The Mental Health Crisis For Frontline Workers Has Already Begun

The economic ramifications of the coronavirus are bleak enough, but the mental health crisis that frontline workers are about to face may be even worse.

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On April 27, the New York Times reported that Dr. Lorna M. Breen, the medical director of the emergency department at NewYork-Presbyterian Allen Hospital, had died by suicide. She had already contracted COVID-19, recovered, and then gone back to work before the hospital sent her home, and her family then brought her to Charlottesville to continue to recuperate there. “She tried to do her job,” Breen’s father told the Times, “and it killed her.”

Even among the endless flood of obituaries for victims of COVID-19, this news feels shocking. There have been harrowing stories about what working on the front lines is really like for health care workers and how the pandemic has been affecting the mental health of doctors and nurses as they try to save lives without enough time or hospital beds or the necessary personal protective equipment (PPE) they need to stay safe themselves. Thousands of health care workers in California have been furloughed or taken pay cuts since mid-March despite being on the frontline of coronavirus. All of them face the very real and deadly risk of getting the virus while working. On top of that, there’s the inevitable psychological toll of watching patients die alone and having to tell families their loved ones have died. And now they’re also having to deal with hoaxes that could put them in danger, protesters who refuse to stay home, and, in some places, people physically attacking them out of fear that they’ll spread the coronavirus.

Meanwhile, all of us are filled with anxiety and dread over the spread of the virus, and the uncertainty of what our future will look like under potentially endless social distancing measures across the world. That, combined with the inevitable economic toll that the virus continues to take — skyrocketing unemployment rates, stock prices plummeting, small businesses shuttering, and essential workers getting sick and burning out — means the fallout of COVID-19 isn’t just tangible, but emotional and mental too. Even as more and more states in the US are opening back up, and as vaccine trials are underway, the lingering psychological issues caused by the pandemic are just starting to take shape. And some of the most vulnerable people are the medical professionals trying to keep us all alive.

“Health care workers, we are trained to carry on and defer."

Dr. Shaili Jain, a psychiatrist and author of The Unspeakable Mind: Stories of Trauma and Healing from the Frontlines of PTSD Science, forecasts three particular mental health crises that will need to be addressed once we begin to reckon with the aftermath of the pandemic. The first and most immediate, of course, is coping with the deaths caused by the coronavirus. “The second issue is the economic adversity that’s going to follow,” she told me. “We know from studies we’ve already done in prior decades that massive unemployment and financial distress leads to increases of PTSD.” Jain referenced a 2016 study that showed links between economic hardship between 2001 and 2010, and higher levels of abusive behavior in families, specifically that increased unemployment rates could have increased men’s controlling behavior toward their partners. “The trauma literally trickles down,” she said. (And already, there have been reports of domestic violence rates going up during the pandemic.)

The third crisis, of course, is what will happen to frontline health care workers who have to power through and keep working with insufficient resources while the president suggests things like injecting light or disinfectants to cure the virus. “They’re at high rates to develop PTSD in the weeks and months that follow,” Jain said. “Health care workers, we are trained to carry on and defer. You do what needs to be done and the grieving, the processing of emotions, the psychological toll, we deal with that afterwards.”

Health care workers, like everyone else, will be affected by an economic recession. Frontline workers are facing massive pay cuts, even as they work long hours in the face of the coronavirus. The cancellation of elective medical procedures means hospitals are making less money, so health care workers are getting furloughed and having their benefits, like 401(k) matching and bonuses, cut. Some have had to quit because they feel — like workers in many other industries — that their working conditions are unsafe because of insufficient PPE. The mental health ramifications will be their next uphill battle, and their burnout will affect all of us if we don’t have enough health care professionals able to work during the next waves of coronavirus cases, which are basically inevitable.

The mental health effects of coronavirus haven’t yet been fully documented, since we’re still in the thick of it, but what we know so far is bleak. A study conducted in China found measurable increases in the number of health care workers reporting depression, anxiety, and insomnia, particularly among women, nurses, and those on the front lines who were directly engaged in diagnosing and treating COVID-19. Past crises can also provide a sense of how this one might play out. “We have studies [from] after 9/11 or after Hurricane Katrina,” Jain said. “We can predict what the trajectories are going to be.” But there are no clear answers yet to the question of how all these people will begin to recover once we’re done triaging the most urgent damage caused by the virus.

