ARTICULO ORIGINALREVISTA DE LA FACULTAD DE MEDICINA HUMANA 2021 - Universidad Ricardo Palma
1 Faculty of Human Medicine, Universidad Ricardo Palma. Lima - Perú.
2 Research Institute of Biomedical Sciences. Universidad Ricardo Palma. Lima - Perú.
3 Graduate School, Universidad Ricardo Palma. Lima – Perú.
Objective: To determine the factors associated with the development of depression, anxiety, and stress in the context of the COVID-19 pandemic in police officers in Lima, Peru. Methods: Analytical cross-sectional study carried out in 210 police officers to whom the Depression, Anxiety and Stress Scale -DASS-21 was applied in October 2020 and a form via Google Forms to obtain sociodemographic and clinical data. Bivariate and multivariate analyzes were performed, using crude and adjusted prevalence ratios, with a confidence interval> 95% and a significance level of p≤0.05. Results: The prevalences of depression, anxiety and stress were 11.43%, 10% and 7.62%, respectively. In the bivariate analysis, anxiety was associated with the number of children (ORc: 3.18; 95% CI [1.10-9.17]; p: 0.032) and comorbidities (ORc: 2.50; 95% CI [1.08-5.75]; p: 0.031) . For depression and stress, no significantly associated factors were found. In the multivariate analysis, an association was found between depression and age (RPa: 2.50; 95% CI [1.02-6.10]; p: 0.044), and between stress and emotional situation (RPa: 3.10; 95% CI [1.08-8.95]; p: 0.034), COVID-19 diagnosis (RPa: 3.18; 95% CI [1.02-9.92]; p: 0.045) and comorbidities (RPa: 4.19; 95% CI [1.22-14.36]; p: 0.022). Conclusions: A low prevalence of depression, anxiety, and stress was observed in the study population. In addition, according to multivariate analysis, the risk factors for stress were: being single, having been diagnosed with COVID-19, and having comorbidities, while being 40 years old or younger was a risk factor for depression.
Keywords: Mental Health; Depression; Anxiety; Psychological Stress; Police; COVID-19 (source: MeSH NLM).
Objetivo: Determinar los factores asociados al desarrollo de depresión, ansiedad y estrés en el contexto de la pandemia por COVID-19 en policías de Lima, Perú. Métodos: Estudio transversal analítico realizado en 210 policías a quienes se les aplicó la Escala de Depresión, Ansiedad y Estrés -DASS-21 en octubre de 2020, así como un formulario vía Google Forms para obtener datos sociodemográficos y clínicos. Se realizó análisis bivariado y multivariado, utilizando razones de prevalencia crudas y ajustadas, con un intervalo de confianza >95% y un nivel de significancia de p≤0.05. Resultados: Las prevalencias de depresión, ansiedad y estrés fueron 11.43%, 10% y 7.62%, respectivamente. En el análisis bivariado, la ansiedad se asoció con el número de hijos (RPc:3.18; IC95% [1.10-9.17]; p:0.032) y comorbilidades (RPc:2.50; IC95% [1.08-5.75]; p:0.031). Para depresión y estrés no se encontraron factores asociados significativamente. En el análisis multivariado se encontró una asociación entre depresión y edad (RPa:2.50; IC95%[1.02-6.10]; p:0.044), y entre estrés y situación sentimental (RPa:3.10; IC95%[1.08-8.95]; p:0.034), diagnóstico de COVID-19 (RPa:3.18; IC95%[1.02-9.92]; p:0.045) y comorbilidades (RPa:4.19; IC95%[1.22-14.36]; p:0.022). Conclusiones: Se observó una baja prevalencia de depresión, ansiedad y estrés en la población de estudio. Además, según análisis multivariado, los factores de riesgo de estrés fueron: ser soltero, haber sido diagnosticado con COVID-19 y tener comorbilidades, mientras que tener 40 años o menos fue un factor de riesgo de depresión.
Palabras Clave: Salud mental; Depresión; Ansiedad; Estrés psicológico; Policía; COVID-19 (fuente: DeCS BIREME).
The police have a challenging job to comply with measures due to the COVID-19 pandemic. This situation
could harm their physical and mental health (1), affecting their work
performance due to exposure to conditions with high psycho-affective and psychosocial impact.
In December 2019, cases of pneumonia caused by the new coronavirus were reported in China; the outbreak spread rapidly becoming a global threat (2). By January 2020, the World Health Organization (WHO) declared the infection caused by COVID-19 as an International Public Health Emergency (3).
