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Prevalence and clinical characteristics of depression and symptoms of anxiety in staff at a health institution in Medellin during the COVID-19 pandemic
Prevalencia y características clínicas de los síntomas depresivos y ansiosos de los trabajadores de una institución de salud en Medellín durante la pandemia por COVID-19
Miguel Restrepo-Martíneza,
Corresponding author
mrm87356@hotmail.com

Corresponding author.
, Marcela Escobara, Luz Aida Marína, Diana Restrepob
a Departamento de Salud Mental, Clínica Las Américas Auna, Medellín, Colombia
b Universidad CES, Medellín, Colombia
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physical distancing and other public health strategies aimed at reducing the rate of contagion appear to have a negative impact on the mental health of an important population group&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">From this perspective&#44; health personnel face an extraordinary challenge&#58; caring for others whilst exposing themselves to contagion&#46; Doctors&#44; nurses&#44; therapists and other healthcare and non-healthcare personnel in clinics and hospitals are required to be prepared to work in extraordinarily complex situations of permanent exposure to COVID-19&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> Thus&#44; health personnel seem to be the group that is most exposed to the psychological challenges of a new normal&#46; This psychological burden is likely due to staff reorganisation&#44; increased work intensity&#44; and the anxiety of being exposed to the virus in hospital and&#44; in turn&#44; bringing the infection home&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Shortly after the pandemic was declared&#44; studies began to be published reporting high levels of stress in health personnel&#44; now called &#34;the first line&#34; of care&#44; which has been reflected in a higher prevalence of insomnia and anxious and depressive symptoms&#44; in addition to a probable increase in suicide rates in this population&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a> Continuing research on this topic makes it possible to generate information that helps to strengthen the response capacity of health systems&#44; in addition to monitoring and positively influencing the mental health fatalities of health workers&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The objective of this study is to determine the prevalence and clinical characteristics of depressive and anxious symptoms in the workers of a health institution in Medell&#237;n&#44; Colombia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A descriptive&#44; observational and cross-sectional study was conducted&#46; Auna is a regional health group with nearly 6&#44;000 employees&#44; which has a network of clinics and medical centres in Peru and Colombia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The Cl&#237;nica Las Am&#233;ricas Auna is a health institution located in Medell&#237;n with 304 beds to provide care for children and adults who require emergency services&#44; hospitalisation and intensive care for patients with highly complex medical and surgical diseases&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Since the declaration of the COVID-19 pandemic&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> the mental health area of Cl&#237;nica Las Am&#233;ricas Auna wanted to align its efforts with the proposals made by the <span class="elsevierStyleItalic">New Health Foundation</span> &#40;a non-profit institution for the observation and optimisation of health systems&#41;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> to strengthen&#44; support and act for health personnel in times of crisis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This programme included&#58; &#40;a&#41; training on precautions to take to prevent the spread of the coronavirus and emotional regulation techniques&#59; &#40;b&#41; identification of people with anxious and depressive symptoms of clinical importance&#44; who are offered individual intervention by psychology and psychiatry&#44; and &#40;c&#41; short acupuncture sessions and active guidelines to promote well-being&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participants</span><p id="par0040" class="elsevierStylePara elsevierViewall">The 2&#44;100 employees of the institution in the healthcare and administrative areas were invited to participate in the study&#46; Between 1 March and 31 May 2020&#44; the Communications Department motivated participation in the study through the different internal communication channels such as the intranet&#44; billboards&#44; word-of-mouth&#44; work group leaders and the email of each employee&#46; The survey was available for eight weeks&#44; the time that the sample collection lasted&#44; and 1&#44;247 employees took the surveys and agreed to participate in the study&#46; There was one inclusion criterion&#58; being an employee of the institution during the sample collection time&#46; Those who did not give their informed consent were excluded&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Variables</span><p id="par0045" class="elsevierStylePara elsevierViewall">Sociodemographic variables were included&#58; age&#44; sex&#44; job &#8212;healthcare&#44; administrative&#8212;&#44; work modality &#8212;face-to-face&#44; teleworking&#8212; and psychiatric symptoms&#58; nine depressive symptoms&#44; seven anxious symptoms and scores from the Patient Health Questionnaire-9 &#40;PHQ-9&#41; and Generalised Anxiety Disorder &#40;GAD-7&#41; scales&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data sources</span><p id="par0050" class="elsevierStylePara elsevierViewall">The information was collected from a survey designed by the researchers for this study&#44; which included 22 questions with Likert-type response options that were easy to understand and answer&#46; It took 10&#8722;15&#8239;min to complete&#46; No pilot test was carried out&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Instruments used</span><p id="par0055" class="elsevierStylePara elsevierViewall">This study employed two psychometric scales available for free use to apply to the Colombian population<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#58; the PHQ-9 and the GAD-7&#46; The PHQ-9 consists of nine Likert-type questions with answers scoring between zero and three points&#46; Possible scores range from zero to 27&#46; Cut-off points five&#44; 10&#44; 15&#44; and 20 are for mild&#44; moderate&#44; moderately severe&#44; and severe depression&#46; With a cut-off point &#62;10&#44; there is a sensitivity of 88&#37; and a specificity of 88&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The GAD-7 consists of seven Likert-type questions with answers scoring between zero and three points&#46; Possible scores range from zero to 21&#46; The proposed cut-off points of five&#44; 10&#44; and 15 are for mild&#44; moderate&#44; and severe symptoms&#44; and clinical evaluation is recommended with scores &#62;10&#46; With these cut-off points&#44; the scale has a sensitivity of 89&#37; and a specificity of 82&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Both questionnaires are validated in Spanish&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#8211;19</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Biases</span><p id="par0060" class="elsevierStylePara elsevierViewall">The researchers took into account the following biases&#58; &#40;a&#41; selection bias&#59; a broad campaign was carried out to disseminate the research through the institution&#39;s communication channels and each person was given numerous opportunities to participate in the study&#59; &#40;b&#41; information bias&#59; the data was anonymised and only processed by the researchers&#44; guaranteeing privacy and use of the information for strictly clinical and research purposes&#59; in addition&#44; validated instruments were used&#44; which explored mental symptoms that occurred in the prior two weeks&#44; which reduces recall bias&#44; and &#40;c&#41; confounding bias&#59; the scope of the study is descriptive&#44; so its objective is not to search for associations&#46; However&#44; other variables that classify the cause or origin of the reported anxious and depressive symptoms according to the respondent were not included&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Sample size</span><p id="par0065" class="elsevierStylePara elsevierViewall">The sample size was 1&#44;247 individuals&#46; The number of people who responded to the survey during the study period determined the sample size&#44; so it is a non-probabilistic&#44; non-representative sample&#44; in which not all individuals had the same probability of being chosen&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Analysis of the information</span><p id="par0070" class="elsevierStylePara elsevierViewall">The information was analysed with the SPSS statistical software version 21 &#40;SPSS Inc&#46;&#59; United States&#41;&#44; licensed&#46; The qualitative variables are presented as absolute and relative frequencies&#46; The quantitative variables are presented as mean&#8239;&#177;&#8239;standard deviation&#44; and median &#91;interquartile range&#93;&#44; based on assumptions of normality &#40;Shapiro&#8211;Wilk test&#41;&#46; Analysis was conducted by subgroups of age&#44; sex and occupation using the Pearson or Fisher &#967;<span class="elsevierStyleSup">2</span> statistic&#44; assuming significant differences from p&#8239;&#60;&#8239;0&#46;05&#46; The prevalence of clinically significant depressive &#40;PHQ-9&#8239;&#62;&#8239;10&#41; and anxious &#40;GAD-7&#8239;&#62;&#8239;5&#41; symptoms was determined&#46; All surveys were fully completed&#44; so there were no missing data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical considerations</span><p id="par0075" class="elsevierStylePara elsevierViewall">This investigation was approved by the Institutional Research Committee&#46; According to Colombian regulations&#44; it is classified as having a lower than minimal risk&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Informed consent was obtained from each participant&#46; The principles of the Declaration of Helsinki of the World Medical Association were taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The confidentiality of and respect for the information provided were guaranteed&#46; This manuscript was constructed following the guidelines of the STROBE Declaration&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">Fifty-nine point zero nine percent of those invited to participate responded to the survey&#46; Of the 1&#44;291 completed surveys&#44; 3&#46;5&#37; &#40;n&#8239;&#61;&#8239;44&#41; did not authorise the use of the information for research&#44; so they were excluded from the sample&#46; Results are presented from the 1&#44;247 surveys that were fully completed&#46; The median age was 36 <a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> &#40;range&#44; 18&#8211;80&#41; years&#59; the other characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Prevalence of symptoms of anxiety</span><p