Introduction
Work-related factors such as excessive workload, prolonged duty hours, and high-pressure environments are critical determinants of mental health challenges among health care workers.Reference Syahrir and Falah 1 Globally, frontline workers including doctors, nurses, and support staff, face elevated risks of anxiety, depression, and burnout, particularly during public health emergencies.Reference Suresh, Nimbarte and Choudhury 2 Studies estimate that approximately 32% of health care workers worldwide experience clinically significant symptoms of depression, while anxiety disorders affect 40%, with prevalence peaking during crises such as the COVID-19 pandemic.Reference Fronteira, Mathews and Dos Santos 3 These conditions not only compromise individual well-being but also undermine the quality of patient care, creating a cycle of strain on health care systems.Reference Kc, Gooden and Aryal 4
In South Asia, the burden is even more pronounced. Systematic reviews report that 35%-38% of health care workers in the region exhibit symptoms of depression, surpassing global averages.Reference Chowdhury, Das and Sunna 5 , Reference Shorey, Ng and Chee 6 Structural disparities, including under-resourced health infrastructure and high patient-to-provider ratios, exacerbate these challengesReference Birkelund, Rasmussen and Shwank 7. In Pakistan, the mental health crisis among health care workers is particularly acute. Recent studies indicate that 45% of Pakistani health care workers reported moderate-to-severe anxiety during the COVID-19 pandemic, with depression rates exceeding 40% in tertiary-care hospitals.Reference Fortin, Soubhi and Hudon 8 , Reference Thapa, Maharjan and Shrestha 9 The country’s health care system grapples with chronic understaffing, limited institutional support for mental health, and recurrent emergencies such as floods and infectious disease outbreaks, which intensify workloads and emotional burdens.Reference Ali, Munir and Ali 10 Despite these pressures, formal mental health support remains scarce, leaving workers to navigate stressors without systemic safeguards.
Mental health disorders among health care workers are a global concern, but their prevalence and drivers in Pakistan remain understudied.Reference Khan, Ashraf and Ullah 11 Existing research highlights gender disparities and institution-specific stressors as key factors, yet gaps persist in understanding how cultural norms and systemic inequities amplify risks.Reference Shahbaz, Ashraf and Zakar 12 The mental health of health care workers in Pakistan represents a critical but under-researched public health issue, particularly given the country’s fragile health care infrastructure and repeated exposure to public health emergencies. Female health care workers in Pakistan face a dual burden: studies suggest they are 1.5 times more likely to experience anxiety than male counterparts, often due to societal expectations and workplace discrimination.Reference Shahzad, Ghafoor and Ahmad 13 Similarly, inter-hospital variations in leadership quality and resource allocation may explain differences in mental health outcomes, though these dynamics are poorly quantified in low-resource settings.Reference Mansoor, Azad and Bin 14
Understanding the scale and contributing factors of these mental health challenges is essential to designing evidence-based and culturally sensitive interventions. This study aims to address this gap by examining the prevalence and key demographic and institutional predictors of anxiety and depression among health care workers in Khyber Pakhtunkhwa, with the practical goal of informing targeted, role-specific mental health policies and support mechanisms.
Methodology
Study Design and Setting
This cross-sectional study was conducted between March and November 2023, targeting health care professionals, including doctors, nurses, and paramedics, working in selected hospitals across multiple cities in Khyber Pakhtunkhwa. The study sites included three tertiary care hospitals in Peshawar like Hayatabad Medical Complex, Lady Reading Hospital, and Khyber Teaching Hospital, as well as one tertiary care hospital each in Abbottabad, Swat, Mardan, and Dera Ismail Khan.
A stratified random sampling approach was employed to ensure proportional representation of health care professionals across hospitals and job roles. Hospitals were selected based on accessibility, and within each hospital, participants were stratified by professional category (doctors, nurses, paramedics, and emergency staff). A random selection was then conducted within each stratum to enhance representativeness.