For this reason, to stop the rapid rise in contagion figures, police personnel have the role of enforcing government provisions for confinement and social distancing. However, on some occasions, people obstruct their police work through threats of violence and lack of public support; this situation could affect their mental health (1). During the current pandemic, a meta-analysis study carried out on police officers from 24 countries in Europe and North America showed prevalences of depression, anxiety, and stress of 14.6%, 9.6%, and 14.2% (4). In Peru, a study carried out in traffic police during the pandemic, showed levels of depression and anxiety of 19.6% and 17.3% (5). This would favor the development of other psycho-affective disorders such as stress.
Due to exposure to the SARS-CoV-2 virus and maintaining compliance with social distancing (6), psycho-affective disorders were generated in the mental health of many police officers (1,4,6). Considering the above, this study seeks to determine the factors associated with the development of depression, anxiety, and stress in the context of the COVID-19 pandemic in police officers in Lima, Peru.
Design and field of study
Analytical cross-sectional study carried out in police officers from the National Police of Peru (PNP) residing in Lima who met the following inclusion criteria: being active PNP police officers, using weapons to perform their duties, and accepting participation in the study voluntarily. Police officers who were part of the health personnel of the institution were excluded.
Population and sample
By means of snowball sampling, an initial sample of 216 police officers was obtained, 6 were excluded for not having completed the measurement instrument completely, so that finally 210 participants were included. The statistical power for the association between depression and COVID-19 was 29.2%, while for anxiety and COVID-19, it was 20.8%, and for stress and COVID-19, it was 43.4%.
Variables and instruments
The Depression, Anxiety and Stress Scale-21 (DASS-21) (7) was applied in
October 2020; After completing the DASS-21 scale, using a form designed by the authors and sent through
the Google Forms platform, the following sociodemographic and clinical data were collected: age, gender,
sentimental situation (with and without a partner), number of children, diagnosis of COVID-19. The
comorbidities variable was composed of ¨yes¨ or ¨no¨, and if it was affirmative, they specified the
disease. The number of children and age were categorized based on antecedents in the mental health area
(8); there were no older adult subjects.
The main variables were measured with the DASS-21 Scale (7), which has three subscales: depression (questions: 3, 5, 10, 13, 16, 17, and 21), anxiety (questions: 2, 4 , 7, 9, 15, 19 and 20) and stress (questions: 1, 6, 8, 11, 12, 14 and 18), which are evaluated separately. The cut-off points used for stress are 8-9 (mild stress), 10-12 (moderate stress), 13-16 (severe stress), and 17-21 (extremely severe stress); for anxiety they are 4 (mild anxiety), 5-7 (moderate anxiety), 8-9 (severe anxiety) and 10-21 (extremely severe anxiety); and for depression they are 5-6 (mild depression), 7-10 (moderate depression), 11-13 (severe depression) and 14-21 (extremely severe depression). The presence of positive stress is considered from 8 points, positive anxiety from 4 points, and positive depression from 5 points. The instrument has a total Cronbach's alpha of 0.90 and the values for each subscale are αdepression= 0.85, αanxiety= 0.72 and αstress= 0.79 (7).
The descriptive analysis of the data was carried out using tables of frequencies and percentages. A bivariate and a multivariate analysis were performed, obtaining crude and adjusted prevalence ratios, with a confidence interval> 95% and a significance level of p≤0.05. In the multivariate analysis, those that had a statistically significant association were included in the bivariate analysis, and generalized linear models of the Poisson family and robust variances were used. All statistical analyzes were performed in the SPSS Version 25 and STATA version 16.1 programs.
This research was approved by the Research Ethics Committee of the Faculty of Human Medicine of the Ricardo Palma University, as stated in the act PG-30-2020 (approved on October 24, 2020). In addition, the ethical principles of biomedical research in human beings of the Declaration of Helsinki 2013 (9) were taken into account and informed consent was obtained from all participants before the application of the questionnaires.
In the present study, the prevalences of the variables depression, anxiety, and stress were 11.43%, 10%, and 7.62%. Table 1 shows that 54.76% of the participants were older than 40 years, and 69.05% were men. In addition, 40.95% of the police officers had a positive diagnosis of COVID-19 infection.
Table 1. General characteristics of police officers in Lima, Peru.
|Variable||Frecuency (n=210)||Percentage (%)|
|Adulthood (older than 40 years)||115||54.76|
|Early adulthood (40 years or younger)||95||45.24|
|3 or more||59||28.10|
|Number of COVID-19 Diagnosis|
|2 or more times||13||15.12|
Depression frequencies, anxiety, and stress are shown in Table 2, according to the levels: normal, mild, moderate, severe, and extremely severe; it is evidenced that the highest percentage within the group that presented psycho-affective symptoms was the mild level of depression with 7.14%.
Table 2. Levels of depression, anxiety, and stress in police personnel in Lima, Peru.
|Variable||Frecuency (n=220)||Percentage (%)|
|Level of Stress|
The factors age, sex, emotional situation, number of children, COVID-19, and comorbidities and their respective frequencies with depression, anxiety and stress are shown in Table 3.
