Our study highlights the increased incidence of mental health illness among ED healthcare workers during the COVID-19 pandemic. The reasons for this are manifold. A few that are worth mentioning are the risk of contracting the disease from the patients and the fear of transmitting the disease to their own families [11]. The ED being the front-line service in dealing with COVID-19 patients was a privileged observatory of the general population with COVID-19-related fears. It admitted patients with or without psychiatric diagnoses, fearing COVID-19 disease, or the related sanitary measures and this cohort included the ED healthcare workers, their relatives, or colleagues. The results of this article also propose the refinement of individualized and long-term sanitary measures strategies with a focus on an oriented prevention policies strategy [12].

The factors that are highlighted in our paper are important as it paves the way to develop mental health assessment and training programs for healthcare workers working in high-risk environments, like ED and ICU.

The study is important from Pakistan, as it is the only study to date that has focused on the mental health assessment of ED healthcare workers during the COVID-19 pandemic. Moreover, the factors that are explored can later be intervened to either minimize or decommission the risk of mental health illness among healthcare workers in the ED.

Although some published literature has looked at healthcare workers’ assessment of mental health during the COVID-19 pandemic, a few have focused on ED healthcare workers (physicians and nurses) [13].

Our study reports a significant involvement of mental health disorders among medical officers and nurses. This is congruent with the previous research demonstrating widespread negative attitudes among healthcare workers in the ED [1, 13]. The involvement of medical officers and nurses seems to be directly related to the increased number of working hours. The presence of these psychological disorders among front-line healthcare workers suggests that they must cope with psychological distress and are at risk of allostatic overload. The increased frequency of depression and anxiety among those who are less than 30 years of age might be due to their less ED working experience and coping mechanisms that are not well-developed to deal with the stress of ED. The COVID-19 pandemic has come up with an added burden to the ED healthcare workers due to added stress, insomnia, the burden of wearing personal protective equipment for long hours, fear of getting infected and subsequently putting their families at risk and patient’s ignorance of not accepting that reality, and seriousness of COVID 19 infection [14].

COVID-19 has affected many front-line healthcare workers. In low-resource settings like Pakistan, it increased the development of psychological problems among healthcare workers who are undoubtedly at increased risk of contracting the disease. The emergency departments of the city are currently working at their full capacity. The increased workload and the stressors of long duty hours may worsen the situation by delving into mental health illnesses. The lack of structured programs and training addressing this important issue is not existent. Additionally, the lack of standard operating procedures, lack of resources, and prolonged wearing of personal protective equipment might make the situation further gloomy. Pandemics bring significant economic crises along with medical, psycho-social, and physical health crises, and in times of economic crises, the only statistically significant protective factor in mitigating mental health effects is the “interpersonal trust” as observed during the 2008–2009 global financial crises [15, 16]. However, the future challenge is probably not interpersonal trust only, but the improvement of trust in institutions, government, policymakers, and the information of rights as well [17,18,19].

Our study findings report an impact on healthcare workers' mental health as reported in China and Pakistan [5, 8, 20]. The frequency of depression and anxiety was in both nurses and physicians, but nurses were in the majority. The reason could be due to their long working hours and insufficient skills for coping and resiliency.

Despite these implications stated above, the study had a few limitations. First, it included healthcare workers from a single center and the results may not be generalizable to other settings. However, the frequency of depression and anxiety might help in the inference of the situation of the other healthcare setups in the city. Second, this study was cross-sectional; thus, causal conclusions should be drawn carefully. Further studies with longitudinal designs are needed to investigate the possible causal relationships and the long-term impact of depression and anxiety on ED healthcare workers. Third, all data collected were self-reported by the participants, and more objective data could be used in the future for similar research. There is a need for an exploratory design to comprehensively assess the problem. Lastly, the sample size of the study is small but its focus on the ED might make its utility important for formulating guidelines for prevention and coping skills for the front-liners who are involved in delivering care during the pandemic.