Sample Size Calculation
The minimum required sample size was calculated using OpenEpi, assuming a 40% prevalence of depression among health care professionals,Reference Fronteira, Mathews and Dos Santos 3 a 95% confidence level, and a 4% margin of error, resulting in a sample size of 576. However, to enhance statistical power, account for potential non-response or incomplete data, and ensure robust subgroup analysis across professional categories, the final sample size was expanded to 651 participants.
Inclusion and Exclusion Criteria
Inclusion Criteria
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• Frontline health care professionals employed in the selected hospitals, including doctors, nurses, paramedics, laboratory personnel, and support staff.
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• Health care workers in emergency wards, critical care units, or emergency response services, including Rescue 1122 personnel.
Exclusion Criteria
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• Health care professionals on long-term leave (e.g., medical, maternity, or personal leave) during the study period.
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• Medical or nursing students, interns, or trainees not fully licensed or employed as frontline health care providers.
Data Collection
Data were collected using a structured questionnaire that included demographic information, professional background, and mental health indicators. Anxiety and depression were assessed using the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9), both of which are widely validated screening instruments.Reference Kelly, Schroeder and Leighton 15 These tools have demonstrated high internal consistency, with reported Cronbach’s alpha values exceeding 0.80, indicating strong reliability in measuring anxiety and depression symptoms.Reference Walker, Goodfellow and Pookarnjanamorakot 16
Primary Outcomes
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• Anxiety levels categorized as high (GAD-7 ≥10) and low (GAD-7 <10).
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• Depression severity classified as moderate/severe (PHQ-9 ≥10) and no/mild (PHQ-9 <10).
Data Analysis
Data were analyzed using R/RStudio. Descriptive statistics (mean, standard deviation [SD], and frequency distributions) summarized participant characteristics. Anxiety was categorized as high (GAD-7 ≥10) and low (GAD-7 <10), while depression was classified as moderate/severe (PHQ-9 ≥10) and no/mild (PHQ-9 <10). Gender-based subgroup analyses compared mental health outcomes between males and females. Chi-square tests (χ2) examined differences in anxiety and depression prevalence across hospitals and professional groups. Independent t-tests or Mann-Whitney U tests assessed mean age differences between groups. The correlation between GAD-7 and PHQ-9 scores was evaluated using Pearson’s correlation coefficient (r) and visualized with a scatter plot and regression line. Boxplots depicted gender-based differences in anxiety and depression scores, with IQR analysis assessing score variability. The distribution of mental health outcomes across hospitals was analyzed using Kruskal-Wallis tests. A p-value < 0.05 was considered statistically significant.
Ethical Considerations
Ethical approval for the study was obtained from the Institutional Review Board of Khyber Medical University (Approval No: KMU/IPH&SS/Ethics/2022/EE/078) and the National Bioethics Committee of Pakistan (Ref: No.4-87/NBCR-1031/23/1086). Written informed consent was secured from all participants, with assurances of confidentiality and voluntary participation.
Results
Demographic and Occupational Characteristics of the Study Population
A total of 6651 health care professionals participated in the study. The majority were from Lady Reading Hospital Peshawar (23%), followed by Hayatabad Medical Complex Peshawar (20%) and Mardan Medical Complex Mardan (16%). The lowest representation was from Mufti Mehmood Memorial Hospital Peshawar (4.1%) and Rescue 1122 Peshawar (4.5%) (Table 1). Among the participants, 65% were male, and 35% were female. The mean age of the participants was 28.4 years (SD = 4.4), with a median of 28.0 years. Regarding professional roles, doctors (38%) and nurses (36%) were the predominant groups, followed by paramedics (17%), other emergency staff (5.3%), and Rescue 1122 staff (4.1%). The Patient Health Questionnaire (PHQ) Final Score was positive for 48% of participants, with 22% reporting no difficulty (PHQ score = 0), 23% reporting some difficulty, 5.7% experiencing high difficulty, and 2.1% reporting extreme difficulty. The Generalized Anxiety Disorder (GAD) score had a mean of 6.4 (SD = 5.0) and a median of 6.0 [IQR: 3.0–9.0]. Anxiety severity levels showed that 42% had minimal anxiety, 35% had mild anxiety, 16% had moderate anxiety, and 7.7% had severe anxiety. The PHQ depression score had a mean of 8.0 (SD = 6.0) with a median of 7 [IQR: 3-11]. Depression levels indicated that 10% of participants had no depression, 24% had minimal depression, 33% had mild depression, 19% had moderate depression, 7.8% had moderately severe depression, and 5.9% had severe depression.
