Front-line doctors face a mental health crisis amid coronavirus. Can medicine overcome the culture of stoicism?
Many doctors put their own mental health last. That needs to change.
The coronavirus pandemic has taken a toll on the American psyche, with a third of Americans now showing signs of clinical depression or anxiety, a rate twice as high as before the pandemic, according to Census Bureau data. Those grim statistics are likely even more dire for the health care workers on the front lines of the crisis, experts say.
While it's too early to truly quantify the effect that treating patients under combat-like conditions will have on doctors in the coming months or years, preliminary research out of China highlights the mental health risk that American health care workers potentially face.
Of more than 1,200 health care workers surveyed in China, roughly half showed symptoms of depression or anxiety, according to a JAMA Network Open article published in March. More than a third of those surveyed reported insomnia. Some 70% said they were distressed. Nurses, women, health workers who had direct contact with COVID-19 patients and those in Wuhan, the epicenter of China's outbreak, reported the most severe symptoms.
The consequences of ignoring doctors' mental health during the pandemic are grave.
In April, Dr. Lorna Breen, medical director of a New York City emergency department, which had nearly been overwhelmed by COVID-19 patients, died by suicide at age 49. She had no prior history of mental illness.
"Make sure she’s praised as a hero, because she was," Breen's father told the New York Times. "She’s a casualty just as much as anyone else who has died."
"We have to see emotional and mental health support as being as important and vital as we see PPE [personal protective equipment]," said Dr. Samantha Meltzer-Brody, a psychiatry professor and director of the well-being program at University of North Carolina.
Every hospital and medical facility should be asking themselves, "what are we doing to prevent the emotional impact of being a health care provider in this environment?" she said.
Why doctors and nurses' mental health is at risk
"Health care workers are not starting with a baseline of zero. They had super elevated depression, suicide rates and burnout prior to COVID," explained Dr. Jessica Gold, an assistant professor of psychiatry at Washington University in St. Louis.
Depression, burnout and suicide plague the medical profession. While there hasn't been much recent research evaluating the incidence of physician suicide in the United States, studies from the 1990s found that the risk for suicide among male physicians was 40% higher than for men in the general population. For female physicians, that risk was 130% higher.
Newer research continues to indicate that suicide rates among physicians outpace rates in the general public.
Layered on top of an already stressful job is a public health emergency the likes of which our country hasn't seen in a century, compounding doctors' existing mental health risks.
The list of stressors for health care workers during COVID-19 is overwhelming even to read. They worried about not having enough PPE to protect themselves from the virus. They agonized over the prospect of running out of ventilators and having to withhold care from the dying. Many practiced outside of their field. They took on grueling shifts, with no sense of when the outbreak would crest. Burnout was brutal, they said. Colleagues fell ill and some died -- 63,000 and nearly 300 respectively according to the CDC. After finishing their COVID-19 duty, some were redeployed. They slept in hotels, isolated, to protect their families, or went home each night, and worried about putting their families at risk. Those far away from the front lines said they felt guilty and inadequate for not being there.
Then there was the helplessness inherent in being unable to save tens of thousands of patients.
"Early on, the predominant emotion was anxiety," said Dr. Michael Devlin, a clinical psychiatry professor at Columbia University, who led group sessions on Zoom for health workers during the pandemic. Hospitalizations in New York City were surging and the doctors he counseled were worried about exposing their families.
"You're putting people in between the two things they care most about — their work and their family," he said. "It's excruciatingly difficult for many people."
Over time, that anxiety gave way to grief over seeing so much loss and death.
Patients' families were barred from the hospitals. In many cases, doctors and nurses were the ones holding the iPad as patients said goodbye to their loved ones through a screen.
"There was all the awfulness of people not being able to say goodbye to loved ones and having to witness that," he said.
Traditionally, medical professionals have relied on a culture of stoicism and self-sacrifice in order to do their jobs. In some ways, it's necessary. "Doctors are trained to try not to have their emotions interfere with their judgement," said Donald Parker, a licensed clinical social worker and president of Hackensack Meridian Health Carrier Clinic, New Jersey's largest nonprofit behavioral health system.
But that same culture also puts doctors at risk of not taking care of, or hurting themselves, experts say.
"You want your doctor to be neutral in emotions and deep in their expertise. That creates an environment where they don't feel free sharing their emotions," said Parker, who has worked in behavioral health for more than four decades.
Without an outlet, even those who have been calm and reserved over the course of their careers can become overwhelmed.
"It spills over," Parker said. "You are left with an intensity in reaction that becomes dysfunctional."
Trauma from COVID-19 could drastically hurt doctors' mental health
Dr. Jo Shapiro's job is taking doctors' mental health and well-being seriously.
After three decades of practicing surgery, Shapiro spent 10 years at Brigham and Women’s Hospital in Massachusetts, directing a program to train physicians to support one another when they experience trauma on the job. She's given peer support training at more than 50 organizations in the United States and around the world, and when the pandemic hit there was even more interest among organizations who wanted to launch new programs or adapt their existing framework to the COVID-19 crisis.
But when Shapiro herself developed COVID-19 early on, she refused to take her own advice about self-care and self-sacrifice.