id="par0085" class="elsevierStylePara elsevierViewall">The presence of symptoms of anxiety in the study population in the two weeks prior was investigated&#46; Forty-nine point nine percent of the population studied did not have anxious symptoms of clinical importance&#46; Mild anxious symptoms &#40;GAD-7&#8239;&#62;&#8239;5&#41; were identified in 31&#46;7&#37;&#44; moderate symptoms &#40;GAD-7&#8239;&#62;&#8239;10&#41; in 13&#46;4&#37;&#44; and severe &#40;GAD-7&#8239;&#62;&#8239;15&#41; in 5&#46;1&#37; of the participants&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists the anxious symptoms grouped into symptoms of lesser clinical importance &#40;not at all-several days&#41; and of greater clinical importance &#40;more than half the days-nearly every day&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Prevalence of symptoms of depression</span><p id="par0090" class="elsevierStylePara elsevierViewall">The presence of symptoms of depression in the study population in the two weeks prior was investigated&#46; Fifty-nine point four percent of the participants had no depressive symptoms&#59; mild symptoms &#40;PHQ-9&#8239;&#61;&#8239;5&#8211;9&#41; were identified in 26&#46;0&#37;&#44; moderate &#40;PHQ-9&#8239;&#61;&#8239;10&#8211;14&#41; in 8&#46;2&#37;&#44; moderately severe &#40;PHQ-9&#8239;&#61;&#8239;15&#8211;19&#41; in 4&#46;7&#37; and severe &#40;PHQ-7&#8239;&#62;&#8239;20&#41; in 1&#46;7&#37;&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> lists the depressive symptoms grouped into symptoms of lesser clinical importance &#40;not at all-several days&#41; and of greater clinical importance &#40;more than half the days-nearly every day&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Neurovegetative symptoms and suicidal ideation according to sex</span><p id="par0095" class="elsevierStylePara elsevierViewall">It was found that 19&#46;3&#37; of women and 12&#46;5&#37; of men had problems related to appetite&#44; whilst 25&#46;7&#37; of women and 19&#46;8&#37; of men had problems related to sleep&#46; Regarding death or suicidal ideation&#44; 62 women &#40;6&#46;4&#37;&#41; and 19 men &#40;6&#46;6&#37;&#41; admitted to this type of ideation in the prior two weeks&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Moderate to severe symptoms of depression and anxiety</span><p id="par0100" class="elsevierStylePara elsevierViewall">Clinically significant symptoms of depression and anxiety &#40;of moderate and severe intensity&#41; were reported by 14&#46;6&#37; and 18&#46;5&#37; of respondents&#44; respectively&#46; These were compared according to sex&#44; age ranges and work modality &#40;remote-virtual&#41;&#46; A higher proportion of moderate to severe depressive and anxious symptoms was found in women&#44; in the face-to-face work modality&#44; and in the youngest participants &#40;aged 18&#8211;25 years&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Possible associations of depressive and anxious symptoms with the other study variables were explored&#46; The presence of symptoms of anxiety was associated with the female sex &#40;p&#8239;&#61;&#8239;0&#46;004&#41; and the face-to-face work modality &#40;p&#8239;&#61;&#8239;0&#46;004&#41;&#46; Symptoms of depression were associated with the female sex &#40;p&#8239;&#61;&#8239;0&#46;005&#41;&#44; but not with the face-to-face work modality &#40;p&#8239;&#61;&#8239;0&#46;133&#41;&#46; Likewise&#44; the presence of moderate anxiety was higher in the personnel who carried out tasks associated with healthcare than in those with administrative tasks &#40;p&#8239;&#61;&#8239;0&#46;046&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">During 2020&#44; workers in the health sector faced unprecedented situations&#58; caring for patients with COVID-19&#44; overcoming social changes&#44; facing intense stressors such as the death of their peers&#44; and making decisions in clinical scenarios of great uncertainty&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This has led to health professionals being described in heroic terms&#46; However&#44; the potential mental health crisis that could develop among health workers has not received enough attention&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The stress they are currently exposed to could affect the physical and mental health of the healthcare workforce and&#44; in turn&#44; reduce their ability to deal effectively with the current health emergency&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The main finding of this study is that one in five people surveyed showed clinically-significant symptoms of anxiety&#44; and one in six symptoms of depression&#46; In the general population of Medell&#237;n&#44; the prevalence of major depressive disorder in the last 30 days is 2&#46;20&#37; &#40;that of any mood disorder&#44; 2&#46;82&#37;&#41; and that of generalised anxiety disorder&#44; 0&#46;46&#37;&#44; &#40;that of any anxiety disorder&#44; 5&#46;08&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Therefore&#44; the prevalence of depressive and anxious symptoms in our study with the health sector population was seven times higher for depression and up to 40 times for anxiety&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Our findings coincide with recent studies carried out in other countries&#44; which have yielded alarming results regarding the mental health of health personnel&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a> For example&#44; the survey carried out by the team of Jianbo Lia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> in 1&#44;257 Chinese health