Table 1. Demographic and Occupational Characteristics of the Study Participants
This table summarizes the age, gender distribution, hospital affiliation, and professional roles of 651 health care professionals across Khyber Pakhtunkhwa. It includes mean age, percentage distribution, and initial descriptive statistics for anxiety and depression
* n (%); Mean (SD), Median [Q1, Q3]
Comparison of High and Low Anxiety Groups
Participants were categorized into high anxiety (n = 1581) and low anxiety (n = 5071) groups based on GAD scores (Table 2). There was a significant difference in anxiety levels among hospitals (P = 0.024), with the highest proportion of high anxiety reported at Hayatabad Medical Complex Peshawar (25%) and Lady Reading Hospital Peshawar (20%). The mean age in the high-anxiety group was 28.2 years (SD = 4.0), whereas in the low-anxiety group, it was 28.5 years (SD = 4.6), but the difference was not statistically significant (P = 0.40). Professionally, doctors (40%) and nurses (39%) had the highest prevalence of anxiety, while the lowest rates were among Rescue 1122 staff (1.9%). However, professional category was not significantly associated with anxiety (P = 0.40).
Table 2. Comparison of Participants with High and Low Anxiety Levels Based on GAD-7 Scores
This table presents the distribution of anxiety severity (GAD-7) across hospitals, professional roles, and gender, highlighting significant differences in anxiety prevalence
* n (%); Mean (SD)
† Pearson’s Chi-squared test; Wilcoxon rank sum test.
Comparison of Depression Levels
In Table 3, we grouped the participants into moderate/severe depression (n = 2161) and no/mild depression (n = 4491) based on PHQ scores. The prevalence of moderate/severe depression varied across hospitals, but the difference was not statistically significant (P = 0.082). Participants with moderate/severe depression had a mean age of 27.9 years (SD = 3.7), significantly lower than those with no/mild depression (28.7 years, SD = 4.7, P = 0.005). The highest proportion of moderate/severe depression was among nurses (40%), followed by doctors (34%), while Rescue 1122 staff had the lowest prevalence (2.3%). Although professional category showed some variation in depression levels, the association was not statistically significant (P = 0.069).
Table 3. Comparison of Participants with Moderate/Severe and No/Mild Depression Based on PHQ-9 Scores
This table compares demographic and occupational characteristics between participants with moderate/severe depression and those with no/mild depression, including statistical comparisons of age and professional roles
* n (%); Mean (SD)
† Pearson’s Chi-squared test; Wilcoxon rank sum test.
Comparison of Anxiety (GAD) and Depression (PHQ) Scores by Gender
Figure 1 illustrates the distribution of Generalized Anxiety Disorder (GAD) scores and Patient Health Questionnaire (PHQ) scores stratified by gender. The boxplots indicate that females exhibited higher median GAD and PHQ scores compared to males, suggesting a greater burden of anxiety and depression among female health care workers. The interquartile range (IQR) for both scores is wider in females, indicating greater variability in mental health symptoms. Additionally, the presence of outliers in both groups reflects a subset of individuals experiencing severe anxiety and depressive symptoms.
Figure 1. Distribution of GAD-7 and PHQ-9 scores stratified by gender.
Boxplots illustrating the differences in anxiety (GAD-7) and depression (PHQ-9) scores between male and female health care workers. Female participants show higher median scores and broader interquartile ranges, indicating more psychological distress.
Distribution of Anxiety and Depression Scores by Gender and Hospital
Figure 2 presents the distribution of Generalized Anxiety Disorder (GAD) scores and Patient Health Questionnaire (PHQ) scores across multiple hospitals, stratified by gender. Across all hospitals, females consistently exhibit higher median scores for both anxiety and depression compared to males, indicating a greater psychological burden. The interquartile range (IQR) appears wider for females, reflecting greater variability in mental health symptoms. Notably, several outliers are observed, suggesting that a subset of individuals experiences severe anxiety and depressive symptoms.
