To our knowledge, this is the first research to use the structured clinical interview for DSM (SCID-I) to detect major depression disorder (MDD) among health care workers (HCWs) who were treating patients with COVID-19 in Egypt.
The current study was a cross-sectional survey that enrolled 270 HCWs and revealed a high prevalence of depressive disorder. Overall respondents, 251(93%) had depressive symptoms based on DASS-21. Twenty-eight percent of HCWs had mild-to-moderate depressive symptoms, and 65% with severe or extremely severe depressive symptoms. By applying SCID-I, 74.3% of HCWs were diagnosed with MDD. In a previous study during the acute SARS outbreak, 89% of HCWs who were in high-risk situations reported psychological symptoms . An Egyptian study similarly reported a high prevalence of severe-to-extremely severe depressive symptoms among Egyptian physicians during the COVID-19 pandemic, the majority (63%) suffered from severe or extremely severe depressive symptoms . Also, the prevalence of depressive symptoms among health care providers was (78.1%) in Jordan .
Two Egyptian studies and another Saudi one reported that severe depression represents 20.5%, 14%, 5.8%, consequently these results are considered low in comparison to the current one. This can be explained by the using of different measures noting the in this study the authors used the confirmatory diagnostic clinical interview according to the DSM [17,18,19].
Another Turkish study reported that 64.7% of physicians had symptoms of depression . Many studies were performed in China: two of them reported that the prevalence of depressive symptoms among health care providers was 50.4%  and 56.0% .
The current results reported higher prevalence of depressive symptoms among HCWs than that of other studies, most probably due to the different conditions in which the HCWs are working in Egypt. HCWs did not deal with such a catastrophic and emerging pandemic before. Moreover, they are facing highly infectious disease with uncertain outcome with deficient infection control supplements and shortage of protective equipment that cause overburden and extraordinary stressors over them [22,23,24,25]. In addition, there are other factors that may explain the high prevalence of depression among HCWs generally such as workloads, burnout, insufficient time to take care of their families during the pandemic, social stigma, health anxiety and fear towards COVID-19 infection and reluctance of the society to support them [26,27,28,29,30].
The current study found that young age was associated with higher scores of depression among HCWs. This finding is supported by a recent Jordanian study conducted during the COVID-19 pandemic, which demonstrated that the young age group of HCWs had a significantly high risk to develop depression . A study in Saudi Arabia stated that the age group from 30 to 39 had a slightly high level of depression and anxiety . This is also consistent with recent studies that demonstrate an elevated incidence of psychiatric disorders in younger adults [31, 32]. This could be attributed to the less adaptive manner of responding to stressors that may justify this result  and the age-related bio-psychosocial changes . Moreover, young HCWs had to spend a long time in emergency units in close contact with COVID-19 patients to gain clinical experiences, causing a high level of stress and fear of acquiring the infection.
The results showed that fear of being infected with COVID-19 or transmitting the infection to family members, fear of death, or family members’ death with COVID-19, were associated with an increase in the severity of depression among HCWs. In line with these findings, recent studies in China and Nepal reported that medical staffs were fearful about transmitting the virus to their families [21, 23, 28]. A recent study reported that the most concerns regarding the COVID-19-related fears among medical staff in Egypt were the fear of being infected and the fear of transmission of the disease to their families . HCWs may isolate themselves to lower the risk of infecting their family members. Thus the absence of emotional support could attribute the increased psychological distress and affect HCWs mental well-being .
The current study found that female HCWs were six times more likely to have depression than male HCWs. Similarly, the results of the Saudi, Jordanian and Egyptian studies indicate that being female increased the risk of depression among health care providers during the COVID-19 pandemic [16, 17, 36, 37]. HCWs with past history of psychiatric illness were seven times more likely to have depression than those without such history according to the current study. In line with this finding, other studies [23, 38] reported that health workers who had a history of medication for mental health problems had a higher risk to exhibit anxiety, depression, and insomnia symptoms compared with those who had no psychiatric history.
In addition, HCWs with decrease in sleep hours were two times more likely to have depression, but depression is associated with decrease in sleep hours and the cross-sectional design of this study cannot answer what started first?
Finally, HCWs who have fear of COVID-19 infection for themselves or relatives were four times more likely to have depression more than HCWs who did not have this fear. Fear of death for HCWs or their relatives double the risk of depression among HCWs. These findings are supported by previous studies [21, 23, 28].
According to these findings, the mental health status of HCWs should be closely monitored by the Ministry of Health to facilitate the appropriate psychological care. They should be provided with appropriate safety measures, their workload should be managed and they should be compensated by the appropriate financial support, to reduce the mental health burden during such pandemic. This study had some limitations which include: first, cross-sectional design does not investigate causality; second, only 56% of the sample size was interviewed using SCID-I, which might limit the strength of using a structural interview instead of self-rating scales. However, this study has some strengths: first, it used structural interview based on SCID-I in addition to self-rating scales; second, it includes many health professions not only physicians.