COVID-19 virus infection does not only affect physical health but also has an impact on the mental health especially of health care providers, who are on the front lines, as they are fighting their global long-drawn battle against COVID-19 . Coronaphobia is a newly emerging phenomenon specifically generated to define excessive fears and worries of contracting COVID-19 virus infection. It has recently been replicated in the research of the mental health burden of the COVID-19 pandemic . The main finding of this study is that the physician, in Egypt, experienced higher levels of coronaphobia during the COVID-19 pandemic. In line with this finding, numerous studies documented intensive and persistent fears and worries not only among physicians but also other health care providers including nurses, technicians, and health workers during the COVID-19 pandemic [2, 7]. The excess fear might be related to the initially insufficient understanding of the virus, the lack of prevention and control knowledge, the shortage and improper use of medical protective equipment, and the exposure to critical life events as the death of patients . Also, as claimed by some of the health care providers, there was the fear of the possibility of the virus transmission to their families or close friends . These concerns would lead the working physicians to isolate themselves from their family members, modify or even change their lifestyle routines, and limit their social connectedness which resulted in psychological pressure, feelings of loneliness and helplessness, and despair .
Work overload, burnout, and stress symptoms during the COVID-19 pandemic would make physicians more prone to developing psychiatric disorders like anxiety, depression, and suicide, which negatively affect their quality of life [23,24,25]. Consistent with this, our study found that 10%, 28%, and 30% of physicians reported thoughts of death or self-harming thoughts, intense anxiety, and depressive symptoms, respectively. Numerous studies had documented the intensified levels of anxiety and depression among health care professionals during the pandemic. A study stated that the prevalence rates of anxiety and depression among physicians were 25.67% and 28.13%, respectively . During the COVID-19 pandemic, it was reported that more than 70% of the medical staff stated intense apprehension, 25% showed anxiety, and 12% presented with depression . A study conducted at the early stages of COVID-19 in China found that 50% and 45% of health care providers had depression and anxiety symptoms, respectively , while another study stated that 14% and 24% of the medical staff experienced depression and anxiety with COVID-19, respectively . The discrepancies in the prevalence of depression and anxiety among the studies may be related to variance in sample size, different assessment tools used, different cultural backgrounds, and different stages related to the pandemic onset.
As illustrated in Table 2, there was no significant correlation between age and coronaphobia. In line with this finding, Ahorsu et al. (2020), the founders of the FCV-19S, stated that age appeared not to affect the response pattern of the fear on the FCV-19S . This study found physicians with higher levels of coronaphobia who were more likely to be females, receiving insufficient training related to the pandemic, dissatisfied with the hospital PPE, and having medical colleagues who were infected with the COVID-19 virus infection. These findings were in line with other studies which also found that females have been reported higher levels of anxiety than males [21, 26], yet, due to the self-reporting nature of most scales used for assessing anxiety, some argued male participants might have minimized symptoms . Studies of previous pandemics and outbreaks also revealed that inadequate staff training , inadequate organizational support , frustration about the efficacy of precautionary measures , being less experienced , and lack of confidence in infection control and caring for affected medical colleagues during the pandemic  were the main variables increasing the risk of psychological distress including anxiety, depression, and stress among health care workers. Furthermore, it was claimed that severe anxiety symptoms experienced among physicians during their duty were related to their suspicion of being infected with the COVID-19 virus .
