By Madeline Roty
Since 1949, May has been Mental Health Month. This May, as the COVID-19 pandemic continues, mental health has become especially relevant and demands increased awareness and action. On April 26th, Dr. Lorna Breen, an emergency room physician working on the frontlines in New York City, died by suicide. Her death drew attention to the toll the pandemic places on the mental health of healthcare workers. The United Nations recently published a policy briefin which they advocated for action to protect mental health and acknowledged healthcare workers as a vulnerable population. Though information is still emerging about the impact of COVID-19, initial data indicate that almost half of healthcare workers are experiencing negative mental health effects related to the COVID-19 pandemic. Recognizing that virus outbreaks contribute to increased psychological distress and burnout in healthcare workers, Kisely et. al. conducted a rapid review and meta-analysis of 59 papers from previous epidemics, including SARS, MERS, Ebola, and Influenza Type A, as well as COVID-19. This rapid review identifies predisposing factors, protective factors, and helpful strategies to prevent and manage psychological distress in all healthcare professionals in any clinical setting. The findings of this study and its implications, limitations, and importance are discussed and used to make recommendations to better protect healthcare workers.
What are Psychological Distress and Burnout?
Psychological distress is a transient period of increased stress during which emotional suffering can impact quality of life. When a stressor is chronic and unmanaged, distress can progress to psychological disorders like depression, anxiety, post-traumatic stress, and substance misuse. Initial symptoms of distress include insomnia, exhaustion, memory problems, and somatic symptoms like headaches and gastrointestinal changes.
Burnout is a syndrome resulting specifically from poorly managed workplace stress. While it is not a medical condition, burnout manifests as exhaustion, depersonalization, and reduced feelings of personal accomplishment. Anxiety, lack of empathy, anger, exhaustion, insomnia, and headaches are common symptoms. It typically begins with emotional stress and disillusionment with work and, if unaddressed, can contribute to the development of more severe problems like post-traumatic stress disorder (PTSD), alcohol use disorders, and depression.
Kisely et. al. found that contact with infected patients was a primary risk factor for developing burnout, acute stress, and psychological stress that can persist for up to three years. Nurses were typically at greater risk than doctors for developing symptoms of distress, probably because nurses frequently have more contact with patients. Given that COVID-19 has been reported in every state and practically every country, the number of providers delivering direct care to infected patients is much greater than in other outbreaks. Additionally, the rate of asymptomatic carriers is believed to be high, forcing healthcare providers to take extra precautions to protect themselves, their patients, and co-workers. Psychological distress and burnout attributed to caring for infected individuals will likely be more common in comparison to other epidemics.
Having pre-existing mental or physical health problems is also a risk factor for psychological distress during a virus outbreak. Studies demonstrate that healthcare workers experience higher rates of psychological distress, suicide, and substance misuse related to job stress than other occupations even during conventional operations. Poor mental health in healthcare workers is a problem that has received little priority, but now, more than ever, requires immediate action as the risk for psychological distress with more chronic and severe outcomes is increased.
Fear of infecting others and time in quarantine or isolation contribute to psychological distress. Some healthcare workers have been forced to quarantine due to exposure to the virus or isolate after becoming infected. Many others are choosing to adhere to a modified quarantine in which they go to work but separate themselves from family, even in the absence of a known exposure. Prolonged periods of quarantine for healthcare workers have been associated with emotional changes including anger, fear, guilt, sadness, and loneliness as well as more severe psychological disorders like alcohol misuse, avoidance behaviors, and post-traumatic stress. The length of time healthcare workers will feel compelled to self-quarantine is unknown. Uncertainty is further increasing the risk for psychological distress.
Systemic factors contributing to distress include increased workload, inadequate training, lack of support, insufficient compensation, and social stigma towards healthcare workers. In some of the hardest hit areas, there have been reports of unsafe staffing ratios. Some workers have reported being reassigned and trained in critical care in only a matter of hours, a specialty that usually requires experience and significant training. As hospitals convert some units to exclusive care for COVID-19 patients, other units are accepting patients outside their typical practice and training.
