Preparing for COVID-19-Induced PTSD Among Health Care Providers
As I write this, I am acutely aware of how lucky I am to be healthy, to have a job that brings me satisfaction and meaning, and to not be personally facing the horrors being experienced by the frontline providers of critically ill COVID-19 patients. My hospital and other relief organizations have asked whether any physicians might be willing to work in a department other than the one they are trained in to help with the surge of COVID-19 patients. With this in mind, I have joined several online physician groups that share information on COVID-19—from pharmacology information to latest peer-reviewed journal articles to information on how to manage a patient on a ventilator. Although certainly overwhelming, these groups do bring a sense of solidarity with all the healthcare workers in a way that I haven’t felt perhaps since residency.
These groups also keep me informed of my colleagues on the frontlines and what they are facing medically, professionally, and emotionally. I watched with sadness and horror a video from The New York Times of a New York City doctor showing the conditions of her overwhelmed hospital. She looked exhausted and beleaguered, but also exuded the willingness to persevere. My husband noted that hospitals with limited space, providers, and resources seemed to be turning into MASH units. We providers have started to feel as if we are “in the trenches.”
I started to wonder if the COVID-19 pandemic would be referred to in the future as World War III. Instead of nations fighting each other, we were all fighting a common enemy: a pandemic. If this is the case, there is no doubt that, as a friend of mine put it, healthcare workers are the frontline infantry.
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Health care professionals are no strangers to stress and tragedy on the job. We live with such perils even as we treat them. In many ways, we were drawn to and trained in a profession that allows us to feel a sense of control over chaos as we intellectualize and treat disease. What happens, however, when health care providers begin to lose the ability to control disease, or when we are faced with an unwinnable war? When healthcare professionals are not able to practice the way they feel is the best or safest way? When they are silenced by their administrators with threats of termination if they speak out against poor working conditions? These are questions being answered before our eyes since January, when the first cases of COVID-19 were discovered in the United States.
Even prior to COVID-19, post-traumatic stress disorder (PTSD) has been shown to be more prevalent in health care providers (about 15%) than in the general population (3% to 4%). Nurses and resident physicians and those in higher stress departments, such as emergency medicine, have been shown to be especially vulnerable populations in terms of developing PTSD. The higher prevalence of PTSD in these populations is likely due to multiple factors, including that they most often bear witness to patients’ suffering and dying. In addition, residents and nurses tend to have lower amounts of control over their work conditions and how they are able to practice in terms of maintaining personal safety. Indeed, one of the key factors leading to nursing burnout and possibly PTSD is feeling that work conditions are unsafe.
This feeling of lack of safety in practice is something that has also been revealed in the COVID-19 pandemic as more and more healthcare providers are reporting surging numbers of patients with COVID-19, yet at the same time reporting that their administration is sending them in to care for patients without the proper personal protective equipment (PPE) or telling them to take off PPE due to “scaring the other patients.” Healthcare workers are among those at the highest risk of acquiring COVID-19 yet providers have been admonished and fired for asking to wear PPE according to their own guidelines, and not the guidelines of the US Centers for Disease Control and Prevention (CDC), which seem to be shifting rapidly to account for the lack of PPE available to providers. This likely amplifies trauma as providers are left feeling out of control of their own safety and their ability to properly protect their patients.
Healthcare providers, physicians, and nurses are people-pleasers, yet we have little control or autonomy in the way we provide care. Under normal circumstances we simply vote with our feet and move to roles and systems that best align with our preferred way to practice. In a pandemic, this is not possible. As in residency, we are once again finding ourselves with very little personal control over how we are able to practice—but now it is impacting how we are able to keep ourselves and our patients safe.
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Over the past 30 years, healthcare in the United States of America has largely become a business. Business management and healthcare endeavors make for strange bedfellows and never has this been more pronounced than during the COVID-19 pandemic. Not only are healthcare providers unable to protect themselves adequately from COVID-19 due to shortages of PPE, but shortages of supplies such as ventilators and beds have forced physicians to make choices about which patients to give treatment to, and which to let die. This has been identified as a situation that can lead to a moral injury among healthcare providers and sets the stage for even higher incidence of PTSD among healthcare providers as the pandemic continues.
The COVID-19 pandemic has also been an awakening about the stress placed on healthcare providers even in normal circumstances, and of the magnitude of issues that will likely plague frontline healthcare providers. As we move forward and perhaps face future pandemics, providers who are able to control how they practice and how they protect and care for their patients will be more resilient to burnout and PTSD.
Building resilience in healthcare professionals is one way to address lowering rates of burnout and PTSD in healthcare professionals, but this alone will not help as the COVID-19 pandemic continues to lay waste to our healthcare professionals’ mental and physical health. We mental health care providers will see in the coming weeks, months, and maybe years an influx of healthcare providers traumatized by what they experienced. Our ability to help health care workers with COVID-19-induced PTSD might be hindered, however, by a variety of obstacles including health care workers’ difficulty acknowledging the need for help, the significant stigma attached to seeking mental health care, limited time to seek mental health care, or because as caregiving professionals, we tend to place our own needs last.
Now is the time for us as mental health care providers to begin to prepare ways to reach out to our colleagues on the frontlines to make our services more easily available starting with the assumption that frontline providers, especially those in hard-hit areas like New York City, are traumatized until proven otherwise. Traditional treatments for PTSD such as medication-management and cognitive behavioral therapy (CBT) can be helpful, as can other types of trauma therapy such as Eye Movement Desensitization and Reprocessing (EMDR) and somatic experiencing but only if frontline providers seek these out. The newly re-emerging field of psychedelic assisted therapy could also be a tremendous resource for the healthcare workers who are suffering from COVID-19-induced PTSD, but again, only to those frontline providers who have access to this treatment.
Making emotional support available through call-lines and free counseling services is a good start in providing support to our frontline colleagues, but given the barriers to seeking and obtaining mental healthcare, we might consider outreach programs specifically built into our frontline providers’ day to day workflow. We might consider ways to destigmatize seeking treatment for mental health issues. We might consider mandatory self-assessments and 360 reviews by staff to try to identify those healthcare providers who might be suffering in silence, or maybe not fully consciously aware that what they are experiencing is PTSD. In other words, what if we were to make mental health care checks and treatments for all frontline providers in this COVID-19 pandemic “opt-out,” instead of “opt-in”?
In the COVID-19 pandemic, there has been much discussion regarding what we are all doing to prevent a surge in COVID-19 patients from overwhelming the health care system. However, I suggest that as mental health care providers we must begin asking ourselves questions that will become increasingly important in the weeks and months to come: What are we doing to prevent the health care system from overwhelming its health care workers? And perhaps more importantly, what are we doing to prepare to better serve the morally, physically, and mentally wounded healthcare professionals who will be without doubt a large group of victims of this pandemic. As the physical impact of COVID-19 begins to subside, we mental health care providers will become the frontline providers to a new epidemic of COVID-19-induced PTSD among health care professionals.
Holly Hendin, PhD, MD, is a faculty physician in the psychiatry department at Dignity Health St. Joseph Medical Group, Phoenix, Arizona, and assistant professor, Health Sciences Associated Faculty in the department of psychiatry at Creighton Medical School, Omaha, Nebraska. She received her PhD from the University of California, Davis and her MD from the University of Arizona, Tucson. Her PhD is in personality psychology, and her graduate research was on narcissism, shyness, and self-esteem. She believes that all forms of therapeutic interventions from yoga and mindfulness-based CBT to eye movement desensitization and reprocessing (EMDR) and psychedelic-assisted therapy can be useful in building a touchstone community of wellness both within the self and outside of the self.
