With coronavirus dominating news cycles for weeks now, it seems difficult ... if not impossible ... to escape the mounting death toll, case load, unemployment figures and economic havoc that COVID-19 has left in its wake. For healthcare providers, first responders and other workers on the front lines, it's far too easy to forget self-care when the focus is so strongly on caring for others. Yet, ignoring warning signals of the physical and emotional toll the pandemic has taken could have far-reaching consequences.
Joshua Morganstein, MD, serves as chair of the American Psychiatric Association (APA) Committee on the Psychiatric Dimensions of Disaster. "The committee's role is to provide education, consultation and resources to APA members, our state-level district branches and leadership," he explained.
Morganstein added the committee's focus has primarily been in response to non-military disasters. However, he noted, some similarities have been drawn between the current global COVID-19 outbreak and the type of stressors and reactions seen in a prolonged conflict. "In a pandemic like this, it's sort of an ongoing disaster," he pointed out. This sense of being at war is particularly true for those fighting the coronavirus on the front lines,
With an infectious disease outbreak, he said adverse psychological and behavioral responses might include difficulty sleeping, feeling unsafe, irritability or anger, distractibility, and increased use of alcohol or other substances as a way of managing. Healthcare workers have additional challenges including increased concerns of exposure for themselves and their families, managing the distress of patients separated from family members, and shortages of staff and equipment.
The best defense, said Morganstein, is a good offense in the form of proactive self-care. He said eating regularly, getting sleep and taking a breather when needed allow people to make better decisions and strengthen the immune system.
"I would really encourage healthcare workers in general to work on ... and encourage each other ... to take care of basic needs," said Morganstein. "I would also encourage having a battle buddy," he continued. Morganstein noted a battle buddy in the military has their friend's back and is more likely to notice early warning signs of struggle, such as increased irritability. "We need people looking out for each other. Battle buddies don't let someone go off a cliff."
Some organizations assign battle buddies and others have team members choose their own support partner. Either option can be effective, Morganstein said. He added the responsibilities are pretty straightforward. Battle buddies check in on each other via text or in person, encourage one another during a tough day and remind one another to take a break.
Morganstein said it's also important to stay informed on current information regarding the pandemic from trusted sources, as accurate information plays an important role in controlling the spread of the disease and can also help alleviate uncertainty to a degree. The caveat, however, is to get the day's information and then step away.
"People want to be encouraged to use media wisely," cautioned Morganstein. "There is a good body of evidence that increasing exposure to disaster-related media in particular increases stress, makes sleep worse, increases people's use of alcohol and results in higher rates of post-traumatic stress and depressive symptoms."
Organizational & Community Support
Organizations play an important role in supporting their workers, noted Morganstein. Citing a 2018 review of social and occupational factors impacting healthcare workers during an infectious disease outbreak (Journal of Occupational and Environmental Medicine, March 2018, S.K. Brooks, PhD, et al.), Morganstein said a number of measures were shown to improve outcomes.
Ensuring people have adequate training in a timely manner and have equipment they understand how to use and that will protect them are the first steps in mitigating stress. Regular communication from the organization and leadership is also critical. Similarly, finding ways to foster collegiality and recognizing the seriousness of the situation but creating positives whenever possible both encourage a sense of camaraderie and help alleviate feelings of aloneness or separation from the larger group. Videos of healthcare workers praying, dancing or singing together that have appeared on social media and broadcast channels are good examples.
Although it won't replace organizational support, Morganstein said there is well documented evidence of the importance of community support, as well. "A feeling of strength among community members is protective," he said, adding the 'community' might be a city, zip code, neighborhood, faith group, military unit or sports team.
"There is no small act of kindness and generosity ... there are only acts of kindness and generosity," he reminded. Whether it's clapping for a healthcare worker, giving to a food bank or waving at a neighbor, receiving and giving kindness is important. "Those things will help our society emerge from this in the most positive way possible," he noted.
The Long View
"Crisis experiences change us and create a new normal," said Morganstein. For some there will be delayed reactions. He noted some people compartmentalize in order to cope and manage in the moment but then have to deal with issues down the road. "To the degree people are able to care for themselves and find support and be able to find outlets to release some of the stress, that can help to reduce the burden they carry forward with them even if it doesn't eliminate it."
Fortunately, Morganstein said, "The vast majority of people, including those who have difficulty along the way, will ultimately do well."
Reaching Out for Help
The healthcare workforce is regularly subjected to high-pressure, highly stressful situations, even prior to the current pandemic. Mental health data shows a higher rate of suicide in physicians than in the general population ... yet many providers do not seek help that is available.
The Medscape National Physician Burnout & Depression Report 2019 found 44 percent of physicians surveyed described themselves as 'burned out' and another 15 percent as either colloquially or clinically depressed. Yet tellingly, 64 percent said they had not sought professional care to address these issues. In the updated 2020 report, which took a generational approach, 61 percent of millennials, 64 percent of generation X and 63 percent of baby boomers said they have not sought professional care for their burnout and/or depression.
In the general U.S. population - where one in five Americans has a behavioral health disorder - the stigma attached to seeking help is beginning to give way under the weight of the sheer pervasiveness of mental health issues and increased acknowledgement of the powerful, effective resources available both to assist in times of acute need and to maintain emotional health. Although some career concerns linger among physicians over seeking help, there is a strong recognition among industry organizations that behavioral health issues must be addressed.
Rather than being seen as a weakness to search out help, there is a growing understanding that recognizing a need and reaching out for assistance is actually a sign of strength. If you would encourage an individual in physical distress to seek help from a clinician, then heed your own advice if experiencing acute emotional distress or ongoing behavioral health issues that have become a cause for concern.
For Connection to Assistance:
Many professional healthcare organizations, including the American Medical Association, have created resources for members experiencing behavioral health challenges. Check your specialty organization or go online to AMA-assn.org for additional information.
While by no means an exhaustive list, other resources for seeking care, include: