**4. Discussion**

Our study indicates the occurrence of maladaptive psychological responses to the COVID-19 pandemic among medical workers in comparison to that in people performing other professions in Poland. The findings from this survey imply that healthcare professionals present with higher levels of psychopathological symptoms in terms of anxiety, insomnia and somatic symptoms than those representing other professions, even after adjustment for potential confounding factors. To our knowledge, this is the first study comparing medical and non-medical professionals in terms of psychopathological manifestation during the COVID-19 pandemic. Over 60% of medical professionals and 48% of individuals working in non-medical professions from the study sample presented clinically relevant psychopathological symptoms. These findings are similar to those reported by a recent population-based study in China that reported symptoms of depression, anxiety, distress and insomnia in 34.0–71.5% of medical workers [18]. Similarly, another study reported that 63% of medical workers in Wuhan, China, demonstrated various psychopathological symptoms [19]. However, a lower prevalence of psychopathological symptoms compared to in our study was observed by the authors of the recent cross-sectional survey study based on over 4000 healthcare workers from Wuhan in which 39.1% of the study participants had psychological distress [20]. Lai et al. suggested that nurses, women, frontline medical workers and those working in Wuhan, China, were more likely to report various psychopathological symptoms [18], which is consistent with our findings in the relation to female sex. The vast majority of our results confirm observations from Asian countries during the initial stages of the COVID-19 pandemic [2,21]. Recently, there have been only a few reports defining the role of factors affecting the development of psychiatric symptoms in the pandemic [19,22–24]. However, there is still a lack of research identifying institutional and individual risk and protective factors affecting the mental health of healthcare workers and other citizens during the pandemic.

This study emphasizes that one of the most important institutional factors that affects mental health is the provision to medical workers of a sense of security in the workplace. The results point to the importance of appropriate protection against infection as the main mental-health-related factor during the pandemic that affects all the domains. This is in accordance with recent studies related to medical staff, which identify access to personal protective equipment as an independent predictor of a lower level of mental distress [25,26] as well as one of the main concerns of healthcare workers [20]. It seems that these results are not revealing; however, at the same time, our findings show that the vast majority of staff deem the institution's activities in providing security to be insufficient. This is likely not unique to Poland, as recent studies have also found a lack of personal protective equipment being reported by medical health workers across other countries [27–29]. Furthermore, the present study highlights that the sense of security could be considered from different perspectives. Both groups of medical and non-medical professionals revealed anxiety about the state of their health. This is consistent with the cross-sectional study performed in China in which the authors suggested the fear of being infected to be a risk factor for mental distress [30]. However, this study highlights another important factor, which is the fear for loved ones, that was visible only among medical professions. Medical workers remain with an internal dilemma related, on the one hand, to a sense of loyalty to the profession and their patients and, on the other hand, to the responsibility for their families [31]. This is confirmed by the recent study from Wuhan in which the authors demonstrated that the majority of healthcare workers were concerned about the infection of family members [20]. This kind of long-lasting internal emotional tension might be manifested in psychopathological symptoms among most medical workers during a pandemic, which has already been observed in 2003 during the outbreak of severe acute respiratory syndrome (SARS) [32] and in 2014–2015 during the Ebola outbreak [33]. Despite the discussed fear regarding the infection of family members among medical professionals on the one hand, we emphasized the protective effect of having children on the development of depressive symptoms and, on the other hand, the relationship between care for an elderly person and the severity of psychopathological symptoms. From an individual-level perspective, this study indicates that men were less prone to the presence of psychopathological symptoms. In our study, male sex appeared to be negatively associated with total GHQ-28 scores, which was observed among both medical and non-medical professionals. These reports are similar to the results of recent studies performed in China in which being female was considered a significant risk factor for the development of severe depressive and anxiety symptoms, and distress [18,22].

We emphasized that following media reports was a risk factor for developing psychopathological symptoms among both groups. Our results correspond with another Wuhan online survey study [34] where spending over 2 h checking COVID-19-related information via social media was correlated with anxiety and depressive symptoms. The issue of the impact of excessive searching for COVID-19 news on mental health is particularly up to date according to recent studies, which confirm that the pandemic affected the content searched on the internet [35,36].

We observed that medical professionals more often than other respondents suffered from somatic symptoms as well as anxiety and insomnia. A higher prevalence of somatic symptoms during stressful situations, such as work in outbreak conditions, can be considered a physiological reaction caused by increased activity of the autonomic nervous system. Although a short-term hyperactivity of the sympathetic nervous system does not lead to any serious health-related consequences, the prolonged hyperactivity of the stress-related hypothalamic-pituitary-adrenal axis might lead to fatigue, depression, and other health-related outcomes [37–39]. As demonstrated by studies on previous outbreaks [40,41], some of the medical workers during the SARS-CoV-2 pandemic may be at risk for post-traumatic stress disorder, which also appears to be connected with prolonged hypothalamic–pituitary–adrenal (HPA) axis overactivity [42,43]. From a psychodynamic perspective, prolonged emotional tension can lead medical workers to channel difficult emotional experiences into somatic symptoms and insomnia, which are easier for them to accept than developing depressive symptoms that may lead to an occupational dysfunction and could be understood as the effect of defense mechanisms.

There are some limitations of this study that need to be discussed. Firstly, we did not record the initial number of individuals approached for participation and the reasons for non-participation were not recorded. Therefore, the representativeness of the sample is limited. Another point is that the assessment of psychopathological symptoms was limited to the use of GHQ-28, and thus, we were not able to record specific diagnoses. It should also be noted that our survey was not administered longitudinally. In this regard, the temporal patterns of psychopathological expressions were not addressed. Another limitation is response bias due to the online form of the questionnaire distribution.

In summary, our study provides evidence that medical professionals are more vulnerable to developing anxiety, insomnia and somatic symptoms in response to the pandemic. In addition, thedeterminants of psychopathological expressions in these two groups differ in terms of age, care for an elderly or disabled person, contact with COVID-19 at work and contact with COVID-19 without protection measures. Apparently, there are present gender differences in psychological responses that are independent of the profession.

Nevertheless, these findings create grounds for personalizing interventions that aim to restore psychological wellbeing in medical and non-medical professionals as well as emphasizing key factors affecting the greater susceptibility for a negative psychological response during the pandemic, some of which are modifiable.

**Author Contributions:** Conceptualization, J.M. and M.C.; methodology, B.M. and D.S.; software, B.M.; validation, D.S. and J.R.; formal analysis, J.R.; investigation, J.M., M.C., B.M., D.S. and J.R.; resources, M.C., D.L., K.F.-W., T.W. and P.G.; data curation, B.M.; writing—original draft preparation, J.M., D.S. and B.M.; writing—review and editing, J.R., D.S. and B.M.; visualization, K.F.-W. and P.G.; supervision, J.R.; project administration, J.R.; funding acquisition, J.R. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by Wroclaw Medical University, grant number ST.C230.18.014 and the article processing charge was financed from the funds granted by the Ministry of Science and Higher Education in the "Regional Initiative of Excellence" programme for the years 2019–2022, project number 016/RID/2018/19.

**Acknowledgments:** This study was supported by the Wroclaw Medical University grant (No. ST.C230.18.014).

**Conflicts of Interest:** The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
