Volume 128, Issue 9 p. 597-598
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COVID-19's crushing mental health toll on health care workers

Beyond its devastating physical effects, the pandemic has unleashed a mental health crisis marked by anxiety, depression, posttraumatic stress disorder, and even suicide. Here, in part 1 of a 2-part series, we examine the growing effort to identify and alleviate the fallout for health care workers

First published: 04 September 2020
Citations: 13
At the height of the coronavirus disease 2019 (COVID-19) epidemic in New York City, personal protective equipment was in such short supply that some nurses resorted to fashioning plastic garbage bags into protective gowns. For weeks, RNA-based tests were so scarce both in the city and elsewhere around the country that health care staff, even after showing symptoms, could not get tested.

Eric Wei, MD, MBA, senior vice president and chief quality officer of New York City Health and Hospitals Corporation says many health care workers were running on adrenaline during the surge in the city. “I think it was very scary to everyone,” he says. “And no matter how resilient you are, this was going to take a huge emotional and psychological toll for people.”

The aftermath is still unspooling in some hard-hit US cities, while others fell into crisis mode over the summer. With the potential for successive surges through the fall and winter, the cumulative toll on the very people charged with saving lives could be devastating. Experts say COVID-19 has laid bare the many weak points in the nation's mental health infrastructure and has underscored the need to address it with the same urgency as other medical interventions.

Roy Perlis, MD, professor of psychiatry at Harvard Medical School in Boston, Massachusetts, says the COVID-19 pandemic is akin to what people might experience during prolonged war or refugee crises. “There's this chronic period of elevated stress that's punctuated by acute exacerbations,” he says. “In general, we're much better at telling ourselves, ‘I can get through this,’ if we know when it's going to end.” But the endpoint for COVID-19 has remained frustratingly murky.

In fact, Dr. Wei says, US military personnel embedded in New York City's hospitals to assist with the clinical care told hospital staff, “this is the closest to combat that we've seen in a civilian setting.”

Once social distancing measures started working and the city passed its peak in COVID-19 cases, Dr. Wei says, the adrenaline began to wear off. The floodgates opened and feelings such as exhaustion, grief, and anger overwhelmed many health care workers. Experts have seen troubling signs of insomnia, anxiety, depression, and burnout. The suicides of an emergency room physician and an emergency medical technician in late April “were collective gut punches to health care workers and emergency physicians and first responders,” Dr. Wei says.

Multiple Stressors, Little Relief

Jessica Gold, MD, MS, assistant professor of psychiatry at Washington University in St. Louis, Missouri, says health care workers initially were focused on how to physically protect their patients, themselves, and their families. “As this has gone on, it has become clear that it's not just a physical risk to health care workers but also a mental one,” Dr. Gold says.

The pandemic has sparked another unprecedented and deeply uncomfortable fear as well: that hospitals could run out of ventilators and other basic supplies. “As health care workers, part of our identity is being able to take good care of people,” Dr. Perlis says. But many have faced the unfamiliar worry of having to make life-or-death decisions for patients multiple times a day.

COVID-19's many unknowns have further added to the stress, with a percentage of patients rapidly deteriorating regardless of the medical interventions used. “I feel like that was something that was incredibly traumatizing to our providers, our frontline workers—this hopelessness,” Dr. Wei says.

Because families cannot be at a dying patient's bedside, nurses and nursing assistants often have been called on to be conduits for video calls and emotional support. Some have foregone breaks to hold patients' hands as they die. “That's not normal,” Dr. Gold says. “And they're wearing this gear that creates a physical barrier, but you're then asking so much from them emotionally, to be there for everybody. So it's just a lot.”

Worse, hospitals in some states that initially were spared by the pandemic became overwhelmed after government officials and the public disregarded science-backed public health measures. “Even the conversations about rationing care are back,” Dr. Gold says. Maintaining the same level of hope and investment can be excruciatingly hard in a hotspot in which “it feels like every day, nobody's listening, nobody's following the rules, nothing's changed, and the numbers aren't going down,” she says.