Many health systems have decided to give hazard pay to eligible frontline workers, though it is not required by federal law. Though there has been much discussion on Capitol Hill on the matter. The HEROES Act proposed in the House of Representative on May 12th includes raises for frontline workers; however, it is uncertain if it will pass in the Senate. Hazard pay is seen as compensation for the risk faced from the threat of the virus, but adequate compensation could also be protective of mental health.
Healthcare workers have been termed essential and called heroes. They are the recipients of generous forms of support like food donations, scrubs and shoe donations, and “parades of lights.” Often they do not feel like heroes, however. Social stigma still exists, especially in other nations like the Philippines, Mexico, and India, where healthcare workers have been shunned from society, evicted from buildings, and even attacked. Rare instances of attacks on healthcare workers in the United States encourage fear and anxiety. Some workers have also sensed that others keep a distance of more than six feet because of the belief that healthcare workers harbor the virus. This stigma is damaging to the mental health of frontline workers.
Protective Factors and Helpful Strategies
Kisely et. al. also identified factors protective of the mental well-being of healthcare workers. Protective factors rely mostly on the system rather than the individual. The helpful strategies to prevent and manage psychological distress focus on increasing protective factors, such as removing the negative risk factors may not be possible. The most consistently reported strategies contributing to better psychological outcomes were clear communication, training and education, adequate personal protective equipment (PPE), and availability of psychological interventions. Encouraging workers to utilize available resources by reducing the stigma associated with mental health is essential.
Frequent breaks and adequate time off are important to allow workers a reprieve from their clinical duties. Workers should be provided with food, housing (if desired), and other living supplies. Family support is a protective factor, so self-quarantining away from family members could result in increased psychological distress. To address this, workers should be given the tools necessary to connect with family during a shift and while quarantining, such as through video chats.
Trusting infection control protocols and a supportive work environment are protective factors. To promote trust in protocols, workers need adequate education and training. Facilities can also make changes to mitigate the risk of infection, like reducing patient density on units and making redeployment to infectious disease units optional when possible. Many nurses volunteered to work in the newly created COVID-19 units, but there have been reports of employees being told that they would be considered “resigned and ineligible for future employment” if they refuse redeployment. This demonstrates poor communication and an unsupportive work environment.
Healthcare workers also need adequate PPE. Given the scale of the pandemic and the uncertainty about when it will end, obtaining and maintaining adequate supplies has been a challenge for many healthcare facilities. There are reports of workers improvising PPE, protesting the lack of PPE, and even being fired after publicizing the lack of PPE. As some hospitals begin to open again for elective procedures and states start to ease restrictions, concerns about adequate supplies of PPE remain unresolved. The shortage of PPE combined with recommendations for infection control based on little evidence and, in some settings, discouragement from procuring their own supplies, has left some healthcare workers feeling scared, uncertain, untrusting, and disposable like “cannon fodder.”
Healthcare workers have an increased risk for psychological distress during conventional healthcare operations, and the increased vulnerability of healthcare workers during virus outbreaks has been established. Despite this, of the 59 papers included in the review, only three evaluated interventions to prevent and manage psychological distress in healthcare workers. Health professions emphasize evidence-based practices, and yet the evidence base for recommendations to protect the mental well-being of healthcare workers is weak. While action is needed now, this is an issue that needs further research to ensure that the best practices and specific interventions are identified and instituted. In the future, more research should also focus on specific professions or settings. For example, the psychological impact of the pandemic could be much greater in long-term care facilities where, in most states, about one-third of COVID-19 related deaths have been reported.
This review could not address several factors absent from the other epidemics studied but will likely contribute to increased psychological distress during and after the COVID-19 pandemic. The impact and magnitude of COVID-19 and its response are unprecedented. COVID-19 has become one the biggest global killers in 2020. Even parts of the country that have not been overwhelmed by the number of COVID-19 patients have had to make adjustments to prevent and prepare for a potential surge in cases. Almost all healthcare settings have restricted visitors, forcing many patients to be alone, sometimes dying without family. This is not only devastating for patients and families, but also healthcare workers. The common occurrence of guilt and grief could lead to greater burnout.