Figure 2. Distribution of anxiety and depression scores by gender across hospitals.
Boxplots showing variation in GAD-7 and PHQ-9 scores among male and female participants across different hospitals. Females consistently exhibit higher scores across nearly all hospital settings.
Interpretation of the Correlation Between Anxiety (GAD) and Depression (PHQ) Scores
Figure 3, showing the scatter plot, illustrates the relationship between Generalized Anxiety Disorder (GAD) scores and Patient Health Questionnaire (PHQ) depression scores. The positive linear trend, reinforced by the regression line, suggests a strong positive correlation between anxiety and depression. As GAD scores increase, PHQ scores also tend to rise, indicating that individuals experiencing higher levels of anxiety are also more likely to exhibit higher levels of depression. The spread of data points suggests variability in the severity of symptoms among individuals, but the clear upward trend confirms a statistically significant association. The shaded confidence interval around the regression line indicates that this relationship is consistent and reliable across the sample.
Figure 3. Correlation between anxiety (GAD-7) and depression (PHQ-9) scores.
Scatter plot with regression line demonstrating a strong positive correlation between anxiety and depression scores. A shaded confidence interval illustrates the consistency of the association across the sample.
Discussion
The primary objective of this study was to assess the prevalence and distribution of anxiety and depression among health care workers in multiple hospitals. Additionally, the study looked to identify key demographic and professional factors associated with mental health burdens and their correlation with a focus on gender and workplace variations.
The study found that 23.8% of health care workers exhibited high anxiety levels, with significant variation across hospitals. Hayatabad Medical Complex Peshawar (25%) and Lady Reading Hospital Peshawar (20%) had the highest proportion of high-anxiety cases. The prevalence of moderate-to-severe depression was 32.5%, but differences between hospitals were not statistically significant. Nurses (40%) and doctors (34%) were the most affected professional groups for both anxiety and depression, while Rescue 1122 staff had the lowest prevalence. Gender-based analysis showed that female health care workers consistently had higher median anxiety and depression scores than their male counterparts. Additionally, the study established a strong positive correlation between anxiety (GAD scores) and depression (PHQ scores), indicating that individuals experiencing high anxiety were also more likely to suffer from depression.
The significant interhospital variation in anxiety levels (e.g., Hayatabad Medical Complex: 25%, Lady Reading Hospital: 20%; P = 0.024) contrasts with the nonsignificant differences in depression prevalence (P = 0.082). These differences are consistent with studies emphasizing how institutional context such as administrative support, workload distribution, and organizational communication can significantly influence mental well-being. This aligns partially with studies linking workplace environments to mental health outcomes.Reference Kelly, Schroeder and Leighton 15 Similar themes were reported in Iranian health care settings, where prehospital emergency workers described resource shortages, ambiguous roles, and ethical dilemmas as primary stressors during the COVID-19 pandemic.Reference Walker, Goodfellow and Pookarnjanamorakot 16 , Reference Farokhzadian, Mangolian Shahrbabaki and Farahmandnia 17 The elevated anxiety in our study’s tertiary care hospitals may likewise reflect acute system pressures experienced during pandemic response periods. On the other hand, the relatively consistent depression rates may point to systemic, long-term occupational stressors across institutions such as chronic understaffing, lack of mental health resources, and burnout as also highlighted in studies of Iranian nurses responding to disaster scenarios.Reference Hussain and Abbas 18 , Reference Hadian, Jabbari and Abdollahi 19
Nurses and doctors in our study reported the highest anxiety and depression scores, a finding echoed in global and regional literature. The disproportionate mental health burden among these groups has been linked to their direct, continuous contact with patients and their roles in life-saving interventions. Research from IranReference Mohammadi, Sheikhasadi and Mahani 20 on bioethical education interventions among paramedics suggests that ethical preparedness may enhance coping capacity in high-pressure environments. This insight underscores the potential benefit of integrating ethical resilience and stress-management training into the professional development of frontline health care workers in Pakistan.