Health care workers have felt like their efforts are being politicized, “when we're accustomed to thinking in terms of the science of medicine,” Dr. Perlis says. “The very idea that wearing a mask has become a political conversation, regardless of your politics as a physician or as a health care worker, is absurd.”

Karen Alter-Reid, PhD, a psychologist and founder of the Fairfield County Trauma Response Team in Fairfield, Connecticut, says she and her colleagues have seen a lot of anger and “just a mass of clogged up grief,” among health care workers and first responders. The anger, she says, can appear as betrayal trauma, or a feeling of being unprotected and unsupported. She also has noted feelings of powerlessness, a sense of failure at not being able to save lives, and classic posttraumatic stress disorder symptoms.

When a trauma occurs, Dr. Alter-Reid says, people normally get a chance to seek help and restore themselves. “There are ruptures in life, and then there's repair, there's kind of a rhythm.” For many health care workers, there was no time for that, and in many cases, a culture of stoicism kept them from even asking for it. “When you can't reach out for what you need, whether you know it or not, you're going to pay some kind of a price,” she says.

Building New Supports

For struggling health care workers who do seek help, Dr. Alter-Reid points to 2 mental health interventions that have worked well so far. One is a psychotherapy approach called eye movement desensitization and reprocessing therapy, or EMDR. The approach, which uses rapid side-to-side eye movements to calm the brain, can be particularly effective in helping patients with posttraumatic stress disorder metabolize blocked memories that are repeatedly retraumatizing them and driving their symptoms. To their relief, Dr. Alter-Reid and her colleagues have found that the approach still works well with Zoom-based therapy.

In group therapy sessions, she says, letting health care workers share their experiences with each other has been particularly helpful in addressing symptoms of numbness and detachment. “It's the brainstem that makes the decisions: fight, flight, freeze,” Dr. Alter-Reid says. Health care workers could not effectively battle COVID-19 or leave their jobs. So instead, many froze out what they were feeling. The group sessions, she says, help participants unfreeze: one person talking about what they have been through and why they are upset breaks the ice for everyone else to follow suit.

At a larger scale, Dr. Alter-Reid and other experts have lauded initiatives by hospitals in cities such as Boston and New York. Through the New York City Office of Emergency Management, for example, the Department of Defense shared its own combat stress management and resilience programs, and a multiagency collaboration is adapting them to the civilian health care system across the city. Dr. Wei says one critical lesson from the military has been the importance of assessing the well-being needs of each unit and each individual before, during, and after deployment.

In New York City, Dr. Wei has helped to provide some critical infrastructure through a program called Helping Healers Heal, which allows health care workers to process psychological and emotional trauma. To fortify the mental health supports during the unprecedented COVID-19 crisis, he and other agency leaders combined 18 facility-based teams—totaling more than 1000 trained peer supporters—with behavioral health providers and staff.

The combined group established an anonymous behavioral health hotline. At its peak, the support system also provided 31 wellness respite rooms that gave staff a quiet place to catch their breath, meditate, write, make artwork, or talk with “peer support champions” trained to provide emotional support. For busy clinical staffers who were less able to take mental health breaks, the team members made wellness rounds to look for and address signs of anxiety, burnout, compassion fatigue, and other symptoms.

Dr. Gold says improving access to telemental health services by reducing some regulatory barriers could help to magnify limited resources, whereas Dr. Perlis cites community mental health centers as other assets in helping to plug holes in the nation's “broken” mental health system. “I do think that part of the battle is recognizing that health care workers may be less comfortable seeking care,” he says. “Even if we're more educated about mental health, we're not immune to worrying about stigma and what our colleagues will think about us.”

“I do think that part of the battle is recognizing that health care workers may be less comfortable seeking care. Even if we're more educated about mental health, we're not immune to worrying about stigma and what our colleagues will think about us.”

–Roy Perlis, MD

Destigmatizing mental health care, he and other experts agree, will be critical given a pandemic whose toll may be felt far into the future.