In the midst of this global pandemic, people are talking about the urgent and critical need for personal protective equipment. They are sharing concerns about the impending lack of respirators and the need for testing. And they are encouraging people to #flattenthecurve through social distancing. But no one is talking about a potential mental health crisis facing health care workers on the frontlines of this pandemic.

To an outside observer, health care workers look strong and resilient in the face of the unknown. They inspire us as they go to work every day, at great personal risk, to keep others safe.

But, as a psychiatrist, I spend much of my life observing and listening — I know that their calm surface appearance is the only armor they have left. Underneath it, many health care workers are barely keeping it together. They are anxious and they are afraid. They aren’t sleeping and they find themselves crying more than usual. The overall feeling in my friends, family, and co-workers is one of an impending doom and an existing gloom that is both physically and psychologically palpable.

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We also know it is only the beginning. As such, it is my duty to sound the alarm and try to protect their mental health — before it is too late.

In truth, personal protective equipment is critical to protecting health care professionals’ physical and mental well-being. Without this protection, they worry that they will get sick and infect others. Given that 20 of the 44 cases in Philadelphia are health care workers, this is a reasonable fear to have. The risk of infection, especially if it is asymptomatic, instills fear of spreading the virus to their patients and families.

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To lower this risk, many health care workers have decided to socially isolate themselves. Some have chosen to have their at-risk family members spend time with relatives away from them and others have isolated themselves, even within their own homes. This significant disruption in social support — in the name of helping and protecting others — could go on for months. It is also quite lonely.

These fears are further magnified when being quarantined because of a positive Covid-19 test. We know from studies during the SARS epidemic that quarantine has a serious effect on the mental health of health care workers. It predicted symptoms of acute stress disorder, depression, and alcohol abuse. Even three years later, quarantine was associated with post-traumatic stress symptoms, which were, again, more severe in health care workers. As a result, many experienced avoidance behaviors and sought to minimize contact with patients. Some didn’t report back to work at all.

Health care workers are also concerned they might die from Covid-19. This could seem like an irrational fear, but frontline health care workers have died in China and Italy and in the United States — and this will only increase. Knowing this, some health care workers have begun drafting living wills.

Some health care workers are using words like betrayal and coercion and moral injury to describe this experience. They feel betrayed by their employers, the health care system, and the government, all of which were woefully unprepared for a pandemic and then chose to ignore their warnings. Some are concerned they will be called upon to do work they have not done in years due to staffing needs. Even still, others are grieving the traumas they will see and the decisions they will be forced to make. Some have said even they will simply not come to work and would rather quit medicine all together.

These choices are not easy to make — between protecting oneself and one’s family and doing one’s job — on top of the life-or-death decisions they may be forced to make due to limited resources. It is no wonder they are not sleeping, are anxious, or afraid. It is no wonder that the preliminary research on coronavirus in China showcases high rates of mental health issues, including depression, anxiety, insomnia, and distress, which are much higher in nurses, women, and those on the front line.

To support health care workers, experts need to intervene to help protect their mental health, not just their physical health. This was done in China and we should follow their lead. Some universities, like UNC Chapel Hill and the University of California, San Francisco, have been leaders in this effort, deploying their psychiatric workforce as volunteers. These approaches are comprehensive and multifaceted. They consider the need for preventive measures (stress reduction, mindfulness, and educational materials), in-the-moment measures (hotlines, crisis support), and treatment (telepsychiatry for therapy, and medication if needed). They also acknowledge that mental health treatment is not just something that happens urgently or in crisis, but rather is something that needs to continue and be available long into the future.

These changes cannot happen overnight. Our mental health system is deeply flawed and understaffed and is in no way prepared to manage the onslaught of mental health issues in health care providers and the citizenry in general after such a mass tragedy. We must think about ways to prevent mental health from deteriorating while also coming up with innovative ways to target at risk groups, particularly health care workers. My friends and family, and the people who are saving lives, cannot afford for us to wait. They could die from the virus, or even from suicide. Mental health cannot be an afterthought in coping with a pandemic.

It took far too long for us to start talking about how to protect health care workers physically. Let’s talk about mental health now — and do better this time.

Jessica Gold, M.D., is an assistant professor of psychiatry at Washington University in St. Louis.

  • I agree with Michael Sharpe. All the very valid concerns Dr. Gold brings up require our attention — but it doesn’t have to be from a phalanx of psychiatrists.

    Psychological support under severe stress and trauma can also come from friends, family, and neighbors. Those who know us well often best know our signs of distress and how to respond to us.

  • In every cizilized country, health systems should exist – or be built pronto – to take care of the psychological health of those who take care of all of us at such excruciating cost to their own well-being. This type of health care is performed by a totally different contingent of specialized doctors and health care workers. So all I could say at this time when the need for that help is very clear : this contingent has to step up to the plate, right away.

  • I’m a registered Associate Marriage and Family Therapist in CA and am searching for a way to volunteer my time to first responders or people suffering from the isolation . If anyone knows where can you please share. Thank you.
    Jaclyn

    • Jacklyn
      Those on the frontlines need all the help they can get. Hopefully, we can learn how to work together in order to scale Mental Healthcare in order to address this!!!

  • I am an RN, and right now I feel like I can barely hold it together. Thank you for your thoughtful article. So many are hurting and aching, I know we all are. I keep thinking I’m in a nightmare that I can’t wake up from.

  • Having spent 40 years working in health systems in crisis around the world, I have experienced repetitive PTSD from making severe rationing decisions while running a hospital in 1970s Central African Republic to reopening a hospital closed by staff and management deaths during the Ebola Crisis in Liberia 2014-15. In recovering from the worst PTSD from rationing care when I had to withhold care from the dying (when supplies were insufficient) to dealing with refugee kids dying from freezing or being burned to death in tents heated by burning tires and plastic water bottles in Afghanistan, I learned long-term recovery and acute mitigation techniques that I have been trying to pass along during COVID 19. If anyone is in a position to use these strategies or pass them along to where they are needed, please let me know. greg@health-mgt.com. Please don’t let my experience go to waste.

  • Appreciate this cautionary article. First responders and health care workers will need a “Bill of Rights” so that they can respond to irrational expectations placed on them by employers, which are detrimental to their physical and mental health and well-being

  • There is no doubt that many of those working in the hot spots will have PTSD / mental health issues given the conditions they are working under, the decisions they are forced to make, and seeing people die in what can be a horrible manner. Even the strongest person can only take so much….

    • well… unfortunately, as one of frontline workers in China, I dont have time for worrying…
      I am either on my shift or on the way to my shift. No weekends and the only dayoff is the day after ur night shift.
      furthermore, lab wokers are undertreated with lower respect and lower benefits.

  • The issues described by Dr Gold are important and well described.

    But we do need to strike a balance between doing the right things for health care staff (which is mostly about teams, leadership, PPE and rest) on the one hand and overmarketing the message of the ‘mental health business’ that we are all fragile and all need counseling on the other.

    Most health care staff are resilient and will cope. We must acknowledge that it is normal to be upset in these circumstances. Let’s not oversell potentially infantilizing ‘mental health’ care. Rather let us make sure that we celebrate the resourcefulness, commitment and resilience of those dedicated people who are devoting themselves to caring for the sick.

    Michael Sharpe MD
    Oxford, UK

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