The current COVID-19 crisis is a wake-up call to how dangerously our health care workforce has been chronically over-stretched. Effective solutions are discussed.
In 2000, HIV/AIDS filled public hospitals in sub-Saharan Africa and physicians were confronted with the challenge of caring for people without available antiretroviral medications. Findings from one study showed that the combination of lack of technical resources and lack of personal empowerment within the culture of the hospital and across the training hierarchy, produced hopelessness and demoralization for trainees and senior physicians alike.1 The incidence of depression and PTSD was significant among health care providers. The response was not only to develop mental health interventions to support the health care providers but also to develop structural solutions: first and foremost to solve the primary technical deficiency of the situation-the lack of effective treatments as well as secondary issues related to the perception of a hospital culture that is unsupportive of their needs.
Similarly, in the current context of COVID-19, while mental health programming for health care workers is critically important, the primary focus of politicians and policy leaders should be to solve the technical problems that feed a lack of a sense of safety among health care workers, as well as to avoid some of the pitfalls that have been seen before in emergency situations.2
Avoiding indiscriminate mental health screening before the crisis is past, to avoid many false positives and the mis-labelling of health care workers as having a mental health disorder.3 During and immediately following a disaster, there will inevitably be a large number of health care workers who have mental health symptoms as reactions to difficult events (limited resources, the death of patients and colleagues, lost jobs, etc).4,5 These will be normal reactions to abnormal situations, and not necessarily evidence of a mental disorder.
Internal compromises, related to moral and ethical dilemmas of practice, can engender significant distress (ie, moral injury). Moral injury usually describes the mental health toll on soldiers or humanitarian field staff working in difficult contexts when they are facing impossible situations and circumstances that are beyond their control. “Moral injury” has been used to explain physician burnout and the alarming increase in physician suicide that existed before COVID-19.6 During COVID-19 the term implies that the situation is out of the control of individual health care workers-as if this is a reality that we have to accept and “deal with it” as we would with war and famine.
The solution is usually suggested in the form of “management must recognize health workers rights and improve their conditions” but without offering any way to get there. We are dealing with dysfunctional care systems, which we could, in fact, change. If this crisis doesn’t lead health care workers to organize, demand better work conditions, and reclaim patient care from management, then an opportunity will have been lost.7
While the moral injury explanation may technically be correct, it’s problematic because the responsibility falls on the individual who is affected by psychological stress and needs to process various traumas with the assistance of a mental health specialist, coupled with self-care techniques such as breathing exercises and relaxation techniques. These can all be helpful, but if we pretend that we are going to cure this collective problem through individual interventions, and wellness programs, we are in for a huge disappointment.
A major goal should be to institute multilayered support in an anticipatory way, similar to the principles outlined in the Inter-Agency Standing Committee Guidelines.8 For the longer term, since not all health care workers will have a lasting, diagnosable mental health disorder, it’s important to articulate multiple layers of intensity of mental health and psychosocial support. To provide everyone one-on-one standard psychotherapy sessions is neither realistic nor the best use of resources. Appropriate responses can include attention to the basic needs and situational issues of health care workers: providing food during shifts; promoting safety and security during work (personal protective equipment); attending to disability and other unprecedented financial concerns; and supporting them at home in practical ways in managing their fear of infecting family members. A next layer includes strengthening community support and focused psychosocial support in the form of crisis counseling (practical, usable, and to the point).9 The final layer provides clinical services for individuals dealing with identifiable mental health problems.
It’s normal, healthy, and necessary to see strong emotional reactions from health care workers in response to this crisis, but we shouldn’t equate these with mental illness or disorder. It’s essential to enhance people’s natural coping mechanisms and resilience and avoid underestimating their natural capacity to cope with adversity. Follow up with clinical services, however, is needed for symptoms that become chronic.
PTSD or something else?
As in any other crises, there will be a focus on “traumatized” people and PTSD diagnoses. It’s important to highlight that health care workers are a vulnerable group who were already dealing with high rates of burnout, depression, and suicide prior to COVID-19.10 The response we will be witnessing is “acute on chronic,” and should not be seen as a one-time event. Even in situations of extreme stress, the main mental health issues remain anxiety, depression, and substance abuse in the shorter term and without support, risk of suicide in the longer term. A large percentage of the affected population will recover with minimal support, so we need to be wary of promoting a narrative of traumatized health care workers.
It’s challenging for health care workers to work in settings with limited resources, especially if their training and professional development has been based on acting as if resources are limitless. Resource management, a staple of supply chain methods in resource-poor contexts and global health delivery, needs to be accepted in the US as well. There is no silver bullet that allows providers to cope effectively in the field. Individuals will utilize different coping mechanisms (spiritual, religious, intellectual), but at the heart of it is acceptance of the realities of practice, that you can’t save them all, that you have to operate with the limited resources in mind, and that the outcome of your hard work will be affected by undesirable realities. Acceptance of these conditions won’t make the work easier, but possibly bearable, from the perspective of mental health. From a clinical perspective, the care of health care workers suffering from moral injury and distress must seek not to "fix it" as for a disorder, but rather to compassionately acknowledge the new realities of health care practice and promote a reformulated sense of purpose and meaning.11
Burnout and an increased incidence of mental health issues are not new to the health care industry. Before COVID-19, providers found themselves in impossible situations on a daily basis.12 Health care workers juggle increasing workloads and demands from regulators and hospital management, insurmountable paperwork, unending EMR checklists on a daily basis. They provide high quality care in the face of insurance coverages and denials, and they survive the situation mentally and physically to do it all again the next day. This crisis is a wake-up call to how dangerously our health care workforce has been chronically over-stretched. Effective solutions will require long-term perspectives and structural changes in health care delivery systems, not simply providing band aids that will keep falling off before this crisis ends.13
Dr Barkil-Oteo is Assistant Clinical Professor, American University of Beirut, Beirut, Lebanon; Dr Raviola is Assistant Professor of Psychiatry, Global Health and Social Medicine, Harvard Medical School, Boston, MA. They report no conflicts of interest concerning the subject matter of this article.
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8. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: Inter-Agency Standing Committee; 2007.
9. Sederer L. Crisis counseling, not therapy, is what’s needed in the wake of COVID-19. Medscape. April 8, 2020.
10. Duarte D, El-Hagrassy MM, Couto TCE, et al. Male and female physician suicidality: a systematic review and meta-analysis. JAMA Psychiatry. March 4, 2020; Epub.
11. Abraham M, Smith RE. Beyond resilience: addressing moral distress during the COVID-19 pandemic. Psychotherapy.net. 2020.
12. Dean W, Talbot SG. Moral injury and burnout in medicine: a year of lessons learned. STAT. July 26, 2019.
13. Flam F. A psychological crisis is looming for medical workers. Bloomberg Opinion. April 10, 2020.