Volume 21, Issue 1 (March 2023)                   Iranian Rehabilitation Journal 2023, 21(1): 39-48 | Back to browse issues page

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Babaei A, Momeni F, Vahedi M, Davoudi M. The Relationship of Cognitive Flexibility and Self-compassion With Depression and Anxiety Among Healthcare Staff During the COVID-19 Pandemic. Iranian Rehabilitation Journal 2023; 21 (1) :39-48
URL: http://irj.uswr.ac.ir/article-1-1324-en.html
1- Department of Clinical Psychology, Psychosis Research Center, School of Behavioral Sciences,University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
2- Department of Biostatistics and Epidemiology, Psychosis Research Center, School of Rehabilitation Sciences, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
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1. Introduction
The COVID-19 pandemic, which was first identified in Wuhan, China, in December 2019, has become a serious global threat [1]. As of March 02, 2021, A total of 113820168 cases and 2527891 deaths have been reported worldwide [2]. In Iran, the first confirmed case of COVID-19 was proclaimed on February 19, 2020 [3]. The Government of Iran declared a state of emergency and ordered a nationwide quarantine during the national holidays, which lasted two weeks. Removal of re-strictions after the holiday leads to the second wave and extensive spread of COVID-19. As of March 2, 2021, A total of 1639679 cases and 60181 deaths have been confirmed in Iran [3].
Many research studies show that healthcare staff has been impacted by COVID-19 psychologically; a screening study in New York indicates acute stress, depression, anxiety, and mod-erate insomnia symptoms among the healthcare workforce [4]. Also, research conducted in China shows a high prevalence of stress, anxiety, and depression in healthcare workers [5]. A review study showed a significant degree of stress, anxiety, depression, and insomnia among healthcare workers [6]. In addition, some studies show that healthcare staff experiences higher levels of mental problems such as insomnia, hopelessness, anxiety, depression, somatization, and obsessive-compulsive symptoms [7, 8, 9]. Although some studies assessed mental health among the general population in Iran, information about the healthcare workforce is limited [10, 11]. Regarding the heavy workload on healthcare staff during this exceptional circumstance and the high risk of infection due to exposure to suspected or confirmed patients of COVID-19, examining the psychological status of the healthcare workforce would be especially necessary. Furthermore, understanding the psychological factors which play significant roles in mental health could be crucial and useful for further interventions. 
Based on the research, higher cognitive flexibility and self-compassion are negatively associated with emotional distress [12]. Cognitive flexibility has been defined as the capacity to shift between thinking about two independent concepts or to think about various ideas simultaneously; also, it can define as the ability to adapt behaviors in response to changes in the environment [13, 14]. Some research demonstrates that psychological flexibility is negatively related to somatization, depression, anxiety, and general psychological distress [15]. Accord-ing to a study in the UK, during the pandemic, psychological flexibility is positively associated with wellbeing and inversely with distress, including anxiety, depression, and COVID-19 distress [16]. Similarly, a study conducted in the USA indicated that higher openness to experience and behavioral awareness is inversely related to general and peritraumatic distress [17]. 
Self-compassion has been defined as being temperate and understanding when we suffer, fail, or feel inadequate, rather than ignoring our illness or afflicting ourselves with self-judgment and criticism [18]. Kristin Neff [18] considered self-compassion to be composed of three principal parts: Self-kindness, common humanity, and mindfulness. Some findings show self-compassion is negatively related to depression, anxiety, and rumination [19, 20]. Correspondingly, a meta-analysis study indicates that self-compassion is an influential factor for wellbeing, decreasing anxiety and depression, and increasing resilience to stress [21]. In addition, the findings demonstrate that self-compassion is a more powerful predictor of de-pression, anxiety, and quality of life (QoL) than mindfulness [22]. According to research, self-compassion mediates the negative relation between mental health and psychopathology and a role as a protective function [23].
The interest in cognitive flexibility and self-compassion is rapidly increasing. More research suggests investigating the impact they have on mental status. Based on the studies men-tioned, cognitive flexibility and self-compassion are two factors related to human capacity in exposure to difficult and unexpected situations. Accordingly, we focused on evaluating the prevalence of depression and anxiety among the healthcare staff and the role of self-compassion and cognitive flexibility in mental status. Although studies examine the effect of the COVID-19 outbreak on various groups’ mental problems, our knowledge, especially on mental aspects that may be beneficial for better coping during the outbreak, is insufficient. Addi-tionally, more studies on the healthcare workforce’s mental situation in Iran are needed, and current information is limited. Therefore, we are optimistic that our study findings can pro-vide useful information for further interventions on healthcare staff’s mental health.