"Although I didn’t have to end up in the hospital, I have never been that sick," she said. As her health worsened, Shapiro continued to work on starting peer support programs when organizations reached out to her.
"The level of hypocrisy that I demonstrated to myself as I was getting sicker and sicker shows you how deep the culture is. I was doing exactly what I tell people not to do," she said.
The stigma attached to asking for support can lead doctors to suffer in silence or use negative coping mechanisms, like alcohol or drugs to self-medicate, experts say.
"Nobody wants to look look like they are incompetent or like you can’t trust them in a battle," said David Pezenik, a licensed clinical social worker, who counseled first responders about grief and trauma after 9/11.
"It usually takes a little while for it to set in and manifest," he said of trauma.
"The patient might not even realize what they’re going through. The first part, before denial is shock. When you’re in shock you don’t even feel the pain."
Not everyone who experiences trauma or burnout will develop conditions like anxiety or depression, but there are some early signs to watch out for, Meltzer-Brody explained.
First it's important for doctors to pay attention to their stress levels, their emotions and the effect their work is having on them. "There are people who are very aware — and those who are less so," Meltzer-Brody said.
Positive coping strategies, like exercise, connecting with family, friends and colleagues, eating well, and taking physical and mental breaks, can help.
If those positive coping strategies fail and a doctor still feels depressed, anxious or can't sleep, it's a sign they may need more formal mental health support.
"Just being able to name it is one thing, having tools to deal with it is a different thing," Meltzer-Brody said.
While some people will bounce back from trauma, others will inevitably suffer long-term mental health consequences.
The worst concern, first and foremost is that someone will develop PTSD and clinical depression and have decreased functioning," Meltzer-Brody said.
Decreased functioning could mean not being able to interact with family members or being unable to go to work. Relationships with significant others or between parents and children could become strained. Developing addiction as a maladaptive coping strategy is another risk. Some may leave the workforce altogether, and others may feel increasingly hopeless and that life is not worth living.
When asked about the potential for doctors dying by suicide, Meltzer-Brody said, "People like me who run these programs think about it every day and worry about it every day."
It's not a lost cause. How hospitals can better support doctors.
COVID-19 has the potential to have a devastating impact on doctors' collective mental health in the U.S. But it could also be the catalyst needed to implement preventative mental health support programs in institutions that aren't investing in them.
Of the dozens of the programs Shapiro has helped launch, the majority began with an unsettling trigger point, such as a medical error in a hospital, the death of a colleague, or a mass casualty like the Boston marathon bombing.
"Things that a caring, compassionate person might be deeply affected by," Shapiro said.
Support programs vary, but the best ones are often multifaceted and involve proactively reaching out to doctors, rather than expecting them to ask for help when they need it, experts say.
UNC offers evidence-based stress first-aid training for front-line workers based on best practices from the military and first responders to lessen the effect acute stressors have on them in challenging situations. There are also virtual groups run by trained mental health providers and an anonymous helpline staffed by clinical social workers.
Doctors are encouraged to call in if, for example, they are increasingly scared to go to work, or if they've gotten in a fight with their spouse and are worried about how it's affecting them.
In her work, Shapiro has found that doctors feel most comfortable opening up with a physician colleague, rather than with a mental health professional, who might not be able to relate to their exact circumstances as intimately.
Her peer-to-peer programs train doctors to support one another during difficult circumstances. If there's any potential that an event could be emotionally traumatic, peer supporters reach out proactively to their colleagues.
"We should think of peer support as preventative," Shapiro said. "Some people, some physicians, some health care providers over the course of doing their work are going to become burnt out, depressed, or will develop PTSD, or become suicidal," she said.
"We know it. We have the data. Let’s not wait. Let’s know that there are certain circumstances, emotions, events that are especially emotionally stressful. Let’s reach out at those times and offer peer support rather than waiting for suffering."
The need is evident. Thousands of health care professionals have utilized UNC's online mental health resources and attended virtual forums since the pandemic began. Shapiro is seeing an uptick in requests for her help starting peer-to-peer support programs. At Columbia, after Dr. Breen died by suicide, demand for one-on-one counseling sessions skyrocketed.
But programs like the ones Meltzer-Brody and Shapiro run are the exception, not the rule.
"If we look at the United States broadly, a tiny handful of places are taking this as seriously as they should be. That’s grossly inadequate to take care of the huge number of health care providers who are facing this," Meltzer-Brody said.
There needs to be a call to arms that doctors' mental health needs are not being met, she stressed.
That call needs to be more than "call your employee assistance program," she said, referring to such assistance programs a good start, but far short of the proactive mental health support health care workers need. Instead, programs like hers should be widespread and available to everyone, which may be a real possibility if newly loosened rules about mental health treatment using telemedicine are extended beyond the pandemic.
"With virtual care there is no reason that it can’t be scaled up," Meltzer-Brody said.
"I think we have to see this as being as important as we see PPE," she reiterated. "Do we have adequate PPE to prevent physical transmission? This is the equivalent of emotional PPE."
If you are struggling with thoughts of suicide or worried about a friend or loved one help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 [TALK] - for free confidential emotional support 24 hours a day 7 days a week. Even if it feels like it – you are not alone.
What to know about the coronavirus:
- How it started and how to protect yourself: Coronavirus explained
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