study, particularly in the translation and back-translation of the survey, as well as survey distribution and data acquisition. We are also grateful to Michael Harris, for his expert review of the manuscript as a native English speaker and medical professional, and to Lewis Buckley and Tom Willetts for their thorough proofreading and language review.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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