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 Table of Contents  
PERSPECTIVE
Year : 2020  |  Volume : 9  |  Issue : 5  |  Page : 51-54

”Watching the watchmen:” Mental health needs and solutions for the health-care workers during the coronavirus disease 2019 pandemic


1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, JSS Medical College, Mysuru, Karnataka, India

Date of Submission04-May-2020
Date of Decision05-May-2020
Date of Acceptance06-May-2020
Date of Web Publication04-Jun-2020

Correspondence Address:
Dr. T S Sathyanarayana Rao
Department of Psychiatry, JSS Medical College, Mysuru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_87_20

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  Abstract 


The coronavirus disease 2019 (COVID-19) has emerged as a global public health threat. As international borders are sealed, economies slashed, and billions quarantined at their homes to prevent the spread of infection, this pandemic has affected society at large, having a long-lasting psychological impact, more than ever. Certain vulnerable groups are more susceptible to this trauma. These include the health-care workers, one of the prominent frontline force against COVID-19. Their mental health needs are not only limited to work pressure, burnout, frustration, and guilt toward the family but also a constant fear of infection, health anxiety, paranoia, and depressive disorders. Complex posttraumatic stress and grief can be the added compounding factors leading to absenteeism and decreased efficiency. This commentary reviews the evidence for the various mental-health care needs of these frontline workers and highlights the possible solutions during such a biological disaster.

Keywords: Coronavirus, coronavirus disease 2019, health care workers, mental health, pandemic


How to cite this article:
Banerjee D, Vijayakumar HG, Rao T S. ”Watching the watchmen:” Mental health needs and solutions for the health-care workers during the coronavirus disease 2019 pandemic. Int J Health Allied Sci 2020;9, Suppl S1:51-4

How to cite this URL:
Banerjee D, Vijayakumar HG, Rao T S. ”Watching the watchmen:” Mental health needs and solutions for the health-care workers during the coronavirus disease 2019 pandemic. Int J Health Allied Sci [serial online] 2020 [cited 2020 Jul 2];9, Suppl S1:51-4. Available from: http://www.ijhas.in/text.asp?2020/9/5/51/285974




  Introduction Top


“We were promised sufferings. They were part of the program. We were even told, “Blessed are they that mourn,” and I accept it. I've got nothing that I hadn't bargained for. Of course, it is different when the thing happens to oneself, not to others, and in reality, not imagination.”[1] These lines of C. S. Lewis may have resonated with many health-care staffs, atleast once in their lifetime in various dialects, as they toil through their day-to-day lives. Although the profession of health care is vested with the responsibility of reducing the distress and burden of others, the health-care staff are the ones who undergo tremendous distress due to their occupation. The World Health Organization theme for the World Mental Health Day “Mental Health in Work Place” may apply to only a few occupations as much as it applies to the health care.[2] It is an irony that nearly or sometimes more than half of the health-care workers across countries have been found to have symptoms of burnout and suffering from psychiatric morbidity.[3] This woeful state of mental health in these professionals reflects their unmet mental health needs, which might not only be accentuated but also be made worse in a pandemic. Health-care workers are at increased risk of infection and various forms of psychological trauma during a pandemic, having to confront a variety of patients with a diverse set of physical and emotional issues. With more than three million cases and nearly two lakhs confirmed deaths across countries, the pandemic of coronavirus disease 2019 (COVID-19) is expected to impose an unprecedented burden on the mental health of the health care professionals.[4] The ever-increasing number of cases, ever-changing protocols, and the ever-dwindling resources does not seem like a good prognosis to the community, which in turn might impact the health of everyone as stated in one of the studies as “no health without a healthy workforce.”[5] As we are invested with this almost apocalyptic future ahead of us, everyone who ponders upon the solutions to change this even by a little bit would eventually end up in the conduit of existing mental health needs and gaps in their delivery, before elsewhere.