personnel subjects&#44; found depressive and anxious symptoms &#40;from moderate to severe&#41; in 14&#46;8&#37; and 12&#46;3&#37; of respondents&#44; respectively&#46; Also&#44; in a recent systematic and meta-analytic review which included 13 studies and 33&#44;062 participants&#44; Pappa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> found a prevalence of anxiety of 23&#46;2&#37;&#44; of depression of 22&#46;8&#37; and of insomnia of 38&#46;9&#37;&#44; which reveals the high prevalence of these mental symptoms in health workers&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Other authors have wanted to determine how some mental health symptoms are related according to the work carried out during the pandemic&#46; In China&#44; Zhang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> conducted a study with 2&#44;182 people with the aim of comparing psychosocial and mental health problems during the COVID-19 outbreak in two groups of workers&#46; They found higher prevalences of insomnia &#40;38&#46;4&#37; vs&#46; 30&#46;5&#37;&#59; p&#8239;&#60;&#8239;0&#46;01&#41;&#44; anxiety &#40;13&#46;0&#37; vs&#46; 8&#46;5&#37;&#59; p&#8239;&#60;&#8239;0&#46;01&#41;&#44; depression &#40;12&#46;2&#37; vs 9&#46;5&#37;&#59; p&#8239;&#60;&#8239;0&#46;04&#41;&#44; somatisation &#40;1&#46;6&#37; vs 0&#46;4&#37;&#59; p&#8239;&#60;&#8239;0&#46;01&#41;&#44; and obsessive-compulsive symptoms &#40;5&#46;3&#37; vs 2&#46;2&#37;&#59; p&#8239;&#60;&#8239;0&#46;01&#41; in the medical group&#46; Similarly&#44; in our study it was observed that individuals with healthcare-related jobs reported anxious symptoms of moderate intensity more frequently than workers in non-clinical areas&#46; Thus&#44; the different stressors during long working hours&#44; sleep deprivation&#44; in addition to anxious and depressive symptoms&#44; could constitute a significant source of fatigue and poor clinical judgement&#44; which has a negative impact not only on the quality of life of the staff health&#44; but also in the proper care of patients in need&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In addition&#44; it is important to bear in mind that&#44; even before the COVID-19 pandemic&#44; health personnel constitute a vulnerable population in itself in terms of mental health problems&#46; In fact&#44; the suicide rate for physicians is 44&#37;&#44; higher than that of the general population&#46; Nursing staff and other healthcare workers are also at high risk&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Some authors point out that this risk could increase given the current situation&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Accordingly&#44; 6&#46;5&#37; of the individuals in our study admitted having had thoughts of death or suicide in the prior two weeks&#46; Other studies have not reported findings on this particular aspect&#44; which should be addressed as soon as possible&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Limitations</span><p id="par0135" class="elsevierStylePara elsevierViewall">Among the limitations of this study are the following&#58; first&#44; because it is a cross-sectional study&#44; the temporal relationship between exposure and disease cannot be accurately established&#59; second&#44; the instruments used to identify both depressive and anxious symptoms&#44; although they are validated instruments and widely used in research&#44; do not allow for diagnoses of depressive or anxiety disorder&#59; third&#44; the data presented only describe what happened at a specific time and cannot be generalised to another time&#44; even in the same study population&#59; fourth&#44; recall biases are possible in this type of study&#59; fifth&#44; the participation of the employees was close&#44; but it was &#60;60&#37;&#44; and sixth&#44; the previously mentioned inclusion and exclusion criteria did not take into account factors such as the time of employment contract&#44; disabilities or annual leave and this will be reflected in a more heterogeneous sample&#44; in itself not representative&#46; However&#44; this study provides important information regarding depressive and anxious symptoms in a large group of employees of a health institution in the city of Medell&#237;n during the COVID-19 pandemic&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Highly prevalent anxious and depressive symptoms were identified in workers of a health institution during the COVID-19 pandemic in the city of Medell&#237;n&#44; Colombia&#46; There was no clear predominance of anxious and depressive symptoms according to sex&#44; as is usual in the general population&#46; Despite the fact that more studies are necessary to measure the impact of these symptoms on health sector personnel&#44; their high prevalence is already worrying&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Healthcare executives and managers need to be aware of the potential increase in psychological stress faced by healthcare workers during the times of COVID-19&#46; Support for health sector personnel and their families could protect against adverse psychological outcomes&#46; In view of the vital role played by this population in times of pandemic&#44; the development of mental health programmes that address the problems of the health sector should be considered a priority&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaAceptado" => "2021-02-15"
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      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:5 [
            0 => "Symptoms"
            1 => "Depression"
            2 => "Anxiety"
