COVID-19 has taken a tremendous toll on health care workers including doctors, nurses, trainees, students, social workers, and support staff. The trauma and grief of losing patients, the anxiety over potentially exposing family members to the virus, and fears of contracting COVID-19 will likely result in significant mental health consequences. While the full impact will be shown with time, studies on disasters and epidemics suggest that the exposure to suffering, death, and constant stress will lead to post-traumatic stress disorder (PTSD), depression, anxiety, and burnout.
To address this, Mount Sinai has launched the Center for Stress, Resilience, and Personal Growth to provide Mount Sinai staff, faculty, and students with no-cost resilience training, mental health screening, individual coaching, and personalized referrals. Deborah Marin, MD, serves as Director, Jonathan M. DePierro, PhD, serves as Clinical Director, and Craig Katz, MD, serves as Senior Advisor. Below, they discuss the top five things to know about providing psychiatric care to health care workers suffering from mental health issues due to COVID-19.
1. The behavioral health consequences. We have already observed a high level of distress in Mount Sinai’s health care workers—Jonathan Ripp, MD, MPH, Director of Mount Sinai’s Office of Well-Being and Resilience, and his team found that 39 percent of 2,579 workers reported clinically significant symptoms of PTSD, anxiety, and depression. These workers may feel disconnected from a sense of meaning and purpose in their work and personal lives and be excessively self-critical for what they did or did not do during the pandemic. These symptoms can result in “presenteeism” (going to work but not being able to work effectively), absenteeism, irritability, chronic exhaustion, and avoidance of work or work-related issues.
2. How to screen for these conditions. Part of “how to screen” includes “who to screen.” Nurses, nurse practitioners, physicians, and physician assistants have received significant media attention; however, it is clear that support staff are equally if not more affected by the pandemic. An example would be a patient transporter who brings patients to and from diagnostic tests and procedures switching gears to transport hundreds of bodies to the morgue. Our research following 9/11 shows some evidence that these support staff members, who are often members of historically disadvantaged groups, will struggle more with long-term mental health effects due to the pandemic.
When assessing health care workers, important risk factors to consider include pre-pandemic and current social support, level of exposure to pandemic-related human suffering, socioeconomic circumstances, pre-pandemic job burnout, and the presence of secondary stressors following the pandemic, such as job loss or childcare concerns. Patients will often not report a symptom unless asked directly, so it is important to be thorough during screening. The National Center for PTSD maintains a list of common measures of trauma-related symptoms and how to obtain each instrument. The American Psychiatric Association also lists DSM-5-specific measurement tools that can assist in screening. There are also many common self-report screening tools, including the PHQ-9, which indexes depression severity; the PHQ-4, a quick screener for depression and anxiety; and the Primary Care PTSD scale for DSM-5. Many of these tools are available for the public as well, so patients can self-monitor.
3. How to treat these conditions. For PTSD, the gold standard psychotherapies are cognitive-behavioral approaches including cognitive processing therapy and exposure therapy. These interventions involve directly and systematically engaging with traumatic memories and revisiting their meaning in a safe, therapeutic space. There is some evidence that non-trauma focused treatments (such as interpersonal psychotherapy) can be helpful too, particularly for patients who cannot tolerate trauma processing. In addition, paroxetine and sertraline are FDA-approved for PTSD, and VA/DoD clinical practice guidelines indicate that there is “moderate quality” evidence to recommend these as well as fluoxetine and venlafaxine for the monotherapy of PTSD. Some patients may benefit from a combination of evidence-based psychotherapy and medication management with these and possibly other medication classes.
For depression and anxiety, in addition to the range of FDA-approved antidepressants and other medications, cognitive-behavioral therapies, interpersonal psychotherapy, and supportive therapy have a strong and reliable evidence base as first-line treatment or in combination with a medication.
4. How to promote resilience. Resilience can be quick for some people, but for others it might be a slow arc toward recovery and rebuilding their lives. Working with collaborators, researchers at Mount Sinai have identified many behaviors that can enhance resilience following adversity, like that posed by the pandemic. These include individual factors including maintaining an optimistic perspective, building emotional and cognitive flexibility, seeking comfort and connection in spiritual practice, and giving and receiving social support. Further, organizational factors that are important for resilience, particularly in health care workers, include cultivating a sense of belonging, connectedness, and mutual respect in teams.
Let’s take one of these factors, cognitive and emotional flexibility, as an example to explore in more detail. We know that individuals who are resilient are often good at seeing situations from many different perspectives. They can use “cognitive reappraisal” to see a challenging situation or negative thought in more positive or neutral terms. One practical application of this skill is seeing the learning potential and the new colleagues that can come from a changing job role, while also acknowledging the inherent challenges in such a transition. This skill, among others, can be cultivated through individual practice or by speaking to a therapist with expertise in cognitive therapies.
5. What to say to patients. While it is essential to screen and, when needed, treat your patients for COVID-related mental health distress, keep in mind that not everyone is comfortable with formal mental health treatment or can equally access care. It is therefore important to talk with patients about numerous options to promote well-being. These include seeking spiritual or religious support, using a mental health or wellness app, or participating in one or more activities that build social connectedness.
Focusing on strengths can also build a sense of hope and therapeutic connection. One approach from Positive Psychology, known as the positive introduction, involves asking patients to tell you a story about one time they handled a difficult situation in a positive way and were particularly proud of how they navigated it.
Dr. Marin is the George and Marion Sokolik Blumenthal Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, specializing in geriatric psychiatry and Alzheimer’s disease. She also serves as Director of Mount Sinai’s Center for Spirituality and Heath and Director of the Ombuds Office.