Covid-19: adverse mental health outcomes for healthcare workers

Frontline medical workers are at risk of not just adverse physical outcomes from coronavirus disease 2019 (covid-19) but psychological ones too.1 Data from previous pandemics, particularly after quarantine, suggest that healthcare workers might develop symptoms of post-traumatic stress disorder, depression, and substance use disorders.2 Preliminary data from China and Italy during the covid-19 pandemic offer further evidence; healthcare workers in China reported depression (in 50.3%), anxiety (44.6%), and insomnia (34.0%).34

Concerns about these data are compounded by high rates of pre-existing mental health and substance use disorders in this population,5 with physicians having rates of suicide among the highest of any profession.6 Although evidence based effective interventions and treatments are available, barriers such as stigma and lack of time limit their uptake, even in normal times.789 Less is known about interventions for the mental health of healthcare workers during pandemics.

In a linked study, Kisely and colleagues (doi:10.1136/bmj.m1642) report a rapid review and meta-analysis of qualitative, cohort, and cross sectional studies that examined the psychological reactions of healthcare staff working in any clinical setting during emerging virus outbreaks of severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), H1N1 influenza, H7N9 influenza, Ebola virus disease, and covid-19.10 Using several databases, such as the Cochrane Central Register of Controlled Trials, PubMed, Embase, Psychifo, and medRxiv, the authors ended up with 282 potentially relevant full text papers that were assessed for eligibility. Ultimately 59 papers met the inclusion criteria. These studies looked at risk factors for stress and psychological distress and successful measures to manage them.

Personal caregiving and socioeconomic stressors, such as having children at home, an infected family member, and a lower household income were associated with adverse mental health outcomes.10 The study confirms that psychosocial and workplace measures can improve employees’ working lives and suggests that these, in turn, can improve mental wellbeing even though they are not explicitly mental health support services. Interventions to ease caregiver or childcare burden or lessen financial stressors, such as hazard pay, although not mentioned in the paper, might mitigate negative mental health outcomes. Self-care is also critical given the benefits of diet, exercise, and sleep.11

Clear communication, access to adequate personal protective equipment (PPE), adequate rest, and both practical and psychological support were associated with better psychological outcomes.10

Concern about inadequate PPE during the covid-19 pandemic have focused on the risk of infection but, importantly, this study highlights the adverse effects that lack of PPE could have on mental health.12 Such institutional betrayal—when trusted and powerful institutions act in ways that can harm those dependent on them for safety and wellbeing—compounds trauma.13 To mitigate this, organizations should support staff voices and efforts to obtain PPE when possible.

Kisely and colleagues suggest that redeployment of staff to care for patients who are positive for covid-19 should be voluntary when possible. They did not, however, explore whether inability to communicate effectively with patients, bans on visitors, and barriers to the clinician-patient relationship were associated with poorer mental health among healthcare workers.

The authors suggest implementing psychological first aid (PFA)—a tailored psychological intervention based on the needs of individual staff to mitigate risk—rather than something such as debriefing, which has been found to be ineffective and in some cases to actually worsen post-traumatic stress disorder.1415 By not being compulsory, being more culturally sensitive, and focusing more on safety, comfort, and connection with social supports and resources, PFA can be a helpful intervention for the acute management of trauma.14 PFA on the frontlines makes sense in the covid-19 pandemic, with its focus on less stigmatizing support and crisis intervention rather than counseling or psychiatric care. Yet focusing only on crisis intervention could miss those who need the care the most and could prevent long term responses from being put in place.

We also need to be thinking about those with a history of psychiatric and substance use disorders who, not surprisingly, are predisposed to have worsening mental health during a pandemic.56 We want to identify the nurse who consumed alcohol before the pandemic and now is drinking a bottle a night to cope, or the doctor who was depressed before and coped by socializing but is now in isolation.

And long ignored, untreated, or undertreated depression plus covid-19 can be a deadly combination. Healthcare providers cannot make the mistake of minimizing these presentations as only crisis induced. They should screen, triage, and refer healthcare workers to the appropriate level and type of services before it is too late.