            3 => "Health sector"
            4 => "Health workers"
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        ]
      ]
      "es" => array:1 [
        0 => array:4 [
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          "palabras" => array:5 [
            0 => "S&#237;ntomas"
            1 => "Depresi&#243;n"
            2 => "Ansiedad"
            3 => "Sector sanitario"
            4 => "Personal sanitario"
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    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The COVID-19 pandemic has represented an extraordinary challenge for health workers as they care for others while exposing themselves to contagion&#46; Doctors&#44; nurses&#44; therapists and other non-care staff in clinics and hospitals are asked to be prepared to work in particularly complex and stressful situations&#44; which makes them vulnerable to mental health problems&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">To determine the prevalence and clinical characteristics of anxiety and depression symptoms in staff working at a health institution in Medellin&#44; Colombia&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Observational&#44; descriptive and cross-sectional study&#44; based on a survey designed for the investigation&#44; which included two scales to screen depression and anxiety symptoms&#44; as well as sociodemographic variables&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A total of 1&#44;247 workers from the health institution were included&#46; Of these&#44; 14&#46;6&#37; reported symptoms of depression and 18&#46;5&#37; of clinically significant anxiety&#46; A higher proportion of moderate to severe depression and anxiety symptoms was found in those working face to face&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Anxiety and depression symptoms are highly prevalent among staff at a health institution in Medellin&#44; Colombia&#44; during the COVID-19 pandemic&#46; Given the vital role of the health sector in times of pandemic&#44; the development of mental health programmes that address the problems of this population should be considered a priority&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Methods"
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            "identificador" => "abst0020"
            "titulo" => "Results"
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            "identificador" => "abst0025"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Afrontar las circunstancias de la vida y el trabajo que la pandemia por COVID-19&#8239;ha impuesto al personal sanitario implica un reto extraordinario&#58; cuidar y atender a otros&#44; exponi&#233;ndose a s&#237; mismos al contagio&#46; A m&#233;dicos&#44; enfermeras&#44; terapeutas y dem&#225;s personal asistencial y no asistencial en cl&#237;nicas y hospitales&#44; se les pide estar preparados para trabajar en situaciones extraordinariamente complejas y estresantes&#44; lo que los hace vulnerables a problemas mentales&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Determinar la prevalencia y las caracter&#237;sticas cl&#237;nicas de los s&#237;ntomas ansiosos y depresivos del personal que trabaja en una instituci&#243;n de salud en Medell&#237;n&#44; Colombia&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; descriptivo y transversal&#44; a partir de una encuesta dise&#241;ada al efecto&#44; la cual incluy&#243; 2 escalas para tamizar s&#237;ntomas depresivos y ansiosos&#44; adem&#225;s de variables sociodemogr&#225;ficas&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a 1&#46;247 trabajadores de la instituci&#243;n de salud&#46; El 14&#44;6&#37; report&#243; s&#237;ntomas depresivos y el 18&#44;5&#37;&#44; ansiosos cl&#237;nicamente significativos&#46; Se encontr&#243; una mayor proporci&#243;n de s&#237;ntomas depresivos y ansiosos moderados-graves en la modalidad de trabajo presencial&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Los s&#237;ntomas ansiosos y depresivos son muy prevalentes entre los trabajadores de una instituci&#243;n de salud de Medell&#237;n durante la pandemia de COVID-19&#46; Dado el papel vital del sector salud en tiempos de pandemia&#44; el desarrollo de programas de salud mental que aborden los problemas de esta poblaci&#243;n deber&#237;a considerarse una prioridad&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Proportion of people with moderate-severe anxious and depressive symptoms&#44; by sex&#46;</p>"
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        "mostrarFloat" => true
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Proportion of people with moderate-severe anxious and depressive symptoms&#44; by age group&#46;</p>"
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        "etiqueta" => "Fig&#46; 3"
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        "mostrarFloat" => true
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        "figura" => array:1 [
