Albert Einstein College of Medicine, MS1
May 16, 2020
We call them the healthcare workers on the “front lines” in this “battle” against coronavirus. I am not sure who first used this decidedly militaristic terminology to describe those involved in “fighting” the COVID-19 pandemic—whether it was the news media, social media, or whether it has always been in our lexicon to refer to viral epidemics in this way—but it is apt. The “front line” in military parlance is the position closest to the conflict zone. If the battlegrounds are our hospitals, our ERs, and our ICUs, then our doctors, nurses, and allied health professionals are the infantry.
Mental Health of the Frontliners
Just as Post Traumatic Stress Disorder (PTSD) affects our combat veterans in staggeringly large proportions, hospital administrators are expecting an analogous surge in mental illness among frontline veterans of the COVID-19 pandemic. “As many as 20% to 25% of healthcare workers in hard-hit areas are likely to develop disorders such as anxiety, depression or post-traumatic stress – a rate similar to what is reported in soldiers returning from combat,” the Los Angeles Times reports (1).
We are currently still very much at war, and all is not quiet on the COVID front. Just last month Dr. Lorna Breen, an ER physician in Manhattan, took her own life. Healthcare professionals on the front lines are witnessing mass casualties accompanied by no proven treatments or cures, a sense of powerlessness, and fear of bringing the virus home to their loved ones. Additionally, they are thrust into deep intimacy with some of their patients, as they may be facilitating video calls with family members and may be present in their dying moments. All of this augments the already high rates of stress, burnout, depression, addiction and even suicide among healthcare professionals.
Mental Health of COVID-19 Survivors
There is also concern that depression, anxiety and PTSD may affect COVID-19 patients upon discharge from the hospital. The emotional toll of time spent battling life-threatening infection, and suffering the stressful and unpleasant experience of being kept alive by mechanical ventilation for days or weeks, puts patients at increased risk for psychological problems in the future. In one study of more than 700 COVID-19 patients in Wuhan, China, 96% of respondents met the cutoff score for probable PTSD (2). It is also possible that the virus itself may cause psychiatric problems, though little is known at this time.
Effects of Quarantine on the Otherwise Healthy
Among those of us who are doing our civic duty and abiding by stay-at-home orders, quarantine has exacted its own psychological toll. In preliminary findings from researchers at San Diego State University and Florida State University, more than a quarter of American adults met criteria for serious mental distress and illness, a roughly 700% increase from pre-pandemic data collected in 2018 (3). The surge in mental distress is evident among all age groups, but was more pronounced among young adults and those with children under 18 at home. Unemployment, financial uncertainty, and social isolation present a new public health worry: an increase in suicide risk.
Lessons Learned from Mental Health Professionals in Italy & the Success of Telepsychiatry
The COVID-19 crisis has forced U.S. politicians and public health officials into a catch-22: risk re-exposing the public to the virus and experiencing a resurgence of infection, or continue lockdown and exacerbate financial and psychological hardship. Either way, I see it as an incontrovertible truth that people are suffering in the current moment, and public officials should invest resources into mental health treatment.
In a JAMA Psychiatry article, leaders from the Departments of Mental Health and Addiction in Lombardy, Italy discuss their main takeaways from the COVID-19 crisis. Among many lessons learned, they stress that healthcare systems need to invest in expansion of e-health technologies (4). I noticed myself that though I could see some of my providers via Doximity and Zoom, others were not well versed in this modality or were part of an institution that did not give them access to it. There is also additional concern about privacy and confidentiality when using these modalities. However, telehealth and telepsychiatry services are particularly critical for supporting those who live alone, those suddenly exposed to marked isolation, those living in households with high levels of conflict, and those who have children or other dependents with disabilities.
Researchers from the RAND Corporation interviewed 20 outpatient psychiatrists transitioning to telemedicine due to the COVID-19 pandemic. While most of them previously had only limited telemedicine experience with their patients prior to the outbreak of COVID-19, the new status quo forced them to transition to fully virtual practices. Findings highlight that although psychiatrists express some concerns about the quality of these encounters (i.e. reduced ability to observe nonverbal cues, privacy concerns), the transition has been largely positive for both patients and physicians (5).
What We Have Already Done & What We Are Planning on Doing
Back home in our own country, Congress has passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act, a $2 trillion stimulus package that includes appropriations for the Substance Abuse and Mental Health Services Administration and the Department of Health and Human Services. The Centers for Medicare and Medicaid Services (CMS) has made several changes that help mental healthcare professionals and organizations remain afloat, such as reimbursing for telehealth services in an amount equivalent to that of in-person appointments.