2. Materials and Methods
Design and registration

Multi-center cross-sectional studies through an internet-based test were conducted from August 22 to September 22, 2020, and the samples were collected via convenience sampling. Based on the Cochran formula for an unknown population, the sample size with a 95% confidence level was calculated, and the result showed that 385 in our target population should be enough to give us the confidence levels we needed. We used Porsline, an Iranian research website, to design an internet-based survey. Most hospitals and medical science departments in Iran use WhatsApp or Telegram platforms. Accordingly, this survey was sent on the internet to those who were willing to participate in the study through these platforms, and all interest-ed healthcare staff clicked the relevant link. 
A total of 551 members participated in the study: 32 of them were medical interns, others were healthcare staff, and most of them were nurses. All respondents were informed that their information would keep confidential. 

Demographic information
The questionnaire included the 10 demographic following items, including age, gender, marital status, educational level, occupation, and any background of chronic illness. In addition, the respondents were asked if they ever received psychotherapeutic help, if COVID-19 infected them, if they knew someone who passed away because of COVID-19 infection, and whether they felt a change in their psychological status during the pandemic.

Assessment of anxiety symptoms
The General Anxiety Disorder-7 Scale (GAD-7) was used to evaluate the prevalence of anxiety symptoms among healthcare staff. GAD-7 was developed by Robert L. Spitzer [24]. The scale consists of 7 items to detect probable cases and severity of GAD over the past two weeks. The reliability of original and Persian forms are described as excellent (Cronbach α=0.92) [24] and good (Cronbach α=0.85) [25], respectively. Participants were asked to respond regarding the COVID-19 outbreak and its consequential effects. Response options included “not at all”, “several days”, “more than half the day”, and “nearly every day”. Overall scores for the seven items range from 0 to 21. Points 5, 10, and 15 were considered cutoff points for mild, moderate, and severe anxiety, respectively. 
Assessment of depressive symptoms
The patient health questionnaire-9(PHQ-9) was used to monitor the severity of depression among healthcare staff over the past two weeks. The questionnaire was developed by Robert L. Spitzer [26]. The reliability of the questionnaire in English form was described as excellent (Cronbach α=0.89) [27], and the Persian form was described as good (Cronbach α=0.85) [28]. Participants were asked to respond regarding the COVID-19 outbreak and its consequential effects questionnaire is a 9-item depression module from the full PHQ. Response options included “not at all”, “several days”, “more than half the day”, and “nearly every day”. Points 5, 10, 15, and 20 indicate mild, moderate, moderately severe, and severe depression, respectively.

Cognitive flexibility inventory
The cognitive flexibility inventory was developed by Dennis and Vander Wal [29]. The inventory is a self-report measure that assesses three features of cognitive flexibility: The propensity to understand difficult situations as controllable, the capacity to consider various alternative explanations for incidents and human actions, and the ability to create multiple alternative solutions to demanding conditions [29]. The reliability of the original form is described as good to excellent (Cronbach α=0.90 to 0.91) [29], and the Persian form revealed good reliability as well (Cronbach α=0.90) [30]. The inventory consists of 20 items, and each response option ranged from strongly disagree=1 to strongly agree=7. The higher scores are related to greater cognitive flexibility, and lower scores indicate great cognitive rigidity.

Self-compassion scale
The self-compassion short form scale has 12 items developed by Filip Raes et al. in 2011 which measures 6 components of self-compassion: Self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identified [31]. The reliability of English and Persian forms are described as excellent (Cronbach α=0.86) [31] and acceptable (Cronbach α=0.79) [32], respectively. Response options include a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always). Greater scores represent higher self-compassion. Since subscale scores are less reliable with the short form and based on developers’ suggestions, subscale scores were not considered in our analysis [31].

