COVID-19 Mental Health Tool Kit

In the fight against COVID-19, healthcare professionals are facing extensive pressure due to the patient care they provide but also for concerns for their loved ones. This can be associated with the additional cognitive, emotional and mental health demands being placed on them as a result of the pandemic. They include dealing with fear, anger and denial, sleep problems, depression and anxiety, acute and post-traumatic stress as well as factors related to their profession such as dealing with healthcare worker stigma, mental resilience, special forms of guilt, conflicts around liability, grief and altruism. This guide explains these factors and provides evidence-based methods for coping.

Pandemics require healthcare staff to be flexible in their roles. This may involve working in an unfamiliar surrounding or in clinical areas outside their usual practice. This can be stressful, especially if it involves assuming a clinical leadership role.

It is advisable to read this guide in conjunction with another produced by the same authors titled: Guide for Communities and Patients in Isolation, Quarantine and Their Families and Friends, which also applies to healthcare professionals.

Married healthcare staff report more fear of the outbreak than those who are unmarried or divorced; this is associated with greater family responsibility. Healthcare staff, including nurses, reported feeling torn between family concerns and healthcare obligations. Concerns for the health of oneself or one’s family is higher among healthcare staff who are living with children or the elderly. Consequently, practical support, special counselling and help with child and elderly care may be necessary. 1, 26, 54

Predisposing factors related to post-traumatic stress disorder include past history of trauma including personal and occupational trauma; perceived threat to life or danger during the crisis; cognitive factors such as thoughts of dying, peri-traumatic dissociation; and family psychological history. 3, 4

Staff working with a high level of exposure to patients suffering from a viral outbreak report greater stress and avoidance, a higher level of post-traumatic stress and higher alcohol misuse than those not working with a high level of exposure to patients. 16,17,18,19

Denial and avoidance were associated with poor mental health, especially in doctors and nurses, and developing post-traumatic stress; however, proactive and outfacing coping strategies, problem-solving and humor have all been shown to reduce the effects of trauma. 7, 8

Lack of motivation to work among healthcare staff was found in both quantitative and qualitative studies to be associated with concern for the well-being of their loved ones, especially those with child and elderly care responsibilities. 25, 26 However the most important factor affecting motivation to work was found to be the perception of the importance of the healthcare staff member’s role in the crisis response. 27 Motivation to work was found to increase after training and education. 26

Staff with more direct patient care responsibilities could be at higher risk of experiencing stress. For example, nurses and doctors are more likely to report a high level of stress than those providing healthcare assistance and allied healthcare professionals. Nurses were more likely to show post-traumatic stress than other hospital employees. 12, 13, 14, 15

During crises, healthcare providers may feel a weakened sense of trust within a healthcare facility, lonely, no longer respected, ostracized, strained relationships with other healthcare providers, and fear of Infection as a result of a small mistake, and strained patient-provider relationships. 2

Performing duties during a crisis that are not normally part of someone’s usual responsibility appears to have a negative impact on mental health, especially if the individual assumed a leadership role. 3, 5

Debriefing that focuses on experiences during the crisis should not be part of routine practice as if was found to have a negative effect; however, active monitoring, watchful waiting and cognitive behavioral therapy shortly after trauma are effective strategies, especially when symptoms are significant. 9, 10

Being quarantined as a healthcare provider was associated with a negative impact on mental health, acute stress symptoms and feeling stigmatized with a subsequent reluctance to work and a decline in performance. 20 The impact of precautionary measures on the ability to do one’s job during a crisis appeared to be an independent factor associated with emotional distress. 21

Compassion fatigue is a diminished capacity to show empathy and can happen in situations where a healthcare professional has to deal with a high number of traumatized individuals and where a high level of empathy is required. 29

Vicarious trauma can happen when working with traumatized individuals. It affects the cognitive status of the provider and may change an individual’s ability of perceive and process information. 30

Learning from the SARS outbreak and the following quarantine, about 20% of healthcare staff experienced feelings of stigmatization and rejection in their communities. About 9% reported reluctance to work and considered resigning in the period of quarantine. 51

Furthermore, there is a risk of reduced morale, professional isolation and reluctance to do administrative work, especially if infection control measures require wearing a mask and avoiding unnecessary contact.52

Evidence suggest that stigma resulting in unease and distrust experienced by healthcare professionals is shared among different persons working in a healthcare facility, both clinical and non-clinical staff, even affecting porters working in healthcare facilities. 2

Stigma related to healthcare staff appears to be affected by individuals that were previously very close, including friends, families and colleagues. Consequently, awareness, support and special care are all needed during and for months after a crisis. This may include assigning a mental health professional or services that can work with healthcare staff and assist them with recovery.

