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Rapid response to:


Managing mental health challenges faced by healthcare workers during covid-19 pandemic

BMJ 2020; 368 doi: (Published 26 March 2020) Cite this as: BMJ 2020;368:m1211

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Rapid Response:

Re: Managing mental health challenges faced by healthcare workers during covid-19 pandemic

Dear Editor

Greenberg et al have suggested that the impact of the COVID19 pandemic on some health professionals is more closely related to Moral Injury than to mental disorder. This assertion seems to be correct, especially in critical services such as ICU, internal medicine or infectious medicine.

This idea warns us of the inadequacy of the planning efforts conducted by many health systems in Europe to address with the foreseeable consequences for these professionals, which are only based on interventions for mental disorders such as adaptive, affective or anxiety disorders. The emphasis is on the professional (individual) and not on the organization (health system).

In many cases, what we are witnessing is that the cause of psychological distress is related to the lack of resources such as ventilators, the breakdown of pharmacy stock, the lack of sufficiently trained staff, receiving contradictions in instructions, the lack of guidelines, interruption of continuity of care in the majority of non-COVID19 related diseases except in case of an emergency, and witnessing patients die in isolation, and far from their loved ones.

Professionals are not able to provide the level of quality of care to which they were accustomed. Patient safety has been compromised and professionals have been powerless in these situations. An increase in litigation, which will be initiated by family members who have lost a loved one or by patients who might have been infected in health centers, is expected in the coming months. This situation, which affects work morale and personal ethics, may represent a new blow to these professionals.

To this situation we must also add that other healthcare professionals have experienced overload, have been infected, have remained in isolation or have been admitted in ICU for a long periods (like other patients), such as the Spanish case. This fact, according to individual differences and environmental support, may give rise to adaptive, affective or anxiety disorders associated with fear of infecting others or with the lived experience.

In Spain we have used the term second victim of SARS-CoV-2 when describing the impact of COVID19 on professionals. Similar outlook is expected in other countries. The challenge for all of us is to recover health systems and address the effects of the pandemic on our healthcare workforce. Patients need them.

What happens to professionals is directly and closely related to the raison d'être of any health system: the patients. Caring for those who care is an old recipe but not an outdated one. Otherwise, patient safety and quality of care will be compromised.

Thinking about what we can do and, in the light of the available evidence, identifying in which cases it is appropriate to intervene individually and in which not, seems necessary. Although Moral Injury and Post-Traumatic Stress Disorders share symptoms, it does not seem that interventions are equally effective in both cases. Approaching the problem as if it is only a mental disorder seems wrong. This approach will likely be rejected by most professionals.

It is probably time to bet, once and for all, on increasing well-being at work, on granting greater autonomy to clinicians, on strengthening the role and capacity of middle managers, and conceptualizing what happened. It is also the time to provide understanding the suffering of the healthcare professionals’ relatives during this period. Lastly, it is time to identify the problem clearly so as not to miss the solutions.

Competing interests: No competing interests

12 May 2020
Jose J Mira
Clinical Psychologist. Professor
Alicante-Sant Joan Health District. Universidad Miguel Hernández. Spain
UMH. Avd Universidad, Altamira Building. 03202 Elche Spain