Statistical analysis
The data were analyzed with SPSS software, version 22. Descriptive statistics were used to indicate demographic features and the prevalence of anxiety and depression in the healthcare population. Independent samples t-test and one-way ANOVA were performed to compare the averages of two independent groups with normal distribution. In addition, a bivariate correlation was used to determine the relationship between factors and linear regression analysis to measure the risk of anxiety and depression. P<0.05 were accepted as statistically significant.

3. Results
Participants’ characteristics

Of 551 participants, 406 (73.8%) were females, 143 (26.2%) were males, and 5 were unidentified. The Mean±SD age of the respondents was 35.22±9.074 years. The participants were 184 nurses, 101 physicians, and 47 midwives. Considering the participants’ responses, 85(15.4%) were infected by COVID-19, confirmed by laboratory tests, 152(27.6%) just had signs of infection, and 309(56.1%) had no signs of infection, and there were 5 missing data. Also, 438(79.8%) claimed they felt a change in their psychological status, 92(16.7%) reported they had lost a person because of COVID-19 infection, 109(19.8%) had a chronic illness, and 130(23.6%) received psychotherapeutic help. The Mean±SD values of anxiety, depression, cognitive flexibility, and self-compassion were 8.48±5.03, 10.14±6.08, 96.63±16.20, and 36.22±7.31, respectively

Prevalence of anxiety
According to the results, 78 participants (14.2%) experienced severe anxiety (scored 15-21), 111(20.1%) moderate anxiety (scored 10-14), 248(45%) mild anxiety (scored 5-9), and 114(20.7%) no significant anxiety (scored 0-4).

Prevalence of depression
Fifty participants (9.1%) experienced severe depression (scored 20-27), 86(15.6%) moderately severe depression (scored 15-19), 124(22.5%) moderate depression (scored 10-14), 187(33.9%) mild depression (scored 5-9), and 104(18.9%) no significant depression (scored 0-4).

Anxiety, depression, cognitive flexibility, and self-compassion in terms of demographic information
Respondents who answered “yes” to the question :“Have you experienced any change in your psychological status since the beginning of the pandemic?” showed significantly higher anxiety and depression and lowered cognitive flexibility and self-compassion (P<0.05, Table 1).

There was a statistically significant difference in cognitive flexibility and self-compassion by gender, but no difference was observed in anxiety and depression (P<0.05, Table 1). The anxiety level was significantly higher in three groups: Married participants, respondents who knew someone that passed away because of COVID-19 infection, and respondents with chronic illness (P<0.05, Table 1). There was a significant difference in the m anxiety, depression, and self-compassion in the participants with a background of psychotherapy (P<0.05, Table 1), and the level of self-compassion was significantly lower in respondents with chronic illness background (P<0.05, Table 1). 

Correlational analysis
As shown in Table 2, there was a relationship between anxiety, depression, cognitive flexibility, and self-compassion.

As one would expect, the association between anxiety and depression based on Cohen guidelines [33]was strongly positive (r=0.78, P<0.001), and there was a large positive correlation between cognitive flexibility and self-compassion (r=0.61, P<0.001). Cognitive flexibility had a moderate negative relationship with anxiety (r=-0.40, P<0.001) and depression (r=-.37, P<0.001). Also, there was a medium negative correlation between self-compassion and anxiety and depression (r=-0.48, r=-0.47, respectively, P<0.001). The assessment of the cognitive flexibility subscale indicates that the control subscale had the most influential correlation with anxiety (r=-0.51, P<0.001) and depression (r=-0.46, P<0.001), and the human alternatives subscale had no significant correlation with anxiety and depression.

Regression analysis
Linear regression analysis could be used to assess the ability of two control measures (cognitive flexibility inventory, self-compassion short form scale) to predict levels of anxiety and depression (GAD-7, PHQ-9). The data of 551 respondents were entered, and the results are shown in Tables 3 and 4. Linear regression analysis (Table 3) demonstrated that self-compassion (β=-0.173; P<0.000) and control (subscale of cognitive flexibility) (β=-0.194; P<0.000) are two factors to reduce anxiety(R2=0.303, Adjusted R2=0.300).

Similarly, self-compassion (β=-0.253; P<0.000) and control (β=-0.175; P<0.000) had decreasing effect on depression(R2=0.267, Adjusted R2=0.264) (Tables 4).