The word grief comes from the Latin word “gravis,” which is carrying the burden of a loss. This includes any loss, for example, loss of life, health, freedom, relationships and work. Human grief is a universal and natural response to any kind of significant loss. The normal grief stages for individuals may include denial, anger, bargaining, depression and acceptance. Physician grief, however, is more complex and different. Death of a patient, for instance, is a significant event associated with added stress for physicians. It is an experience that almost all physicians have had. 55, 60

Physicians often experience grief when faced with the death of a patient under their care. Nearly 30% of physicians report personal bereavement after a patient’s death. Physicians in training report the need for more emotional support. Interestingly, less than a quarter found discussing the patient’s death with a senior physician was helpful.  57

Physician grief can be associated with loss, self-doubt, sadness and a feeling of being powerless. Physicians and nursing staff cry; 76% of nurses and 57% of physicians report the primary reason for crying on the job is identification and bonding with the suffering of dying patients and their families. 58, 61

Acknowledging the feeling of loss, didactic preparation, pursuing healthy coping strategies, rest, relaxation, nourishment, sense of security, trust, hope in the future, time spent alone and with others and adequate professional grief support have all been found to be favorable interventions in physician grief. 56, 59

Suppressing physician grief is unnatural. Some patient deaths result in significant emotional reactions that can remain suppressed for decades and erupt suddenly with vivid recollection. Physician grief can be concealed by an awareness of professional responsibilities; consequently, a physician’s own emotional aspects can be suppressed to sustain attention on the technical aspects of the physician’s role. Without education, there is a danger of an anti-emotion culture in medical circles. Physician grief can fluctuate between expressing emotions and suppressing them. This is known as dual process bereavement. 62

The word ‘resilience’ originates in physics as is defined as the property of a material to return to its original shape after being bent or compressed. In psychiatry, mental resilience is one’s ability to recover or adapt from extreme traumatic conditions such as a crisis, pandemic or serious threat. 32 Mental resilience is important for all communities during a crisis but has special importance for healthcare staff.

The terms mental resilience, mental immunity and mental hygiene are often used synonymously. 36 Individuals with mental illness have lower levels of resilience; however, resilience is modifiable and can improve with intervention. 38

Resilience is a dynamic and continuous process that encourages positive adaptations and is closely associated with mental health.  It is an essential component of psychosocial recovery. Resilience is not just about the resistance to traumatic events but also the ability to grow and develop under difficult conditions.  The components of building strong mental resilience involves an understanding of the impact of trauma and the development of positive meaning and internal cohesion between one’s thoughts, emotions, and actions. 37

Social support during and after crises appears to enhance psychological resilience.  Lack of social support is associated with a risk for mental health problems including anxiety, depression and post-traumatic stress disorder. 3, 6

Negative work cultures and poor support from supervisors have been associated with mental health symptoms among healthcare staff exposed to a severe acute respiratory syndrome outbreak. 6 However, protective factors appear to be more important than risk factors in mental resilience. These include establishing a sense of purpose and support provided by families and friends, especially if it is based on shared culture, religion or recreational interests. Extended networks are important for healthcare staff and has been associated with both individual and community resilience. 39

Altruism may help protect healthcare staff against negative mental health. Studies show that altruism provides a buffering effect on the development of post-traumatic stress disorder. 1

As long as it isn’t overwhelming, reasonable altruism, a helpful and kind behavior towards others, has been found to be associated with good physical, mental and moral well-being, and it has been associated with longevity. 50

Evidence from previous outbreaks suggest that exposure to an outbreak at work, being in quarantine or the death or illness of a relative or friend from an outbreak contributes to post-traumatic stress disorder for healthcare staff. However, altruism may help protect healthcare staff against negative mental health impact. Studies suggest that altruism provides a buffering effect on the development of post-traumatic stress disorder. Altruistic acceptance of risk was negatively related to the disorder. 1

There is evidence that peer support interventions designed to develop psychological support within teams are successful in improving the ability of healthcare staff to support their colleagues and in reducing the stigma around mental health. 11

Training and preparedness were found to be protective of mental health and have been associated with an increase in confidence and more positive well-being in trauma-exposed staff. 22, 23

Continuous training and education for clinical and non-clinical healthcare staff about mental health are associated with more understanding and recognition of mental health problems. Positive coping strategies have been associated with enhanced resilience, altruism and reduced stigma and can favorably influence the predisposing factors for developing mental illness. Mental health training programs have been shown to reduce work-related illness and absence from work. Education and training of healthcare managers and leaders about mental health is strongly encouraged. 3

Healthcare staff have a positive impact on life. As a result, they experience positive outcomes such as personal growth, appreciation for life and a sense of achievement; however, there is evidence that healthcare staff are at increased risk of mental health symptoms during a crisis such as the current pandemic. These symptoms include several types of worries, special forms of guilt, lack of motivation, traumatic stress symptoms and stigma among others. There are many effective coping strategies and interventions, which include good social support, kind and extended professional and peer support, cognitive behavioral therapy, practical support, counseling, encouraging reasonable altruism, building mental resilience and continuous mental health training and education for clinical and non-clinical staff.