During the COVID-19 pandemic, unlike other epidemics, there has been widespread isolation due to social distancing, creating economic hardship. A recent study projected that unemployment, isolation, and uncertainty resulting from the pandemic could contribute up to 150,000 “deaths of despair”– deaths caused by drugs, alcohol, or suicide– in the United States alone. The unemployment rate climbed to 14.7% in April, surpassing the rate during the 2009 Great Recession. It is projected to improve to only slightly better than the Great Recession by the second half of the year. Multiple communities in the United States have already reported an increase in overdoses since March. Studies from crises including Hurricane Katrina and the Great Recession suggest the surge in alcohol sales in March is not just stockpiling; there could be an increase in binge drinking and alcohol use disorders that persist beyond the duration of the pandemic. The conditions of their job place healthcare workers at a higher risk for developing mental disorders like substance misuse and depression, and they are not being spared from economic stressors either.
During the Great Recession, healthcare jobs grew. This March, the healthcare sector lost 43,000 healthcare jobs, the greatest monthly drop since 1990. That number grew to 1.4 million by April. The decline has been less than in other sectors, and most of the lost healthcare jobs are expected to return as the pandemic subsides, but, unlike previous crises, healthcare workers are at risk for psychological distress from being furloughed or laid off and the uncertainty that comes with it.
Why It Matters
If the well-being of workers is not enough incentive to make investments in mental health, the impact of negative mental health outcomes on preparedness and finances should be. Depression and anxiety, consequences of persistent psychological distress, cost the global economy $1 trillion every year. Chronic exposure to stressors can suppress the immune system, increasing the risk for severe infections, resulting in missed work. Absenteeism is a bottom-line problem, as it can cost employers $1,685 per employee every year.
Burnout is also associated with increased job turnover, decreased patient satisfaction, medical errors, and reduced quality of care. The nursing shortage has been acknowledged as a problem well before the pandemic. Over one million nurses were expected to retire by 2030. Even prior to the pandemic, the growth in the nursing profession was not sufficient to keep pace with the increased demand for health services from an aging population with more complex health needs and the simultaneous loss of expertise from the field.
In one survey of nurses, 3 out of 5 respondents indicated that they might leave their job or specialty because of the COVID-19 pandemic. While this is preliminary data, it is seemingly supported by stories of nurses walking out or quittingdue to lack of PPE, insufficient infection control protocols, and the emotional toll of caring for patients, isolating from family, and fearing infection. During conventional times, 30-50% of all new nurses change jobs or leave the field entirely within the first 3 years of practice, often citing burnout as a primary reason for leaving. Kisely et. al. identified being younger and less experienced as a risk factor for psychological distress in other outbreaks, but early research suggests that being older is a risk factor for psychological distress during the COVID-19 pandemic. However, there is no data to suggest that being younger is protective. In the worst-case scenario, if mental health is not prioritized, older nurses will retire sooner and a greater number of younger nurses will leave the profession, accelerating the nursing shortage.
In its policy brief, the United Nations acknowledged that “ensuring the mental health of healthcare workers is a critical factor in sustaining COVID-19 preparedness, response, and recovery.” The nursing shortage is an emergency preparedness issue due to the reliance on nurses during crises; however, preparedness is a long-term issue and has previously been a weak incentive for investment. Following the pandemic, hopefully, that will change, but turnover has immediate financial implications as well. It is expensive. The average cost of turnover ranges from $37,700 to $58,400 per nurse, and hospitals can lose $5.2 million to $8.1 million annually.
Insurance reimbursement is often based on quality of care and patient outcomes, including readmission and healthcare-acquired infection rates. The shortage of nurses has an impact on the quality of care and patient safety. Insufficient staffing is associated with increased mortality rates, more hospital-acquired infections, higher readmission rates, and increased provider burnout. Better staffing is associated with fewer deaths, fewer failure-to-rescue events, lower rates of infection, and shorter hospital stays.