Dr. Aaron Reeves, an associate professor at Oxford University, studies how social policy affects health, well-being, and equality. He also does research on suicide rates during economic recessions. During the last financial crisis, suicide rates spiked, as did measurements of domestic violence and marital discord. “The recession has already arrived, though it may not have formally shown up in some data sources,” Reeves told me. “That economic uncertainty is going to be important in creating that sense of hopelessness about the future.”

“In this kind of moment, your crisis in your sense of identity can be very, very powerful.”

As we still struggle with how and when this pandemic will end, there’s a degree of uncertainty and hopelessness about the future. And, Dr. Reeves added, the way we typically counter that is with support from loved ones. But the social distancing rules necessary to fight the spread of the virus have broken down typical support networks, as we’ve been physically cut off from friends and family. There’s also a question of means and who has access to treatment, along with underlying mental health conditions, like anxiety and depression, that were already present well before the pandemic. And finally, there’s the issue of people grappling with their sense of identity as they lose their social network, their jobs, and their daily routines. “People’s identity is bound up with the work that they do,” Dr. Reeves said. “In this kind of moment, your crisis in your sense of identity can be very, very powerful.”

Dr. Breen’s suicide, though tragic, lines up with what we know about clinicians and mental health. Physician suicide rates are already alarmingly high, more than double what they are for the rest of the population. Doctors rank high in burnout and depression, and that was before a pandemic forced them to work long, harrowing shifts with insufficient supplies. Health care workers also have to deal with “moral injury,” a term that comes from military parlance, which happens when someone has to do something that goes against their moral beliefs.

“In medicine,” Jillian Mock writes for Scientific American, “it can occur when the business side of health care hinders a physician’s ability to care for patients; for instance, if there are not enough ventilators for the number of COVID-19 patients who need them.” This pandemic is forcing health care workers to make decisions for the greater good, now often at their own expense or the expense of others, which can lead to even more anxiety and PTSD. Instead of staying home like many of us have the privilege to do, they have to go to work, thereby putting themselves and their families at risk of getting sick. They also have to make seemingly impossible choices, like who will get a ventilator when there are so many people who need one and so few available.

“The optimist in me wants to think about post-traumatic growth, where people survive horrendous things like war, Holocaust, a pandemic, and they emerge almost enhanced, like a super-version of themselves,” Jain said. “The realist in me is also very aware that there was an epidemic of burnout in doctors and nurses before COVID hit, anyway.”

Jason Hill, an ER doctor working in Manhattan, wrote a three-week diary for BuzzFeed News cataloging the incredible burden the coronavirus has put on him and the people he works with. “I admitted four of my colleagues today,” he wrote on April 3. “Together we’ve saved lives and lost lives and everything in between. But now they are on the other side of the curtain… The front line really feels like the front line today.” Hill bakes his purportedly single-use N95 mask in the oven to disinfect it, since he’s been wearing it for days in a row. Some days at work, he hands out juice and blankets; other days, he has to work as a palliative care doctor for patients who are beyond the point of being saved by any treatment.

Another New York City doctor spoke to BuzzFeed News in late March about his day-to-day in the hospital. “It’s pretty common to see someone crying in the hallway,” he said. “The morale among ER people is extremely low. People are anxious, making morbid jokes about dying. Talking about what would happen if I quit, I didn’t sign up for this… An attending will come in and say, ‘I’m flashing back to Vietnam.’”

"Maybe you could get sick. Maybe you could get your family sick. If it’s all true, would you still want to do this?”

Dr. Lia Okun, a psychologist and the associate director of house staff and medical student mental health services for NYU, told me: “Our frontline workers are incredible and they’re doing amazing things for us. The other side is they’re sacrificing a lot for us.” At NYU, dozens of students volunteered to graduate early and began working in university-affiliated hospitals. But others have been shut out of completing their clinical work, feel paralyzed about how to help now, and are simply waiting to be thrown into a public health emergency.

“Physician burnout is something we’re quite concerned about,” Okun said, because it can be a “gateway” into more severe mental health issues. “What it means is they start feeling kind of numb, kind of hopeless. Hopeless about their own efficacy to help, down on themselves and lacking empathy for themselves. That’s what our brain and body does when we’re emotionally overwhelmed.”

