The Impact of COVID-19 on the Mental Health of Healthcare Providers

COVID-19 not only affects the respiratory system but also has psychological impacts on both those who have the disease and those who are COVID-19 negative. COVID-19 has drawn new attention to hand hygiene, masks, social distancing, and quarantine measures as the fundamental disease control tools. These disease management requirements have many effects on the mental health and well-being of the population. The mass quarantine imposed by nationwide lockdown programs can produce feelings of isolation, anxiety, and distress, due to feelings such as a sense of getting cornered and loss of control. Studies of previous epidemics have reported that the psychological impact of quarantine can vary, from immediate effects, such as irritability, fear of contracting and spreading infection to family members, anger, confusion, frustration, loneliness, denial, anxiety, depression, insomnia, and despair, to extreme consequences, including suicide.(1)

Effects such as posttraumatic stress disorder (PTSD) have been reported, with the symptoms positively associated with the duration of quarantine.(2) Post-quarantine psychological effects may include significant socioeconomic distress and psychological symptoms due to financial losses.(1) The psychological impact is not confined to adults and older individuals. Children who are (or are suspected to be) infected with COVID-19 and need to be isolated or quarantined might require special attention to meet their fear, anxiety, and other psychological effects.(3)

Impact of COVID-19 on Medical Education

Classes and Conferences

COVID-19 is disrupting routines in hospitals and medical schools, and is changing the training and education of medical students. Before COVID-19 became widespread in the United States, many medical students had not thought about how it was going to affect them and their education.

The largest impact has been the cancellation of in-person medical classes, with most replaced by recorded lectures or live streaming on platforms such as Zoom. There has been a loss of collaborative experiences between students and between students and faculty. In-person classes permit real-time feedback and the back-and-forth dialogue that develops when the student is in class, and that is difficult to replicate in online forums. One technique currently being implemented that attempts to recapture this collaborative environment involves the use of small group meetings in an online forum.

The cancellation of in-person classes will present a challenge to re-engage students within the community spirit of medical school once restrictions are lifted. Interactive learning groups, such as small group case-based learning and team-based learning, can continue during the COVID-19 pandemic through webinars and teleconferences and may provide insight into how medical school will look going forward.(4)

Clinical clerkships, an important component of medical education, have been canceled at many medical schools. Medical conferences also have been canceled due to COVID-19. These conferences, and the presentations that medical students give at them, are essential to building up medical students’ research and communication skills, as well as enhancing their confidence in engaging in public speaking. Medical students will miss out on the valuable experiences of presentations, clinical rotations, and collaborative experiences, all of which have been the standard of medical education for generations of training future doctors.

COVID-19 and Telemedicine

COVID-19 has opened the door for telemedicine, which has been available for several decades but didn’t become widely used until March 2020, when CMS declared that virtual visits did not violate HIPAA restrictions and that compensation for a virtual visit would be same as that for an in-office doctor–patient visit. It is now time to change how we train future physicians and develop novel ideas of how clerkships, conferences, and didactic learning can work. The younger generations of students and faculty in medical school probably are best equipped to integrate technology and webinars into both providing healthcare delivery and sharing medical knowledge in innovative, online settings that may enhance the education of future physicians. Medical schools that are better able to adapt to the current unique situation presented by COVID-19 will show their ability to think outside of the box and actually change how medicine should be both learned and practiced. Medical school faculty must be innovative in devising ways for students to exhibit their skills, work ethic, teamwork, and dedication to providing healthcare to our patients. Persistence and adaptability during the COVID-19 era will make it possible to provide a quality education to medical students in spite of all these new challenges.(5)

The Impact of COVID-19 on Healthcare Professionals

Healthcare workers responding to the novel coronavirus pandemic are facing highly stressful conditions as they treat patients during an unprecedented international public health crisis. Public focus remains fixed on the biological risks to healthcare workers, while their psychological peril is often neglected. Past research on epidemics has shown that they can have severe psychological effects on the general population, triggering the development of new psychiatric symptoms or causing pre-existing ones to get worse. The psychiatric disorders that most commonly develop include depression, anxiety, panic attacks, somatic symptoms, posttraumatic stress disorder symptoms, delirium, psychosis, and even suicidality.(6-8) Healthcare workers are at higher risk than the general population of developing severe adverse psychological outcomes during times of disaster.(9) Spoorthy et al.,(10) in the Asian Journal of Psychiatry, report that healthcare workers responding to the COVID-19 pandemic are experiencing a significant amount of stress, anxiety, depression, and insomnia.

Psychological Effects of Coronavirus

The coronaviruses are a large family of single-stranded RNA viruses causing mild to severe illnesses of the upper respiratory tract in humans.(11) Although coronaviruses have spread among humans and animals for centuries, three prominent coronaviruses that arose from animal reservoirs have caused widespread illness and death: SARS-CoV; MERS-CoV; and SARS-CoV-2.(12,13)

Healthcare workers treating patients with known or suspected cases of COVID-19 may be at high risk of developing emotional issues.