Table 3. Frequencies of the depression, anxiety, and stress variables according to the factors studied in police officers in Lima, Peru.
|Adulthood (older than 40 years)||14||14.73||81||85.27||6||6.32||89||93.68||8||8.42||87||91.58|
|Early adulthood (40 years or younger)||10||8.69||105||91.31||15||13.04||100||86.96||8||6.96||107||93.04|
|Number of Children|
|2 or more children||15||12.50||105||87.50||17||14.17||103||85.83||10||8.33||360||91.67|
|COVID-19 Diagnosis Number|
|2 or more times||3||23.08||10||76.92||2||15.39||36||84.61||1||7.69||12||92.31|
For the bivariate analysis in the crude prevalence ratio, in psycho affective disorder: anxiety, it was found that only the factors number of children (RPc: 3.18; 95% CI [1.10-9.17]; p: 0.032) and comorbidities (ORc: 2.50; 95% CI [1.08-5.75]; p: 0.031) are significantly associated; however, for depression and stress no significantly associated factors were found. (Table 4)
Table 4.Bivariate analysis between study variables and the level of depression, anxiety and stress in police officers in Lima, Peru.
|Raw RP||A 95% confidence interval||P-value||Raw RP||A 95% confidence interval||P-value||Raw RP||A 95% confidence interval||P-value|
|Adulthood (40 years or younger)||1.69||0.78-3.64||0.177||0.48||0.19-1.20||0.118||1,21||0,47 a 3,11||0,692|
|Middle adulthood (older than 40 years)||1.00||1.00||1,00|
|Female||0.91||0.39-2.11||0.841||0.69||0.26-1.82||0.463||2,23||0,87 a 5,69||0,093|
|Without a partner||0.61||0.25-1.47||0.276||0.57||0.21-1.50||0.260||1,87||0,71 a 4,70||0,205|
|With a partner||1.00||1.00||1,00|
|Number of children|
|2 or more children||1.25||0.57-2.73||0.576||3.18||1.10-9.17||0.032||1,25||0,47 a 3,32||0,654|
|Yes||1.70||0.79-3.62||0.167||1.58||0.70-3.57||0.266||2,40||0,90 a 6,37||0,078|
|Yes||0.71||0.22-2.27||0.569||2.50||1.08-5.75||0.031||2,27||0,84 a 6,14||0,106|
In the results of the multivariate analysis, it was found that the risk factor for having depression was age less than or equal to 40 years (RPa: 2.50; 95% CI [1.02-6.10]; p: 0.044). To present some degree of stress, the significant risk factors were: without a partner (RPa: 3.10; 95% CI [1.08-8.95]; p: 0.034), having a positive COVID-19 diagnosis (RPa: 3.18; 95% CI [1.02 -9.92]; p: 0.045) and present some comorbidities (RPa: 4.19; 95% CI [1.22-14.36]; p: 0.022). In contrast, no other associations were found between the other variables. It is observed in Table 5.
Table 5. Multivariate analysis between study variables and the level of depression, anxiety and stress in police officers in Lima, Peru.
|adjusted PR||A 95% confidence interval||P-value||adjusted PR||A 95% confidence interval||P-value||adjusted PR||A 95% confidence interval||P-value|
|Early adulthood (40 years or younger)||2.50||1.02-6.10||0.044||0.98||0.32-3.01||0.979||1.82||0,49 - 6.70||0.365|
|Middle adulthood (older than 40 years)||1.00||1.00||1,00|
|Number of children|
|2 or more children||1.71||0.64-4.59||0.282||2.91||0.67-12.55||0.151||2.66||0.76-9.31||0.125|
Due to the nature of their work, police personnel must be physically present to work and serve
communities during the COVID-19 pandemic, which is why they are often exposed to high-stress situations
that can affect their performance work and personal life (1). The outbreak of
this disease has had a mental impact, manifesting depression, anxiety, stress, and insomnia, among
In the investigation, a prevalence of depression of 11.43% was obtained; a result close to that found by Stevelink et al. in a study carried out in 40,299 police officers in the United Kingdom (14) reported a prevalence of 9.8%. The prevalence could be due to the high exposure to traumatic events to which they are subjected during the exercise of their profession.
About 1 in 10 people; this is consistent with the systematic review by Wagner et al., who report a median prevalence of 10.6% in four studies conducted on police officers from Italy and Canada (15). The percentage found would correspond to the association between anxiety and the perception of little support received.