  Mental Health among Doctors Top


Despite being so close to accessing the mental health facilities and having a relatively good social capital, health care staffs seem to be more likely to have symptoms of “burnout” and dissatisfied with their work-life balance than other workers. This observation might emerge as a surprise to the public, but not to those who have worked in the health care department, who will only acquiesce to this observation. Burnout and dissatisfaction have been so common in the profession that it has become more of a norm rather than an exception. “Burnout” is a syndrome characterized by emotional exhaustion, feelings of cynicism, and a low sense of personal accomplishment. This might not only have detrimental effects to the patients such as poor quality of care, increased medical errors, and lack of professionalism but also personal consequences to the staffs such as interpersonal relationship issues, an increase in substance use, and even suicidal ideations.[6] Although this has been an area of research in the past few decades, the tenets of the stoic philosophy in medicine are so deep-rooted to uproot, as evident by doctors continuing to work hard, despite the stress and poor well-being, leading to this state of affairs many a times. The attitude toward distress as a sign of “professional-weakness,” has also been perpetuated by the stigmatization of mental distress and the glorification of self-sacrifice in the community, which also prevents these individuals from seeking help.[7] This has been most often than not found to have detrimental effects on both the individual and the system. The individual factors which lead to “burnout” and psychiatric morbidity which have been identified are vulnerable physicians with traits of idealism, perfectionism, and a great sense of responsibility; prolonged patient contact; avoidance based coping strategies; presenteeism due to fear of career repercussions and letting down colleagues; and failure to prioritize one's own health needs and recognize their vulnerability to illness. The systemic factors would include the imposition of heavy workload and long working hours trying to compensate the resources in hand and achieve a higher quality of care; rigid organizational structures; adoption of maladaptive patterns of teachers that are often reinforced; and highly regulatory systems of clinical governance leading to reduced autonomy.[8],[9] While the medical profession seems to be demanding its subjects to be working longer in a scrupulous and austere way, it is the same demand that is inflicting suffering on its individuals. It is so much so to the point that it makes one think if the system cares enough about its workers as much as it does about its service, which brings us back to the stoic philosophy of medicine.

Several barriers are noticeable as one walks towards the path of solutions and interventions for this public health issue. Lack of time, confidentiality issues, stigma, costs, academic concerns, fear of being labeled weak, and shrugging work, and fear of an unwanted intervention are few barriers that have been identified in seeking help, among medical students and resident doctors.[10] Another major challenge in individual-level interventions is the poor awareness of the staffs to the modalities of seeking help.[11] Randomized controlled trials focused in stopping stigma by teaching doctors about distress have been successful in significantly reducing burnout and anxiety among doctors.[7] Key components of positive mental health, such as general coping and personal growth autonomy, have also been noted to be particularly important in the workplace.[12] While individual interventions such as improving individual resilience and teaching relaxation techniques have been found to reduce burnout, they were more effective in combination with organizational interventions, and the latter was found to have long-lasting positive effects. A systems-level approach of fostering a supportive organizational culture; eliminating harassment and perfectionist expectations; integrating doctors' well-being to professionalism and patient care and recognizing the same as a missing quality indicator; and an internationally coordinated research effort has been strongly advocated to address this global public health issue.[13]


  Mental Health Needs of Health Care Staff in Coronavirus Disease 2019 Top


Health-care facilities evolve from cisterns of stress and psychological trauma to reservoirs of the same amidst pandemics. The major challenge of the health-care system during a pandemic is that it cannot manage the pandemic without any collateral damage to itself. The health-care workers face a tremendous amount of stress through a high and persistent risk of exposure, prolonged case shifts, separation from family, experiencing workforce quarantine, moral injury, scarce supplies, the uncertainty of the event, a sudden surge in death count, death of colleagues, lack of reinforcements, and fatigue and burnout. The loneliness and increased burden of work may result in anger, which might lead to inter-personal issues with family members and sometimes assaults in the work setting, causing further distress.[14] These reservoirs of stress are fertile grounds for psychiatric disorders, the incidence of which might further impair the workforce over and above the impairment caused by the unattended distress and “burnout” in the community. Chronic levels of distress contribute to unhealthy coping methods, resulting in poor health and decreased efficiency.[15] Those working in isolation caring for critically ill patients are particularly more vulnerable, with about 20% of them reporting posttraumatic symptoms during the SARS outbreak.[16] A study among health-care workers in hospitals with fever clinics or wards for COVID-19 reported 50.4%, 44.6%, 34.0%, and 71.5% of symptoms of depression, anxiety, insomnia, and distress in the participants, respectively. Women, frontline workers, and nurses were found to be the most affected.[17]

