Gabriel Perna | May 26, 2020
“I hope they don’t forget about us when this is past.”
That’s what an ICU nurse told Yale New Haven Health CEO Marna Borgstrom and other executives when they were talking about the support and generosity of the community during the COVID-19 pandemic.
For frontline providers who have dealt—and will continue to deal with—packed-to-the-brim ICUs and way-too-high patient death rates, experts say the mental health toll of this pandemic will linger for a while.
“They have seen things. They have been the only source of support for a lot of people who have drawn their last breath. This will impact health care workers for a long time,” Borgstrom said.
A study from researchers in China, published in JAMA Network Open, found that of 1,300 health care workers surveyed from the frontlines of the COVID-19 pandemic in Wuhan, more than half reported symptoms of depression, 45% reported symptoms of anxiety, 72% reported symptoms of distress and 34% reported insomnia. Those on the frontlines reported more severe degrees of all measurements of mental health symptoms than other workers, the researchers found.
“Essential and frontline workers are making an impossible choice every day, risking their health and their family’s health. Saving lives. Keeping society afloat. They are making such a tremendous sacrifice for our communities. I expect many of them will experience higher rates of depression, anxiety and post-traumatic syndrome disorder (PTSD),” says Renee Schneider, the vice president of clinical quality at Lyra Health and a clinical psychologist.
Many health care organizations are taking this problem head on, trying to tackle it before the mental health issues grow worse. When it comes to providing mental health support for frontline providers, experts shared a few areas to get started.
Focus on enabling resiliency
COVID-19 will have a mental health impact on everyone. But for those providing the care, it’s going to be a tough hill to climb.
“They are seeing much more death than they expected, dealing with the anxiety of virus exposure and may have separated themselves from their families,” says Deborah Marin, MD, Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai Health System in New York City.
Marin also predicts many frontline providers from the COVID-19 pandemic will suffer from PTSD. In NYC, the epicenter of the coronavirus in the U.S., two emergency workers committed suicide in April, including the medical director of the emergency department at NewYork-Presbyterian Allen Hospital.
These mental health concerns have prompted Marin’s Mount Sinai to open a Center for Stress, Resilience and Personal Growth. She says the center will focus on early interventions, screening for depression symptoms and resiliency training. Mt Sinai specializes in resiliency and post-disaster intervention through its 9/11 first responder monitoring and treatment services. Based on what the health system has learned in that program, it estimates 25 to 40 percent of first responders and health care workers will experience PTSD as a result of COVID-19.
“We will be having classes to improve methodologies to improve one’s resilience,” Marin says. “There are lots of behavioral and mindfulness techniques that can be used —writing down affirmations, focusing on spirituality. It’s all work from Dennis Charney, MD, the Dean of Mount Sinai Medical School and what they know are resilience building factors.”
Michael Goldberg, the president of Child & Family Psychological Services, a private outpatient behavioral health provider in Massachusetts, is working with Atrius Health and other frontline providers on resiliency training of its own. Goldberg says the “Provider Resiliency Program” includes evidence-based practices, using Albert Roberts’ Seven-Stage Crisis Intervention Model to guide trauma response. He says he is making the resource free for every behavioral health provider in Massachusetts.
Establish a systematic approach
Patrice Harris, MD, President of the American Medical Association (AMA), advises health care organizations to take a systematic approach to becoming a resilient organization and proactively caring for the mental health problems of frontline providers. She says a systematic approach means the onus isn’t on individuals.
“Self-care is important, but we think institutions and organizations need to put systematic solutions in place. This COVID-19 pandemic is occurring on top of a crisis we had pre COVID-19 regarding physician burnout. If you have this pandemic, which is a crisis on top of a pre-existing crisis, that exacerbates the issue. We want frontline clinicians to feel supported within their institutions,” Harris says.
Health care leaders, she says, can use surveys and workgroups to understand the specific problems frontline providers are having within their organization. Once they have that data in hand, they can develop the proper resources to address those issues. Goldberg is taking the systematic approach a step further. His organization is developing a system wide measurement method to track outcomes rather than relying on patients to self-report their progress.
Marna Borgstrom, Yale New Haven Health
Increase access to care delivery services
Schneider says that another way to approach this issue is by increasing access to mental health providers. “No one wants to call around to a dozen or so providers to find out who has availability and can treat their particular problem they are experiencing. It’s important for CEOs to look at the solutions they’re offering and make sure they are increasing access, rather than serving as a barrier to access,” she says.
Glen Tullman, CEO of Livongo, a digital health company, says technology enables people to get help when they need it. It can also be used to address the reality of the country’s mental health provider shortage—according to one report, mental health demand is set to outstrip supply as soon as 2025.
“The idea that anyone can make an appointment to see a psychiatrist or psychologist…there aren’t enough of them out there. In the new world, we’re going to have to use digital health,” Tullman says. From the six months between September 2019 and March 2020, Livongo saw a 140 percent increase in usage of its behavioral health digital programs, he notes.
Goldberg also advocates for the usage of telehealth and virtual care. “One of the reasons people don’t go for behavioral health is they have to drive to an office, park, go in and drive home. Telehealth is more convenient, more flexible and more accessible,” he says.
Create a cultural in which frontline workers can seek help
Schneider advises CEOs to foster a culture where it’s acceptable and safe for clinicians to have mental health problems and it’s courageous to seek help. She says they can do their part by sharing their own stories and setting an example for everyone within the organization. “That really serves to normalize the problem of having a mental health problem,” she notes.
One roadblock, experts say, is that physicians and clinicians in general tend to have a self-reliant mentality and don’t always find the need to address these issues. “Medical professionals as a whole are likely to avoid behavioral health services. They tend to be people who thrive in a crisis and a challenge. They’re more likely to care for others than themselves and less likely to seek mental health support,” Goldberg says.
Matt Lambert, MD, CMO of Curation Health, has worked in an emergency room for 23 years. He says there is a terrible paradox in health care around providers seeking help.
“The first thing they do when you tell someone you’re thinking of hurting yourself or self-medicating with opioids is take away your clinical privileges. I can’t think of any stressful situation that will be improved by adding financial stress,” Lambert says. “This is why so many things go unreported. The first time you show vulnerability, they cut your work and cut your pay.”
Lambert suggests that CEOs and other top executives work to change both corporate culture and regulations so providers seeking help can continue to earn a living while receiving that care.
Appoint an executive to inform frontline workers
Harris says that organizations should have a Chief Wellness Officer or an executive in human resources who can drive any of the systematic changes and initiatives required to address mental health.
“You may need to appoint a team with input from frontline providers on potential solutions. After getting their input, you need to figure out the plan of action,” she says.
Often, anxieties around COVID-19 are around a lack of personal protective equipment (PPE). Other times it comes from exposing risks to their family, being able to find childcare while working or even transportation and parking concerns. A point person can be effective in helping clinicians know where they can turn to address these anxieties.
In general, Marin says HR and key stakeholders within an organization should be educated on the long-term mental health impact this pandemic could impose on providers.
“Getting the HR folks and employee health services up to speed on what the symptoms are so they can at least identify them is important. What if an employee isn’t performing well and needs coaching? Are they not performing well or developing mental health problems because of this? Everyone has to learn about this and get educated,” she says.