The prevalence of stress was 7.62%, a figure lower than the combined prevalence of 14.2% of post-traumatic stress syndrome reported by Syed et al. (4) in a systematic review and meta-analysis that included 60 cross-sectional and 7 longitudinal studies conducted in police officers worldwide. In this sense, the low percentage observed in the present study may be due to the personality profile and acquired resistance of Peruvian police officers, which gives them a greater capacity to face stressful situations optimally and with low vulnerability (6), allowing them ensure that the general population complies with the preventive quarantine measures implemented by different governments of the world due to the COVID-19 pandemic.
In the bivariate analysis, the first factor significantly associated with having a higher prevalence of anxiety had two or more children with CRR: 3.18; 95% CI [1.10-9.17]; a similar finding to that found by Kimhi et al. in a study carried out in 300 people (general population) of Israel (9), where it was reported that the more children they had, the higher the prevalence of anxiety (p < 0.01); Furthermore, in a similar study carried out by Fitzpatrick et al. In 10,368 adults (national sample) from the United States (12) a significant correlation was found between both variables (p: 0.001).
The second factor associated with the development of anxiety symptoms was having comorbidities (RPc: 2.50), which presented a statistically significant association, this coincides with the study by Wu et al. conducted in 281 criminal police officers in China (16), which indicates that having a history of chronic disease was significantly associated with anxiety (p: 0.020). Likewise, the study carried out by Stevelink et al. (14) reveals that the percentage of self-reported hypertension was high in those who presented anxiety symptoms (p < 0.001).
In the multivariate analysis, depression was significantly associated with being less than or equal to 40 years of age (RPa: 2.50). In a similar study, Stevelink et al. (14) found that police officers under 30 years of age have a greater association with symptoms of depression (p < 0.001). This is due to the ease that people in this age group have in accessing alarming information about COVID-19, which predisposes them to develop affective disorders (17).
Likewise, in the multivariate analysis, an association was found between stress and the variables: not having a partner (RPa: 3.10; 95% CI [1.08-8.95]), positive COVID-19 diagnosis (RPa: 3.18; 95% CI [1.02- 9.92]) and having comorbidities (RPa: 4.19; 95% CI [1.22-14.36]).
In this sense, in the variable sentimental situation, the evidence shows that single individuals present greater emotional exhaustion than married individuals and less personal achievement. Single police officers experience more burnout than married ones, so they may need organizational support to deal with burnout. (18)
On the other hand, the police officers who were diagnosed with COVID-19 experienced greater stress than those who were not diagnosed; similar to the meta-analysis study conducted by Krishnamoorthy et al. (19), which included 50 studies at the international level and reports that 96% of patients with COVID-19 presented post-traumatic stress.
In addition, it was found that those with some comorbidity experienced a higher degree of stress (RPa: 4.19), which presents a statistically significant association, and coincides with the study by Blanco-Álvarez et al. carried out in 66 officers of the Costa Rican Penitentiary Police (20), where it is reported that stress was significantly associated with psychophysiological diseases such as asthma (p < 0.05) and insomnia (p < 0.01). Likewise, the study carried out by Walvekar et al. In 108 police officers from India (21), he reported that 38% of them had cardiometabolic syndrome, and they also found that high levels of serum cortisol due to work stress were significantly related to symptoms of cardiometabolic syndrome (p < 0.001).
A limitation in the study is that the self-reported scales of depression, anxiety and stress are not always aligned with the diagnostic evaluation of mental health professionals, this could generate an underreporting. In the study, a low statistical power was obtained for some associations, so it is recommended to carry out more studies of better power to clarify these associations. In addition, it is recommended to analyze the variables: resistant personality, resilience, and time of service (7) as protective factors against the development of affective disorders.
In view of the circumstances that police officers face, this work is opportune to develop health interventions (22) that strengthen mental health and allow them to develop psychosocial skills necessary to face extreme situations and the use of technology to provide timely medical and psychological guidance. Likewise, it is necessary to promote the importance of the availability of quality Personal Protective Equipment for the health care of the police officers. Thus this will give them a sense of security that would reduce their vulnerability to the development of psycho-affective disorders.
A low prevalence of depression, anxiety, and stress was observed in the study population. In addition, according to the multivariate analysis, the risk factors for stress were single, having been diagnosed with COVID-19, and having comorbidities, while being 40 years old or younger was a risk factor for depression.
Authorship contributions: The authors participated in the genesis of the idea, project
collection and interpretation of data, analysis of results and preparation of the manuscript of
this research work.
Financing: This research has not received specific funding from public sector agencies, commercial sector or non-profit entities.
Interest conflict: The authors declare that they have no conflict of interest.
Received: August 18, 2021
Approved: September 28, 2021
Correspondence: Katherine Danae Apaza-Llantoy
Address: Avenida Alfredo Benavides 5440, Santiago de Surco, 15039, Lima – Perú.
Telephone: +51 922 767 411