Medical schools like NYU often offer their students mental health support, in order to prepare them for the inevitable hardships of being a working doctor. Now that these students will be graduating into a world reshaped by COVID-19, that support is even more necessary. “We always offered individual therapy. We always offered group psychotherapy for the students,” Dr. Okun said. “One of the things that’s so different about the environment of PTSD is that we don’t really know how to predict how dangerous or not dangerous the situation is. With the students, we talked a lot about what are the worst-case scenarios. Yeah, maybe you could get sick. Maybe you could get your family sick. If it’s all true, would you still want to do this?”

But even when health care workers have access to psychological support and treatment, that doesn’t necessarily mean they’ll be able to take advantage of it. “Part of what’s so complicated is the environment is so demanding that the interventions we want to help with on the mental side of this, they’re hard for people to access,” Okun said. “They’re too busy.”

The idea of frontline health care workers as essentially civilian war heroes has been constant during the pandemic. In the US in particular, television ads hail them as heroes — so do governments and even toy companies. (Though it should be mentioned that many doctors are being targeted simply for doing their jobs.)

This is a fine sentiment to feel — and accurate, considering how many of us are lucky enough to simply stay home and wait out the pandemic, emerging every evening for a round of appreciative applause. UN Secretary-General António Guterres called the outbreak the biggest challenge for the world since WWII, and COVID-19 has now killed more Americans than the Vietnam War. But the problem with the hero narrative is that not only does it suggest a kind of superhuman ability to overcome traumatic experiences and serious, dangerous shortages of PPE — heroes don’t need N95 masks, after all — it also suggests that the coronavirus was a sudden and unpredictable disaster. When in fact, there are a number of ways this pandemic has been exacerbated by government failures.

“There’s a lot of comparison to 9/11 and the frontline workers being a lot like the first responders,” Okun said. “It’s hard to say because I think in some ways, the medical community understood much sooner and much earlier that this was going to be very bad in a way that maybe us in regular positions were not as able to understand.”

The burden of caring for the sick isn’t true just for emergency room doctors, but rather, everyone who works in or even adjacent to the health care system right now, including therapists. Many are now overrun with patients struggling with the anxiety of quarantine and the fear of living daily life in the face of so many risks and unknown factors. “This can really tap into existential issues, especially when your normal healthy ways of coping are cut out,” Jain said. “We’re seeing it already, calls to mental health crisis lines are up. I was on a call with a colleague this morning who says patients she hasn’t heard from for several months or a year, she’s hearing from them.”

For therapists in particular, the trauma isn’t just going to come from their own lives, but from trying to help other people with their struggles. “We have this term called vicarious traumatization. Just by listening and supporting people that live with trauma and PTSD, you’re absorbing some of their trauma and pain. It’s almost like, hey, part of the job,” Jain said. “Fundamentally, the only way you can combat that is being vigorous about your own self-care.” That self-care, of course, can be tough to maintain in a world where you’re discouraged from going outside, or seeing other people, or getting any kind of physical affection from anyone you’re not living with.

"Just by listening and supporting people that live with trauma and PTSD, you’re absorbing some of their trauma and pain. It’s almost like, hey, part of the job.”

Any way you look at it, a significant part of the population is bound to deal with some form of PTSD after the immediate threats posed by COVID-19 have passed, whatever our new normal may be. Frontline workers will have an even greater hurdle, considering the chaos and crushing loss they have to witness and experience, but there are still measures that can be implemented to make this less of a burden for the people keeping us alive right now.

“I admire this program implemented in London after the 2008 London terrorism bombings,” Jain said. The program used a “screen and treat” approach, identifying people who were traumatized by the bombing, as well as advertising resources to health workers in national and London media. People who called into a dedicated helpline for the crisis were sometimes referred to the screening team if they needed more resources. “The therapists did a nice job doing active outreach to identify people in need versus passively waiting for folks to show up — which many won’t,” she added. Jain said that while health care workers are good at taking care of each other, they’re not “necessarily that good at taking care of their own health.”

But, of course, the other solution requires a total overhaul of what we think the American health care system should be. “I’ve been hearing a lot of chatter about COVID perhaps sparking a fundamental change in American health care, which has become very top heavy and business-focused,” Jain said. “This has contributed to burnout and moral injury in doctors, and workplace attrition. It would be great to see frontline clinicians have a seat at the table.”

Regardless if they’re a frontline worker or if they’re at home waiting for this miserable period in their life to pass, most people will leave this period with some kind of PTSD. The hope, then, is that they can eventually recover. “We do think a lot of people will heal naturally,” Jain said. “This will be an awful time they’ll never forget. But people will heal.”●

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