Integration between physical health (body) and mental health (mind) is essential to the current psychological state of physicians. In this study, the relationship between coronaphobia and the associated psychological symptoms cannot be ignored. Physicians with high levels of coronaphobia were more likely to have death wishes and/or self-harming thoughts as well as more anxiety and depressive symptoms. In line with our findings, excessive anxiety and fears of COVID-19 virus infection were found to be associated with suicidal thoughts and intense feelings of hopelessness . Moreover, it was reported that during the pandemic, the prolonged worries would increase levels of anxiety, depression, and stress in individuals or increase the severity of the pre-existing psychiatric symptoms . Similarly, the higher the scores on the fear of the COVID-19 virus scale, the higher the levels of anxiety and depressive symptoms measured by the Hospital Anxiety and Depression Scale (HADS) . These replicated results might suggest that physicians with severe fear of COVID-19 might have been suffering or being at greater risk to develop these comorbid disorders. It was found that comorbid physical health conditions, history of mental health disorders, and substance use were significant risk factors of stress, depression, and anxiety among health care providers during the COVID-19 pandemic . However, this study failed to find a relationship between increased scores of coronaphobia and histories of mental, medical, or substance use disorders among physicians. These findings could be rationalized as being a conservative community where mental disorders and substance use were associated with stigma, which might lead some participants to deny having mental or substance use disorders. Also, most of the participants in our study were young adults (mean age = 34.57 years), we can argue that chronic medical diseases are not common at this age (only 21% had a medical disease). Of interest, physicians who were smokers reported lower levels of coronaphobia in this study. It was claimed that nicotine smoking could be viewed as a remedy that acutely reduced anxiety symptoms, especially during stressful situations . It also could be related that they usually have less trait anxiety, as a consequence of blunting the sympathoadrenal axis .
Frontline physicians are the ones currently working with COVID-19 patients. Forty-seven percent of the frontline physicians were residents, while 66.4% of the second-line physicians were specialists and consultants. In Egypt, residents of all specialties and medical officers were usually at the frontline (for example in emergency rooms). They were in direct contact and manage the patients before referral to their 2nd on-call supervisors (specialists and consultants). This would explain why most consultants were located in the second-line hospital departments.
The frontline physicians caring for COVID-19 patients, compared with their second-line counterparts, were supposed to experience higher levels of anxiety and depressive symptoms, and sleep disturbances . As expected, owing to the nature of their current work duties, this study found that frontline physicians were more likely to be residents, working more than 8 h daily, received sufficient training related to the pandemic and have a history of medical colleague affection with COVID-19 infection when compared with their second-line counterparts. However, although the mean scores of coronaphobia, anxiety, and depressive symptoms among frontline physicians were higher than those of their second-line counterparts, the difference was not statistically significant. Consistent with our results, in terms of excessive fears and depressive symptoms, a recent study did not find any differences between the medical staff at the frontline areas (working in the respiratory, emergency, ICU, and infectious diseases departments) and those with lower risks of contact with COVID-19 patients (second-line medical staff working in other departments) . Similarly, another study found no differences in self-rated anxiety and depressive symptoms among the staff in the COVID-19–associated department and other departments . This lack of significant differences between the frontline and second-line staff was probably attributed to several reasons. First, second-line physicians might experience feelings of sympathy (towards both COVID-19 patients and frontline physicians), guilt, isolation, and apparent feeling of worthlessness due to the inability to share in the present crisis . Second, with increasing admissions of COVID-19 patients and shortage of medical staff, the second-line physicians might be worried about being allocated by the government to work in the frontline areas despite being insufficiently trained or qualified to work with COVID-19 patients . Third, their fears might be fueled by the floods of information from TV and media about suffering, illness, and the death of their frontline colleagues. All these feelings might in turn lead to the intensification of symptoms of fear, anxiety, and depressive symptoms among second-line physicians, and explain the absence of significant differences in the emergence of psychological symptoms when compared with their frontline counterparts.
The results of the current study should be interpreted in the context of its limitations. First, because of the disease outbreak, we were unable to conduct face-to-face interviews, instead, depended on self-rating scales with response bias, so these scales only provided a preliminary screening; thus, further confirmation and intervention were warranted. Second, the selection of participants from Sharkia Province, despite being one of the largest provinces in Egypt, would limit the generalization of our findings. Third, being a cross-sectional study might limit the cause–effect relationship. So, further future longitudinal studies are needed. In addition, it was difficult during the pandemic to include a control group of nonmedical personnel. Although these limitations were present, to our knowledge, this study would be the first in Egypt and the Middle East to assess the psychological impact of the COVID-19 virus infection among physicians using a new specific assessment tool for evaluating the corona virus-related fears.