In 2003, the severe acute respiratory syndrome (SARS) outbreak induced serious emotional problems and psychiatric symptoms in 18% to 57% of healthcare professionals, both during and after the event.(14) As a result of the 2015 Middle East respiratory syndrome (MERS) outbreak, stress and dysphoria were documented among healthcare professionals. These psychiatric effects resulted in misconduct, often in the form of absenteeism, and errors of commission and omission that affected the quality of care.(14) The COVID-19 virus has a mortality rate of 2%, higher than that of SARS and MERS combined.(15) Additionally, COVID-19 has a higher transmission rate than SARS, and many patients with COVID-19 present with milder symptoms, contributing to the spread of the virus as cases go unrecognized.(16) Healthcare workers during the COVID-19 pandemic will be at risk for mental health disorders and are likely to experience even greater psychological effects than the SARS and MERS outbreaks. Moreover, the COVID-19 pandemic has commanded constant media coverage and prompted global social media correspondence, a societal outturn that was not seen during the SARS outbreak. This international connectivity has contributed to the widespread panic associated with the virus, which may point to more severe mental health issues in healthcare workers responding to COVID-19 as compared with SARS.(17,18)

Healthcare workers treating patients with COVID-19 who may be at high risk of developing emotional issues include primary care nurses, nursing technicians, and doctors who are in direct contact with patients and their bodily fluids, especially doctors in emergency departments and intensive care units.(19,20) As a result of the exponential increase in the demand for treatment, many healthcare workers will work long hours under a significant amount of stress.(21) Healthcare workers may face stressful challenges in providing high-quality treatment, such as inadequate staffing or shortages of resources such as personal protective equipment (PPE). Difficult decisions, such as how to allocate insufficient resources among equally compromised patients, may contribute to mental health issues or moral injury.(22) These stress factors and work overload make healthcare professionals particularly prone to psychological distress, thus increasing their probability of developing psychiatric disorders.(23-25)

Vicarious Trauma

Vicarious trauma or secondary traumatic stress is always a concern during times of disaster. In this phenomenon, healthcare professionals experience psychological symptoms similar to patients’ trauma because of long-term exposure to those patients. Symptoms of vicarious trauma include appetite loss, fatigue, physical decline, sleep and attention disorders, irritability, numbness, fear, and despair.(26) Such internal pressures could adversely affect healthcare professionals’ decision-making, thus leading to the degradation of their health.(20)

Li et al.(26) evaluated 214 healthy individuals from the general public, 234 front-line nurses, and 292 non–front-line nurses using the Chinese version of the vicarious traumatization scale to identity the severity and risk factors of vicarious traumatization among medical staff. Their study found that both the general population and medical staff suffer from vicarious trauma. Front-line nurses are prone to vicarious psychological trauma due to continuous and direct exposure to patients with COVID-19 and the physical and psychological distress experienced by those patients; psychotherapists should be aware of this threat and attend appropriately to front-line nurses’ psychological states.(27,28) Interestingly, however, the study’s results suggest that vicarious traumatization of non–front-line nurses is more severe than that of front-line nurses. This finding may be explained by the fact that front-line nurses have more knowledge, education, and training on the pandemic than non–front-line nurses, a possibility that implies that transparent reporting of epidemic information is beneficial to social and psychological conditions.(26)

Physician Burnout

The spread of COVID-19 intensified stressors in the healthcare system that lead to physician burnout.(29) Burnout syndrome can be described as “increased exposure to workplace stressors that results in emotional exhaustion, depersonalization, and decreased sense of personal accomplishment.”(20,30) Evidence shows that physician burnout was already epidemic prior to the coronavirus pandemic; a specific study by Shanafelt et al.(31) reported that from 2011 to 2014 more than half of U.S. physicians were experiencing burnout. Furthermore, in 2016, burnout was reported by Korean healthcare workers involved in the MERS epidemic.(32)

The COVID-19 pandemic establishes a workplace environment with all the criteria for inducing chronic workplace stress, resulting in rampant physician burnout rates, which are now at an epidemic level. Hospital administration and individual physicians should be aware of the current heightened risk of burnout syndrome and take proactive measures to mitigate the effects of burnout in those physicians and healthcare workers who are at the highest risk for burnout.(30)

Bottom Line: Just as COVID-19 has uncovered a racial disparity, with Blacks and Hispanics having a greater incidence, morbidity, and mortality than Caucasians, COVID-19 also has revealed that those who have contacted the disease are experiencing psychological manifestations in addition to the physical and physiologic impacts. The physical and physiologic consequences of COVID-19 have received extensive media and academic coverage. However, the psychological consequences of COVID-19 have not been adequately explored, nor has the healthcare profession created a plan of action for managing healthcare professionals who are experiencing mental health issues related to COVID-19. We believe that the first step is recognition of how COVID-19 is affecting future doctors’ medical education, how COVID is contributing to medical errors, and how COVID is adding to the already high incidence of physician burnout. Now that we have recognized that COVID-19 is causing significant psychological problems in healthcare workers and that the pandemic has far-reaching consequences regarding the health and well-being of both healthcare providers and our patients, we are going to be motivated to help find solutions to this problem.

References

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