BACKGROUND: Long-term deterioration in the mental health of healthcare workers (HCWs) has been reported during and after the COVID-19 pandemic. Determining the impact of COVID-19 incidence and mortality rates on the mental health of HCWs is essential to prepare for potential new pandemics. This study aimed to investigate the association of COVID-19 incidence and mortality rates with depressive symptoms over 2 years among HCWs in 20 countries during and after the COVID-19 pandemic. METHODS: This was a multi-country serial cross-sectional study using data from the first and second survey waves of the COVID-19 HEalth caRe wOrkErS (HEROES) global study. The HEROES study prospectively collected data from HCWs at various health facilities. The target population included HCWs with both clinical and non-clinical roles. In most countries, healthcare centers were recruited based on convenience sampling. As an independent variable, daily COVID-19 incidence and mortality rates were calculated using confirmed cases and deaths reported by Johns Hopkins University. These rates represent the average for the 7 days preceding the participants' response date. The primary outcome was depressive symptoms, assessed by the Patient Health Questionnaire-9. A multilevel linear mixed model (LMM) was conducted to investigate the association of depressive symptoms with the average incidence and mortality rates. RESULTS: A total of 32,223 responses from the participants who responded to all measures used in this study on either the first or second survey, and on both the first and second surveys in 20 countries were included in the analysis. The mean age was 40.1 (SD = 11.1), and 23,619 responses (73.3%) were from females. The 9323 responses (28.9%) were nurses and 9119 (28.3%) were physicians. LMM showed that the incidence rate was significantly and positively associated with depressive symptoms (coefficient = 0.008, standard error 0.003, p = 0.003). The mortality rate was significantly and positively associated with depressive symptoms (coefficient = 0.049, se = 0.020, p = 0.017). CONCLUSIONS: This is the first study to show an association between COVID-19 incidence and mortality rates with depressive symptoms among HCWs during the first 2 years of the outbreak in multiple countries. This study's findings indicate that additional mental health support for HCWs was needed when the COVID-19 incidence and mortality rates increase during and after the early phase of the pandemic, and these findings may apply to future pandemics. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04352634.

Centro de Investigación Biomédica en Red de Salud Mental Instituto de Salud Carlos 3 Madrid Spain

Columbia University Mailman School of Public Health New York NY USA

Department of Biostatistics Mailman School of Public Health Columbia University New York NY USA

Department of Child and Adolescent Psychiatry NYU Langone Health New York USA

Department of Clinical Neuro and Developmental Psychology Vrije Universiteit Amsterdam Amsterdam The Netherlands

Department of Epidemiology 2nd Faculty of Medicine Charles University Prague Czech Republic

Department of Epidemiology Columbia University Mailman School of Public Health New York USA

Department of Mental Health Graduate School of Medicine The University of Tokyo 7 3 1 Hongo Bunkyoku Tokyo 113 0033 Japan

Department of Population Health King Abdullah International Medical Research Center Ministry of National Guard Riyadh Saudi Arabia

Department of Psychiatric Nursing Graduate School of Medicine The University of Tokyo Tokyo Japan

Department of Psychiatry Clinical Psychology and Mental Health La Paz University Hospital Madrid Spain

Department of Psychiatry Universidad Autónoma de Madrid Madrid Spain

Department of Psychiatry University Medical Center Groningen University of Groningen Groningen The Netherlands

Department of Psychiatry University of Ibadan Ibadan Nigeria

Department of Psychology Koc University Istanbul Turkey

Department of Public Health Kitasato University School of Medicine Sagamihara Japan

Department of Public Health School of Medicine Universidad Nacional de Colombia Bogotá Colombia

Department Psychiatry A Razi Hospital La Manouba Manouba Tunisia

Dirección de Salud Mental Ministerio de Salud Lima Peru

Escuela de Salud Pública CL Faculty of Medicine University of Chile Santiago Chile

Escuela de Salud Social y Comunitaria Universidad del Chubut Chubut Argentina

Faculty of Health and Social Work University of Applied Sciences Emden Leer Emden Germany

Faculty of Medicine Federal University of Pelotas Pelotas Brazil

Faculty of Medicine of Tunis University of Tunis El Manar Tunis Tunisia

Faculty of Medicine University of São Paulo São Paulo Brazil

Faculty of Social Sciences and Communication Universidad Europea de Madrid Madrid Spain

Graduate Education Division Universidad El Bosque Bogotá Colombia

Harvard T H Chan School of Public Health Harvard University Cambridge USA

Health Psychology Institute Faculty of Psychology University of the Republic Montevideo Uruguay

Hospital La Paz Institute for Health Research Madrid Spain

Instituto Altos Estudios Dr Arnoldo Gabaldon Maracay Venezuela

Instituto de Investigación del Hospital Universitario La Princesa Madrid Spain

Instituto Nacional de Psiquiatría Ramón de La Fuente Muñiz Mexico City Mexico

Interdisciplinary Centre for Health Studies Department of Public Health School of Medicine Faculty of Medicine Universidad de Valparaíso Valparaíso Chile

Medical Intensive Care Abderrahmen Mami Hospital Aryanah Tunisia

National Institute of Health Named After Academician S Avdalbekyan Yerevan Armenia

National School of Public Health Universidad de Antioquia Medellín Colombia

New York State Psychiatric Institute New York USA

Parnassia Psychiatric Institute Parnassia Groep The Hague the Netherlands

Question Driven Design and Analysis Group New York USA

Research Science and Technology Direction Universidad San Francisco Xavier de Chuquisaca Sucre Bolivia

Salud Global Bolivia La Paz Bolivia

School of Medicine University of San Carlos of Guatemala Guatemala City Guatemala

Universidad del Chubut Escuela de Salud Social y Comunitaria Chubut Argentina

Università Degli Studi Di Cagliari Cagliari Italy

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