Before the COVID-19 pandemic, working in healthcare was stressful. Research on mental distress in healthcare workers had already shown that, compared with those in other industries, healthcare workers were more likely to suffer from psychiatric disorders, that approximately half of all physicians were experiencing burnout, and that doctors suffered higher rates of suicide than the general population.1-3
The novel coronavirus outbreak threatens to exacerbate work-related stress among certain healthcare workers and to amplify their psychological suffering.4 Troublingly, research on the mental effects of other pandemics on medical personnel has demonstrated that distress is not limited to the duration of the outbreak but instead persists long after exposure to victims has ceased.5
There are several reasons that pandemics like COVID-19 jeopardize healthcare workers’ mental health. Data from past pandemic experiences can help us understand why and how COVID-19 may harm mental health and how these negative influences can best be mitigated.
Healthcare workers are facing unexpected stressors.
Despite evidence that longer shifts are associated with negative effects on both workers and patients, the mental and physical exhaustion that healthcare workers across the globe are likely enduring due to extended shifts and higher workloads is not unfamiliar to most frontline workers.6-8 What is unfamiliar, however, is the nature of what they face at work. Aspects of the COVID-19 pandemic that are affecting many healthcare workers in new ways include:
Risk of infection. Other types of unexpected tragedies—like terrorist attacks—have been associated with anxiety and depression in those who have cared for victims; but, COVID-19, while also unexpected, is distinct from other tragedies in ways that influence its overall psychological impact. The most obvious distinction is the direct threat of infection on healthcare workers who attend to the sick.9 Healthcare workers are confronted daily with the unsettling reality that they themselves are regularly exposed to the potentially lethal culprit and at risk for spreading the virus to their own families and colleagues.10
Sense of helplessness. Another novel feature of the COVID-19 pandemic is the helplessness felt among healthcare workers who lack access to the beds or equipment they need to provide patients with the best care they can, as well as to the personal protective equipment (PPE) to protect themselves.10 Losing high volumes of patients due to lack of resources is new territory for most healthcare workers.
Moral injury. Today, frontline workers are making previously inconceivable triage decisions. They are forced to make medical choices that would normally involve patients’ family members without that critical input because patients’ loved ones are forbidden from entering hospitals.10,11 It has been suggested that these events cause what is referred to as moral injuries—a term that originated in the military to describe the psychological distress that results from perceived injustices—and thereby have lasting harmful effects on mood and self-esteem.12
Lack of social support. While stress is higher than ever for frontline workers, coping mechanisms that involve social support are largely unavailable as a result of policies around COVID-19. Lessons from the severe acute respiratory syndrome (SARS) outbreak taught us that, not only did working in jobs that increased the risk of contracting the virus enhance the likelihood of suffering posttraumatic stress symptoms, but so too did social isolation.5 On top of the work-related trauma and lack of social support, many of those on the frontlines are also enduring the added stress imposed by school closures and difficulty obtaining daily essentials, including food.10
Data are beginning to reveal the nature of the psychological toll.
Initial research into the psychological effects of COVID-19 on medical staff in Wuhan showed that mental distress is abundant among those caring for COVID-19 patients.13 Interestingly, the psychological impact of COVID-19 appeared to fall most heavily on young women. Multiple other lines of research have corroborated this finding that being female is a risk factor for certain types of psychological distress associated with caring for COVID-19 patients.14,15
An online survey conducted from February 19th to March 6th, which included more than 2000 Chinese participants, found that more than nonmedical health workers, medical health workers were more likely to experience psychosocial disturbances, including anxiety, depression, insomnia, and obsessive–compulsive symptoms.14 In addition to female sex, residing in rural areas and being at risk for contact with people with COVID-19 also increased the likelihood of experiencing these symptoms.
Research on the prevalence and evolution of the psychological impact of caring for SARS patients has shown that the initial anxiety associated with feelings of vulnerability and uncertainty were eventually replaced in many instances with depression and avoidance once the infection was under control.15 It is therefore important that we not only address the mental impact of COVID-19 on healthcare workers today but also in the weeks, months, and even years to come.
How can we mitigate the negative psychological impact?
One of the most useful things we can do right now to address the psychological effect of COVID-19 on our healthcare workforce is to look to what we know from previous experience. Based on data from previous pandemics and observations during COVID-19, the following approaches may help to minimize the overall psychological impact of the novel coronavirus.
Providing practical support. Data from medical staff involved in the response to Middle East respiratory syndrome (MERS) have shown that healthcare works believe that specific means of support played a protective role in mental health.16 These modes of support included developing and implementing infection-control measures, reducing work intensity by offering more medical staff and PPE, and providing practical guidance.
Proactively identifying those who are suffering. Research on those who endured the SARS outbreak suggests that it is important to identify those who are at high risk for enduring psychological distress, monitor them, and provide relevant support if they do not recover psychologically.17
Developing evidence-based prevention and treatment tools. Some experts suggest that greater investment in tools for mental health are necessary to help ensure that medical workers recover psychologically from acutely stressful situations.13 For now, we can leverage data from previous pandemics to develop interventions to help prevent the development of long-term psychological trauma as well as those to address long-term distress when it does occur.
Healthcare workers are uniquely positioned to address some of the most pressing issues related to the COVID-19 pandemic. Nonetheless, their ability to provide clinical care does not make them invulnerable to the psychological toll accompanying it. Based on observations on how other pandemics have ultimately affected the psychological health of frontline workers, it is likely that we do not yet fully understand the long-term mental impact of COVID-19.17 While healthcare workers are often resilient, they are human and need the same psychological support that others do in times of turmoil.17 It is therefore important to not only look to our current knowledge base but also to collect and analyze data on the specific ways this pandemic affects our healthcare workers. This information will be invaluable for guiding us in how best to intervene to improve long-term mental health outcomes related to COVID-19 as well as for informing our behavior in the case of future pandemics.18