Female health care workers exhibited significantly higher median anxiety and depression scores than males, corroborating studies that identify gender as a key social determinant of mental health. While societal expectations (e.g., caregiving roles, workplace discrimination) are frequently cited, our findings call for an intersectional lens.Reference Raza, Banik and Noor 21 As female nurses in Pakistan often face compounded stressors due to hierarchical workplace cultures and limited upward mobility, whereas female doctors may struggle with balancing clinical duties and familial responsibilities. Structural factors, such as inadequate maternity leave policies and underrepresentation in leadership roles, likely exacerbate these disparities.Reference Husain, Chaudhry and Blakemore 22
The strong positive correlation between GAD and PHQ scores reinforces existing evidence of shared etiological pathways between anxiety and depression. Neurobiological models suggest that chronic stress dysregulates the hypothalamic-pituitary-adrenal (HPA) axis, elevating cortisol levels and predisposing individuals to both conditions.Reference Luo, Fei and Gong 23 In high-stress professions like health care, this comorbidity may reflect prolonged exposure to traumatic events, sleep disruption, and moral injury—factors amplified in resource-limited settings like Pakistan.Reference Malik and Nisar 24 , Reference Deneva and Ianakiev 25
Limitations of the Study
Certain limitations must be acknowledged. The study design is cross-sectional, which limits the ability to establish causal relationships between workplace factors and mental health outcomes. Additionally, self-reported measures of anxiety and depression may be subject to response bias, as participants might underreport or overreport symptoms due to social desirability or stigma. Lastly, while the study considers professional categories, it does not account for other confounding factors such as shift schedules, work experience, or personal coping mechanisms that may influence mental health outcomes.
Conclusion
The findings of this study highlight a significant burden of anxiety and depression among health care professionals, particularly among nurses and doctors. Anxiety levels varied significantly across hospitals, with the highest prevalence observed at Hayatabad Medical Complex and Lady Reading Hospital. Although professional category was not statistically associated with anxiety and depression, nurses and doctors exhibited the highest prevalence, while Rescue 1122 staff had the lowest. Gender-based analysis revealed that female health care workers experienced a greater psychological burden, as evidenced by higher median GAD and PHQ scores. Additionally, a strong positive correlation was observed between anxiety and depression, indicating that individuals with higher anxiety levels were more likely to suffer from severe depressive symptoms.
Recommendations
Hospitals should implement routine mental health screenings using GAD-7 and PHQ-9 to detect and manage anxiety and depression early. Targeted support, including stress management programs and counseling, should be prioritized for high-risk groups like nurses and doctors. Given the higher burden among female health care workers, gender-sensitive mental health strategies must be integrated. Hospital administrations should improve work conditions by managing workloads, rotating shifts, and establishing psychological support units. Institution-specific programs should address hospital-specific variations, while long-term research is needed to evaluate intervention effectiveness. Mental health should also be integrated into occupational health policies to ensure stigma-free access to necessary resources, ultimately enhancing health care workforce’s well-being and system efficiency.
Data availability statement
All the data generated and analyzed in this study is included in this article.
Author contribution
Z.K. and M.I.: Conceptualization, statistical analysis, manuscript drafting; A.R. and U.A.: Methodology, data validation, data collection; I.U.H and F.A.: Supervision, manuscript review, study design; K.R and F.A.: Methodology, data interpretation; M.I.: Data curation, field supervision; J.K. and K.R: Project administration, policy relevance, manuscript review; Z.K.: Oversight and critical review.
Funding statement
This study was funded by the Higher Education Commission (HEC) of Pakistan under the National Research Program for Universities (NRPU) Project (Reference No: 16055). The project is titled “EMPATHI—Emergency-Associated Mental Health Issues of Pakistani Frontline Health Workers and Their Management Through Telehealth Intervention.”
Competing interests
No financial or nonfinancial competing interests.
Ethical standards
Ethical approval was obtained from the Institutional Review Board of Khyber Medical University (Approval No: KMU/IPH&SS/Ethics/2022/EE/078) while informed consent was obtained from all participants and the right to withdraw without penalty
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