With an extra 1.7 million mental health workers needed in the low and middle income countries and about 40%–60% of patients with severe mental disorders not receiving adequate care even in routine circumstances, this parallel pandemic of psychological issues stands as a gargantuan threat to the whole of health care. Hence, organization of the resources will be the need of the hour. There are international guidelines to address the mental health and psychosocial support needs in humanitarian aid workers during emergency situations. However, they are not being successfully implemented.[15] Even when institute specific plans are made and implemented, these have not been without any obstacles. An institute in China attending to the COVID-19 pandemic observed that the medical staffs were reluctant to participate in their interventions as they felt the interventions were not in concordance with their needs. They were worried about carrying the infection to their families more than them being infected. They perceived that they were not adequately trained in dealing with uncooperative patients and psychological issues expressed by the patients. They were feeling incapable when faced with critically ill patients. Furthermore, they were disappointed with the shortage of supplies of protective equipment and expressed that they needed more rest.[18] In the preparation for a pandemic, a few viable interventions that might reduce the psychological burden significantly are clear guidelines and expectations, communication, concern for the well-being of service providers, logistical support, peer and spiritual support, and psychological support.[16] The key actions advised by the inter-agency standing committee in emergency situations also almost resonates with these interventions, which includes a concrete plan to protect and promote staff well-being; prepare staff for their roles; facilitate a healthy working environment; address potential work-related stressors; ensure access to healthcare and psychosocial support; provide special support to staff who are traumatized; and make support available after the mission.[19] Fostering individual and organizational resilience have also been found to play an important role in preparing for the pandemic. Folkman and Greer's framework for maintaining psychological well-being and psychological first aid have been considered to be apt in promoting individual resilience during pandemic situations. Organizational justice, which includes relational and decisional justice, is one of the factors attributed to the development of organizational resilience.[20]


  Conclusion Top


”Emergencies erode normally protective supports, increase the risk of diverse problems and tend to amplify pre-existing problems of social injustice and inequality.”[21] Therefore, it is imperative to understand the preexisting supports, needs, and barriers in the mental health-care of the staffs, clearly. Prioritization, organization, and customization are the pillars that translate the scarce mental health services into a functional capacity, paving way for all these interventions. It is more effective to evaluate and improvise existing interventions rather than developing new ones. Recent researches have re-emphasized on the importance of organizational interventions as much as individual interventions, especially in a pandemic where a sustained response is necessary.[9],[13],[14] Interventions made should emphasize working relationship and belongingness and arouse confidence among the staffs in the interventions.[5] Opportunities for staff feedback and integration of individual perspectives with organizational structure should be made, to not only improve the efficacy of the interventions but also to stay relevant to the community.[15] Avoidance is a core symptom of trauma and supervisors or peer supports should actively reach out, to protect the mental health of the workers.[14] As mentioned before, they clearly have an increased prevalence of various issues like burnout, absenteeism, depression, health anxiety, and suicidality. Last but not the least, the well-being of the workforce should be of the utmost concern, for there is “no health without a healthy workforce.”[13] COVID-19 has emerged as a global health threat. The health-care workers being on the frontline fighting the infection evidently has unique psychosocial vulnerabilities. The solutions include preparedness, awareness, and planning. As much it is important to plan meticulously, it is also vital not to plan in an undue manner, for the end of this crisis will not be the end of distress or suffering and the summons of the clinical workforce are perpetual and not transitory. To best put it in the old words of Keller, “Although the world is full of suffering, it is also full of the overcoming of it.”[22]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lewis CS, Observed AG. Faber & Faber. London. 1961;1988:25.  Back to cited text no. 1
    