4. Discussion
In this study, the first aim was to examine the prevalence of anxiety and depression among the healthcare staff, and the results showed that 29.9% of respondents significantly experienced both anxiety (scored 10-21) and depression (scored 10-27), 4.4% just experienced anxiety and 17.2% just experienced depression. The findings suggest that being married, losing someone because of COVID-19 infection, having a background of chronic illness, and back receiving psychotherapy may be risk factors, and staff with these features probably needed a higher degree of support and mental protection. It can be argued that married people have more concerns than single people, like fear of infection and transmission to their partner or children. In addition, having a background of chronic illness and receiving psychotherapy can perceive by a person as debilitating factors during infection. It would seem clear that the healthcare workforce who lost someone because of COVID-19 is under considerable pressure than others who did not, and investigating the process of grief among these people can be a subject of a new study. Likely, the pain and problems of patients with COVID-19, observing their death, and the fear of COVID-19 disease can cause feelings of depression and anxiety in healthcare workers. Some studies have shown that the nurse-patient relationship causes psychological symptoms, such as depression in nurses [34], and the feeling of more stress in the workplace and fatigue associated with patient care are the risk factors for anxiety and depression in nurses. 
The second aim of the current study was to estimate the role of cognitive flexibility and self-compassion on anxiety and depression during the pandemic. Correlational analysis revealed that self-compassion and the propensity to understand difficult situations as controllable (control subscale) are influential in decreasing anxiety and depression severity. The scores of self-compassion and cognitive flexibility were significantly higher in males than females, as other studies suggested [34, 35]. The findings of this study indicate that self-compassion creates more tolerance, and probably healthcare workforces with higher scores of self-compassion perceive difficult situations as more meaningful and constructive than others; therefore, they act kind and understanding toward themselves and others in comparison with people who perceive the condition catastrophic and harsh, as Gilbert and Irons suggest that self-compassion make inactive the threat system [36]. Based on the findings of this study, one would say that cognitive flexibility helps the healthcare workforce to feel more assertive and powerful against the pandemic because they understand problems as more challenging and controllable compared to people who feel ineffectual.
Regarding research, higher cognitive flexibility scores are associated with cognitive restructuring ability to reduce subjective distress [37]. Therefore, our study proposes that self-compassion and cognitive flexibility are two factors that can strengthen the mind’s ability significantly to tolerate difficult and long-lasting situations like the COVID-19 pandemic among the healthcare workforce and reduce the levels of anxiety and depression. 

Study limitations
As the data presented here were collected from a cross-sectional design, the study did not provide an inference for causation. To avoid possible infections and the difficulty of attending to hospital, we conducted an online-based survey. Therefore, the possibility of selection bias should be regarded. Most respondents were nurses, and according to a different experience of each job in the health system, the result may be a bias for other healthcare jobs. In addition, we did not assess the mental status of respondents before the outbreak; thus, the results should interpret with caution because it would not be certain determine whether the outbreak just caused the outcomes or not.

5. Conclusion
The object of this study was to focus on a quick assessment of two major factors of mental health (anxiety and depression). Therefore, it would seem that further psychological interventions are required to assess the conditions and other aspects of mental health among healthcare staff in more detail. In addition, more information is needed for providing well-organized treatment for those suffering from anxiety or depression and preventive interventions for staff with subclinical symptoms. During the study, we recognized that many healthcare workforces were experiencing burnout; further investigation into burnout and related factors is strongly recommended.

Ethical Considerations
Compliance with ethical guidelines

All ethical Issues were considered in this article. All participants were informed about the purpose of the study and its stages. They were also confident in the security of their statistics and free to leave the study whenever they want. They knew that the results of the studies can be made public. Informed written consent has been obtained from individuals.

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization, study design, and definition of intellectual content: Fereshte Momeni and Ashkan Babaei; Searching the literature: Ashkan Babaei; Conducting the study procedures and data collection: Fereshte Momeni and Ashkan Babaei; Data analysis: Ashkan Babaei and Mohsen Vahedi; Editing: Mohammadreza Davoudi; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

We thank all who participated in our study. Additionally, we express our deep respect to all healthcare staff and their enormous efforts to fight COVID-19.

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Article type: Original Research Articles | Subject: Nursing
Received: 2021/04/8 | Accepted: 2022/11/23 | Published: 2023/03/1

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