Burnout contributes to the nursing shortage, which contributes to an increased workload, and an increased workload is a risk factor for burnout. This cycle needs to be broken not only to protect the well-being of healthcare providers but to promote preparedness for the next crisis, improve the bottom-line, and ensure patient safety and quality care.
Immediate action is needed to protect the mental well-being of everyone, especially vulnerable populations like healthcare workers. At the federal level, there has been some recognition of the growing mental health crisis. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, a $2 trillion dollar stimulus package, provides $425 million for the Substance Abuse and Mental Health Services Administration (SAMHSA) and increased funding for behavioral health initiatives and the expansion of telemedicine. Between March and April, the National Alliance on Mental Illness (NAMI) reported a 41% increase in traffic to their hotline as compared to last year. As many people cannot currently receive mental health services in-person, expanding access to telemedicine is essential and will continue to be essential as the number of people seeking care continues to expand.
Mental health has historically been underfunded and a low priority. Before the pandemic, a shortage of mental health workers – with less than one mental health professional available per 10,000 people – prevented meeting even the pre-pandemic demand for such services. While increased funding is progress, mental health needs to be a priority beyond times of crisis and will still require more funding. Additionally, the federal government has demonstrated an indifference to the well-being of healthcare workers in its failure to provide or require hazard pay, and its unwillingness to admit failures in supplying PPE to protect workers. Such indifference contributes to poor mental health and is an issue that needs to be redressed immediately.
To reduce the number of individuals in need of mental services, interventions to prevent and manage psychological distress must be implemented at the community level. Fortunately, many health systems have expanded access to psychological interventions for healthcare providers. For example, a facility in Jacksonville, Florida created 24-hour drop-in peer-to-peer chat sessions on Zoom. Minnesota Mental Health Advocates, a nonprofit organization to help people access mental healthcare, has launched a new, free program for healthcare workers that will connect them with a personalized list of resources, provide check-ins, and make recommendations for activities that are good for mental health.
Providing increased services does not negate the systemic factors contributing to psychological distress, and prevention is better than management. Healthcare facilities need to evaluate policies to ensure that they are supportive of mental health. Access to PPE, education and training, and adequate time off are essential. Many workers have used social media to expose the harmful conditions and policies in their workplaces. Management can encourage employees to bring up concerns with them, rather than the news, by clearly communicating with their employees, listening to concerns, and addressing those concerns.
Isolation, fear of exposure, uncertainty about another wave, economic consequences, and systemic challenges like limited supplies of PPE will continue to exist for an unknown amount of time, perhaps until a cure or vaccine is approved. As the United Nation brief shows, mental health is a worldwide issue that will require international cooperation and collaboration to adequately address. Even as the curve flattens, the mental impact of COVID-19 will peak. Heroes are human, too and are not immune to tragedy, fear, and uncertainty. Action needs to be taken now to protect the mental well-being and lives of heroes like Dr. Breen.
If you or someone you know is in crisis, please contact the American Foundation for Suicide Prevention. If you are an essential worker in need of support, For the Frontlines is a hotline with free crisis counseling available. If you feel you would benefit from mental health help, additional resources are provided below:
- National Suicide Prevention Lifeline
- Stop, Breathe, & Think App: Meditation Tuned to Your Feels
- SAMHSA’s National Helpline
- Mental Health First Aid: Mental Health Resources
- American Counseling Association: Mental Health Resources
Madeline Roty is pursuing her Master’s in Biodefense at George Mason University. She graduated from the University of Michigan School of Nursing in May 2019. She is a registered nurse as well as a certified health coach. Her interests include healthcare preparedness, global health, and health education. She recently authored an article with Dr. Gregory Koblentz for the Bulletin for Atomic Scientists. Check out her other articles for the Pandora Report about the ASM Biothreats 2020 conference and mental health during the COVID-19 pandemic.