2.
WHO. World Mental Health Day. WHO; 2017. Available from: https://www.who.int/mental_he alth/world-mental-heal th-day/2017/en/. [Last accessed on 2020 Jan 05].  Back to cited text no. 2
    
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Imo UO. Burnout and psychiatric morbidity among doctors in the UK: A systematic literature review of prevalence and associated factors. BJPsych Bull 2017;41:197-204.  Back to cited text no. 3
    
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World Health Organization. Coronavirus Disease 2019 (COVID-19): Situation Report, 72;2020.  Back to cited text no. 4
    
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Carrieri D, Briscoe S, Jackson M, Mattick K, Papoutsi C, Pearson M, et al. Care under pressure: A realist review of interventions to tackle doctors' mental ill-health and its impacts on the clinical workforce and patient care. BMJ Open 2018;8:e021273.  Back to cited text no. 5
    
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Medisauskaite A, Kamau C. Reducing burnout and anxiety among doctors: Randomized controlled trial. Psychiatry Res 2019;274:383-90.  Back to cited text no. 7
    
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Brečka TA, Vňuková M, Raboch J, Ptáček R. Burnout syndrome among medical professionals: Looking for solutions. Act Nerv Super 2018;60:33-9.  Back to cited text no. 8
    
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Carrieri D, Mattick K, Pearson M, Papoutsi C, Briscoe S, Wong G, et al. Optimising strategies to address mental ill-health in doctors and medical students: Care under pressure'realist review and implementation guidance. BMC Med 2020;18:1-0.  Back to cited text no. 9
    
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Grover S, Dua D, Shouan A, Nehra R, Avasthi A. Perceived stress and barriers to seeking help from mental health professionals among trainee doctors at a tertiary care centre in North India. Asian J Psychiatr 2019;39:143-9.  Back to cited text no. 10
    
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Bhugra D, Sauerteig SO, Bland D, Lloyd-Kendall A, Wijesuriya J, Singh G, et al. A descriptive study of mental health and wellbeing of doctors and medical students in the UK. Int Rev Psychiatry 2019;31:563-8.  Back to cited text no. 11
    
12.
Picco L, Yuan Q, Vaingankar JA, Chang S, Abdin E, Chua HC, et al. Positive mental health among health professionals working at a psychiatric hospital. PLoS One 2017;12:e0178359.  Back to cited text no. 12
    
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Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020;368:m1211.  Back to cited text no. 14
    
15.
Surya M, Jaff D, Stilwell B, Schubert J. The importance of mental well-being for health professionals during complex emergencies: It is time we take it seriously. Glob Health Sci Pract 2017;5:188-96.  Back to cited text no. 15
    
16.
Huremović D, editor. Psychiatry of Pandemics: A Mental Health Response to Infection Outbreak: Springer; 2019.  Back to cited text no. 16
    
17.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.  Back to cited text no. 17
    
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Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e15-6.  Back to cited text no. 18
    
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Banerjee D. How COVID-19 is Overwhelming Our Mental Health. Nature India. https://www.natureasia.com/en/nindia/article/10.1038/nindia.2020.46. [Last accessed on 2020 Mar 26].  Back to cited text no. 19
    
20.
Maunder RG, Leszcz M, Savage D, Adam MA, Peladeau N, Romano D, et al. Applying the lessons of SARS to pandemic influenza: An evidence-based approach to mitigating the stress experienced by healthcare workers. Can J Public Health 2008;99:486-8.  Back to cited text no. 20
    
21.
Inter-Agency Standing Committee. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Setting: Checklist for Field Use. Inter-Agency Standing Committee; 2008.  Back to cited text no. 21
    
22.
Keller H. Optimism: An Essay. New York: TY Crowell; 1903.  Back to cited text no. 22
    




 

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