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">959 &#40;76&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Not at all-several days&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">More than half the days-nearly every day&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have felt anxious&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">997 &#40;79&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">250 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have not been able to stop or control worrying&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;051 &#40;84&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">196 &#40;15&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have been worrying too much about different things&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;005 &#40;80&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">242 &#40;19&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have had trouble relaxing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;015 &#40;81&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">232 &#40;18&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have felt so restless that it is hard to sit still&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;114 &#40;89&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">133 &#40;10&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have become easily annoyed or irritated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;079 &#40;86&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">168 &#40;13&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have been afraid that something awful might happen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">994 &#40;79&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">253 &#40;20&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Anxious symptoms in the last two weeks&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Not at all-several days&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">More than half the days-nearly every day&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Little interest or pleasure in doing things&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;139 &#40;90&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">114 &#40;9&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have felt down&#44; depressed&#44; hopeless&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;132 &#40;90&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">115 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have had trouble falling or staying asleep&#44; or have slept too much&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">943 &#40;75&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">304 &#40;24&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have felt tired or had little energy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;011 &#40;81&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">304 &#40;18&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have had a poor appetite or have overeaten&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;026 &#40;82&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">221 &#40;17&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have felt bad about yourself or that you are a failure or have let yourself or your family down&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;146 &#40;91&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have had trouble concentrating on things&#44; such as reading the newspaper or watching television&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;120 &#40;89&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">127 &#40;10&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">You have been moving or speaking so slowly that other people could have noticed&#59; or so fidgety or restless that you have been moving around a lot more than usual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;177 &#40;94&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70 &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thoughts that you would be better off dead or of hurting yourself in some way&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;227 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Depressive symptoms in the last two weeks&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Organizaci&#243;n Mundial de la Salud&#46; Coronavirus disease 2019 &#40;COVID-19&#41; Situation Report &#8211; 11&#46; WHO Bull&#46; 2020&#59;&#40;January&#41;&#58;1&#8211;7&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Wuhan Municipal Health Commission&#46; Report of clustering pneumonia of unknown etiology in Wuhan City&#46; 2019&#46; &#91;Internet&#93;&#46; Disponible en&#58; <a target="_blank" href="http://wjw.wuhan.gov.cn/%0Dfront/web/showDetail/2019123108989">http&#58;&#47;&#47;wjw&#46;wuhan&#46;gov&#46;cn&#47;&#37;0Dfront&#47;web&#47;showDetail&#47;2019123108989</a>&#46; Citado 10 May 2020&#46;"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Vaccines and treatment of COVID-19 &#91;Internet&#93;&#46; European Centre for Disease Prevention and Control&#46; Disponible en&#58; <a target="_blank" href="https://www.ecdc.europa.eu/en/covid-19/latest-evidence/vaccines-and-treatment">https&#58;&#47;&#47;www&#46;ecdc&#46;europa&#46;eu&#47;en&#47;covid-19&#47;latest-evidence&#47;vaccines-and-treatment</a>&#46; Citado 4 Sep 2020&#46;"
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mental health and the COVID-19 pandemic"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "B&#46; Pfefferbaum"
                            1 => "C&#46;S&#46; North"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2020"
                        "volumen" => "3"
                        "itemHostRev" => array:3 [
                          "pii" => "S0196070919301620"
                          "estado" => "S300"
                          "issn" => "01960709"
                        ]
                      ]
                    ]
                  ]
                ]
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Article information
ISSN: 25303120
Original language: English
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