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The fight against COVID-19 is often compared to a war effort, and with good reason. In addition to the rapid mobilization and widespread sacrifice required, the mental health effects of the pandemic are already proving similar to challenges faced in wartime.
And in no segment of the population is this more true than for medical workers on the front lines, who in addition to falling ill at higher rates—in New York City, nearly 1,000 of the city’s medical workers had tested positive for the virus as of mid-April — are grappling with serious strains on their emotional and mental health.
“People are seeing things on the job that they haven’t seen in their lifetimes,” said Neil Leibowitz, chief medical officer of Talkspace, a therapy app that since March has been offering free hours of therapy to doctors, nurses and social workers. “Many people in the medical field, we haven’t had a war in their lifetime, we haven’t had mass destruction or anything equivalent to this. How rapid this is, and the overall mortality rate, is very overwhelming.”
“ “Medicine has traditionally had this very machismo culture. You suck it up and keep going and you’re not supposed to show weakness.” ”
Given safety regulations that require COVID-19 patients to remain isolated, medical staff are also often the only people interacting with severely ill or dying patients, creating an extra layer of potential emotional distress. On top of this, many workers are grappling with stressors including long hours, inadequate equipment, separation from loved ones, and a concept known as “moral injury” — an effect often seen in soldiers who have had to make decisions or witness traumatic events that go against their usual moral beliefs.
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“People are having to make life or death decisions that are really difficult, and under normal circumstances they would never have to make,” said Dr. Carole Filangieri, an NYU Langone Health neuropsychologist who has been working internally to support the hospital staff’s mental health. “I would imagine there will be a lot of what we call second-degree trauma, and PTSD (post-traumatic stress disorder). And some people with PTSD have moral injury, but it also can be separate. So there has to be a comprehensive approach and recognition that people will be suffering in different ways.”
Perhaps unsurprisingly, higher rates of coronavirus-related PTSD are expected to manifest among frontline medical workers than in the broader population. “That’s part and parcel with how PTSD works,” Leibowitz said. “With people who are closer to the actual event, rates are higher.”
Though much of the focus is currently on New York City’s medical staff, Filangieri said, “I think it’s also going to be a national issue. New York is the epicenter right now, but it’s not going to remain the epicenter.”
Finding solutions in the short-term
Though treating trauma is often seen as more of a long-haul proposition, hospitals have also been working to provide real-time support to staffers struggling in the midst of this crisis.
“We’re looking at what’s happening around the country, and there are hotlines being set up in various jurisdictions, support groups being set up and facilitated virtually, and a couple of different groups that have done more focused types of interventions,” said Dr. Lynn Bufka, senior director of practice research and policy at the American Psychological Association. “In Boston, for example, the Center for Anxiety and Related Disorders is beginning to put together a program specifically for nurses.”
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Some of these immediate-term treatment options are building on pre-existing programs. In February 2018, the New York City Health + Hospitals Corp. (NYCHHC) launched a branch of Helping Healers Heal, a mental health support system for employees that has recently been scaled up and tailored to address the specific challenges medical staff are facing at the moment.
“I feel very fortunate that we had this robust team in place going into this pandemic,” said Dr. Eric Wei, NYCHHC Chief Quality Officer and emergency medicine physician, who helped bring the program to the city’s hospital system. “We have a 24/7 behavioral health hotline that staff can call internally, that’s being manned by psychiatrists and psychologists. We’ve built 26 respite wellness rooms [across NYCHHC’s 11 member hospitals] that staff can stop by if they need to take a break from the chaos, talk to somebody, take a drink of water and have a snack.”
Additionally, the program has behavioral health experts doing “wellness rounds” in participating city hospitals, checking in throughout high-stress areas like ICUs and surgical units to watch for signs of distress among staff. “What they’re looking for are signs of anxiety, stress, burnout, compassion fatigue, and then immediately providing support and linking staff to additional support if needed,” Wei said.
Though many frontline staff feel too busy to seek out mental health resources at the moment, Filangieri said, systems are being put into place to be available for when they feel ready. And some medical workers are already reaching out for short-term support.
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“We’re seeing a large uptick from health professionals,” Leibowitz added. “Right now, it’s about helping them adjust, providing support, lending an ear.”
Facilitating support among peers
In addition to more focused professional help, some programs are looking to create networks of connection among frontline workers who have been through similar experiences and can provide some much needed empathy and identification.
“One of the really heartening things I’ve heard is that many of the units are doing their own virtual get-togethers and gatherings,” Filangieri said. “They’re not necessarily talking about COVID-19 patients, per se, just hanging out together and socializing. And that’s been very helpful.”
The NYCHHC program has a more formalized version of this, training “peer support champions” who are available during shifts to reach out one-on-one and in some cases set up group check-ins for medical staff facing distressing situations, such as the death of a patient.
“Medicine has traditionally had this very machismo culture. You suck it up and keep going and you’re not supposed to show weakness,” Wei said. “There was this kind of acknowledgment that we could do better in taking care of each other. So it’s about changing the culture so that somebody goes to a doctor or nurse who was taking care of that patient and asks if they’re OK, lets them know they’re important to the team, maybe tells them about a similar case they had. Just debriefing and taking a pause before moving on to the next crisis.”
Preparing for longer-term treatment
Addressing the mental health effects of the pandemic is currently a balancing act, as providers rush to triage immediate issues while also laying the groundwork for treatment of longer-lasting trauma.
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“I’ve been telling frontline staff that while they might not want to utilize [treatment] right now, I don’t want them to think that when this is over we’re rolling up the sidewalks and moving on,” Filangieri said. “Because when it’s over, that’s probably when people will start to process what they’ve seen, what they’ve had to do.”
Treatment may range from one-on-one counseling and cognitive behavioral therapy to ongoing peer support groups, in some cases drawing on models developed during previous crises.
“NYU Langone was one of the epicenters for mental-health care after 9/11, so there are still clinics in place to help survivors and first responders who have PTSD,” Filangieri said. “There’s already a model that we can implement when this is over. People who were first responders still get mental health treatment and have been in long-term psychotherapy, for example.”
Hospitals and organizations like health-care unions are currently assessing what programs will look like moving forward, as well as what kind of government funding will be available. “What we’re seeing now is the first time people have had a chance to take a breath and kind of process what they’ve been through in the past six weeks, so we’re seeing grief, anger, shock, some beginnings of PTSD,” Wei said. “We’re working with outside partners like the Greater New York Hospital Association, which is bringing together the health-care systems in their membership to talk about what programs they have, what’s working and not working, sharing and learning from each other.”
Hospitals are also looking to borrow trauma treatment techniques from the military, as well as those developed in countries that were hit with the virus earlier, Wei said.
While the majority of health-care workers currently facing emotional distress are likely to recover on their own once the crisis has passed, Bufka said, offering stress-management programs in the short-term is key to preventing longer-term damage.
“Support, intervention, training, meeting a person’s immediate physical and psychological needs—that will help more people get to the point of not developing a mental illness,” Bufka said. And for those who do suffer from longer-lasting mental or emotional distress, options need to remain open and easily available.
“It’s nice to be called a hero, but the last thing we want to do is, once the crisis is over and the attention is gone, to leave people to suffer alone,” Wei said. “This has to be a sustained effort.”