In a bipartisan effort backed by the American Medical Association, the American College of Emergency Physicians and the American Psychiatric Association, lawmakers are pushing for the inclusion of enhanced mental health resources for health care workers in the next coronavirus aid package. They are calling for the establishment of a grant program within the Department of Health and Human Services (HHS) that will allow health care employers to confidentially assess and treat the mental health of frontline workers (6). Additionally, the group is recommending that Congress fund an HHS study to identify the factors that contribute to health worker distress and burnout, barriers to accessing treatment, ramifications for patient outcomes and the health care system, as well as ways to address the aforementioned problems.
Take Care of Yourself So You Can Take Care of Others & Plan for the Future
Physicians are often the leaders of the medical team. To use a military analogy, doctors are the commanders of a brigade containing other physicians, nurses, technicians and allied health workers. Thus, the physician’s role is to plan for the future, anticipate further attack, learn from the mistakes and successes of the past, and implement new tactics and technologies that will enable us to conquer the enemy more effectively next time. But we must also remember that we, too, are vulnerable to infection, to depression, and to suicide. Recognizing these feelings in ourselves and in each other and normalizing seeking help from our mental health colleagues and support from each other can help ease the psychological burden.
We are also always advocates for our patients. Our specialized body of knowledge enables us to use our expertise to influence healthcare policy. If there is a need and the healthcare system is falling short of addressing it, it is our duty to organize and lobby for mental health funding, investment in e-health and telemedicine technologies, and contingency plans for the future.
In case you have not noticed by now, I aspire to be a psychiatrist. I am drawn to the field for a myriad of reasons: the fascinating pathology, the humanism inherent in psychiatric practice, and the ability to help give a patient their sense of “self” back. I have experienced the psychological effects of COVID-19 both through the lens of a medical student and as a patient. As medical students, my fellow classmates and I have been attempting to take care of ourselves and each other while we balance a virtual curriculum with quarantine and social isolation. I myself have turned to yoga and meditation as activities that I can engage in within the confines of my home to keep myself physically and mentally healthy. Leaning on my social network for support via Zoom happy hours and nighttime Facetime calls has become the norm. As a patient, I have struggled to conduct virtual visits with my own healthcare providers across the country, who were blindsided by the pandemic and forced to make rapid adjustments to their practice. This is the time for medicine to make the contingency plans. To think about questions such as “what interventions can be done virtually?” and “what will we do if the pandemic becomes episodic?”
My future role as a budding psychiatrist will be to treat the aftermath of the 2020 COVID-19 outbreak. The psychological trauma endured by health workers and laypeople alike will be present for years to come. My hope is that I and other medical students in my generation will take it upon ourselves to become well-versed in telemedicine as a modality for treatment delivery. I would encourage us to think of our expertise as not confined to the hospital or clinic, but to offer our services on a broader scale to those who may not have in-person access to us. In an increasingly globalized world, this pandemic is a potential opportunity for us to reconsider how to best maximize patient access to our services, whether that be because of a viral pandemic, or to overcome longer-term barriers like limited mobility or lack of proximity.
(1) Wilber, D. Q. (2020, May 6). Hospitals prepare for wave of mental health disorders among their workers. The Los Angeles Times. Retrieved from https://www.latimes.com/politics/story/2020-05-06/hospitals-prepare-for-wave-of-mental-health-disorders-among-their-workers
(2) Güler Boyraz & Dominique N. Legros (2020) Coronavirus Disease (COVID-19) and Traumatic Stress: Probable Risk Factors and Correlates of Posttraumatic Stress Disorder, Journal of Loss and Trauma, DOI: 10.1080/15325024.2020.1763556
(3) Twenge, J., & Joiner, T. E. (2020, May 7). Mental distress among U.S. adults during the COVID-19 pandemic. https://doi.org/10.31234/osf.io/wc8ud
(4) de Girolamo G, Cerveri G, Clerici M, et al. Mental Health in the Coronavirus Disease 2019 Emergency—The Italian Response. JAMA Psychiatry. Published online April 30, 2020. doi:10.1001/jamapsychiatry.2020.1276
(5) Uscher-Pines L, Sousa J, Pushpa R, et al. Suddenly Becoming a "Virtual Doctor": Experiences of Psychiatrists Transitioning to Telemedicine During the COVID-19 Pandemic. Psychiatry Online. Retrieved from https://ps.psychiatryonline.org/pb-assets/journals/ps/homepage/Suddenly%20Becoming%20a%20%E2%80%9CVirtual%20Doctor%E2%80%9D%20-%20Experiences%20of%20Psychiatrists%20Transitioning%20to%20Telemedicine%20During%20the%20COVID-19%20Pandemic.pdf
(6) Weixel, N. (2020, May 6). Lawmakers push for mental health funding for providers in next aid package. Retrieved from https://thehill.com/homenews/house/496415-lawmakers-push-for-mental-health-funding-for-providers-in-next-coronavirus-aid