In their article Wu and colleagues,1 similarly to other authors,2, 3 present the effects of stress on medical staff during the coronavirus disease 2019 (COVID‐19) pandemic as an unprecedented challenge for all communities. Their observation is within current literature trends, which identify seven population subgroups affected by the psychosocial consequences of the COVID‐19: general population affected by restrictive measures, people subjected to quarantine, positive for the virus (isolated/hospitalized), health care personnel, relatives of persons who died, and mentally ill patients.2

Knowledge about the COVID‐19 increases over time. However, the proportion of COVID‐19 cases in health care workers is still very high (up to 20%).4 Medical staff is still mobilizing to work with patients infected by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). At the same time they often feel verbal social support but also feel social stigma and a huge stress due to developing the COVID‐19 and spreading it.2-4 In some countries they still learn to wear protective clothing from the internet pages, are supplied with equipment that does not fully meet the requirements or is rarely tested for coronavirus.4, 5

Generally, perceived stress and insufficient coping behavior contribute significantly to higher mortality rates in a dose‐response pattern.6 Although robust evidence suggests that chronic stress plays a significant role in the onset of severe psychiatric conditions such as major depressive disorder, bipolar disorder, and posttraumatic stress disorder,7 perceived stress is more strongly associated with death than mental health conditions per se.6 On the other hand, mental health conditions are associated with multimorbidity, influence the quality of life worldwide, and are linked to a wide range of adverse health outcomes such as higher risk of cardiovascular events, metabolic syndrome, and death.6 A possible explanation of stress‐related harm includes deregulation of stress‐related activation of neuroendocrine hypothalamic‐pituitary‐adrenal (HPA) axis, subsequent rise in cortisol levels and deregulation of immune/inflammatory system.6 As corticosteroids can activate latent viruses,8 they can potentially increase the spread of viruses. Hyperactivated HPA axis increases also levels of catecholamines (noradrenaline and adrenaline) that can block the activity of macrophages—critical for virus clearance.8 Other explanations may include stress‐related undesirable health behaviors such as a sedentary lifestyle or substance abuse/dependence, which might affect the prognosis of mental and somatic diseases.6 Neurologic manifestations of SARS‐CoV‐2 infection such as anosmia, ageusia, ataxia and seizures, and the presence of viral‐like particles in brain and capillary endothelium suggest that the virus may be neurotropic9 and these brain changes can potentially affect further stress tolerance.

The truism is that medical health workers who are well, best serve their patients.2 Another truism is that there is “no health without mental health.”10 Coronavirus appears to pose a particular threat to men.5 The death rate among men seems to be 50% higher than among women,11 which might be the result of the fact that men smoke more cigarettes than women. Smokers made up 26% of those that ended up in intensive care or died due to the COVID‐19.12 Stress is generally a modifiable health risk factor and possibly associated with lifestyle choices.7 Currently, males and females have difficulty coping with a stressful COVID‐19 situation.7 However, one study based on the Chinese population found that being female, at risk of contact with COVID‐19 patients and living in rural areas, are the most common risk factors for insomnia, anxiety, obsessive‐compulsive symptoms, and depression in medical health workers during the COVID‐10,3 which also are stress‐related conditions.

To keep health care workers safe during the COVID‐19 pandemic, resources to support them in expediting the implementation of telemedicine need to be designed.2 Such online and by phone support are easily provided in the field of psychology, psychiatry, and psychotherapy.2 As Wu and colleagues1 suggested the public should be concerned about the stress in medical staffs and possible crisis intervention strategies, but a special mental help service need to be dedicated to female health care workers, living in rural areas, and being at risk of contact with COVID‐19.3 Support for male health care workers should additionally include smoking cessation help. There is also a need to conduct research to clarify the role of stress in COVID‐19 complications in male and female medical staff.