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The mental health of doctors during the COVID-19 pandemic

Published online by Cambridge University Press:  28 April 2020

Niall Galbraith*
Affiliation:
Department of Psychology, University of Wolverhampton, UK
David Boyda
Affiliation:
Department of Psychology, University of Wolverhampton, UK
Danielle McFeeters
Affiliation:
Department of Psychology, University of Wolverhampton, UK
Tariq Hassan
Affiliation:
Department of Psychiatry, Queen's University, Providence Care Hospital, Kingston, Ontario, Canada
*
Correspondence to Niall Galbraith (n.galbraith@wlv.ac.uk)
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Summary

Doctors experience high levels of work stress even under normal circumstances, but many would be reluctant to disclose mental health difficulties or seek help for them, with stigma an often-cited reason. The coronavirus disease 2019 (COVID-19) crisis places additional pressure on doctors and on the healthcare system in general and research shows that such pressure brings a greater risk of psychological distress for doctors. For this reason, we argue that the authorities and healthcare executives must show strong leadership and support for doctors and their families during the COVID-19 outbreak and call for efforts to reduce mental health stigma in clinical workplaces. This can be facilitated by deliberately adding ‘healthcare staff mental health support process’ as an ongoing agenda item to high-level management planning meetings.

Type
Special Article
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © The Authors 2020

Research has consistently shown that the healthcare professions experience higher levels of work stress than the general population, even under normal circumstances,Reference Aiken, Clarke, Sloane, Sochalski and Silber1,Reference Caplan2 and stress in doctors is associated with both physicalReference Buddeberg-Fischer, Klaghofer, Stamm, Siegrist and Buddeberg3 and mental health problems.Reference Coomber, Todd, Park, Baxter, Firth-Cozens and Shore4,Reference Rogers, Creed and Searle5 Healthcare professionals also have a higher likelihood of suicidality relative to other occupational groups,Reference Schernhammer and Colditz6,Reference Lindeman, Läärä, Hakko and Lönnqvist7 and work-related stress is a common factor in those who complete suicide.Reference Kõlves and De Leo8,Reference Brooks, Gendel, Early and Gundersen9

Studies have also shown that many doctors find it difficult to tell their colleagues or employers about their mental health difficulties.Reference Hassan, Ahmed, White and Galbraith10 The most commonly cited reasons are perceived stigma and anticipated damage to future career prospects.Reference Hassan, Sikander, Mazhar, Munshi, Galbraith and Groll11Reference White, Shiralkar, Hassan, Galbraith and Callaghan13 Suicidal ideation in doctors can present particularly strong fears of stigmatisation.Reference Gerada14 Such concerns may be underpinned by feelings of shame and professional failure, and associated worries about fitness to practise and licence restrictions.Reference Shanafelt, Balch, Dyrbye, Bechamps, Russell and Satele15Reference Hampton17

Not only do doctors find it difficult to share mental health concerns with colleagues, they are also often reluctant to get professional help. Research shows that many doctors would rather seek help from friends and family than look for psychological/psychiatric consultation.Reference Hassan, Sikander, Mazhar, Munshi, Galbraith and Groll11 Again, the same worries about career prospects and stigma underpin these preferences. Furthermore, there is evidence that many doctors are even reluctant to disclose mental health problems to their friends and family.Reference Henderson, Brooks, del Busso, Chalder, Harvey and Hotopf18

The mental health challenges faced by doctors during the COVID-19 crisis

During acute health crises, healthcare services are placed under excess pressure, making working life even more stressful than normal.Reference Tam CW, Pang, Lam and Chiu19 In a pandemic, the number of patients requiring treatment increases significantly, placing strain on healthcare resources and on personnel alike. Additionally, doctors perceive a greater risk to self owing to their exposure to the patients who are most poorly – adding further stress.Reference Shiao, Koh, Lo, Lim and Guo20,Reference Chen, Lee, Barr, Lin, Goh and Lee21 Compounding this stress is the shortage of personal protective equipment (PPE) that can arise during a pandemic.Reference Devnani22 The perceived risk of infection is warranted: a meta-analysis of the occupational risk from the 2009 swine flu pandemic (influenza A (H1N1)) reports that the odds of healthcare personnel contracting the virus were twice those of comparison groups.Reference Lietz, Westermann, Nienhaus and Schablon23 This heightened risk for doctors and nurses might be due to their greater exposure to the respiratory secretions of patients.Reference Bhadelia, Sonti, McCarthy, Vorenkamp, Jia and Saiman24

A further stressor is the increased risk of infection for the families of healthcare professionals on the front line.Reference Wong, Yau, Chan, Kwong, Ho and Lau25 Data from the 2009 swine flu pandemic shows that 20% of doctors and nurses with symptoms reported symptoms in at least one of their family members.Reference Choi, Chung, Jeon and Lee26 One way for front-line doctors to mitigate infection risk to their families is through social distancing. However, although the protective benefits of social contact and support at times of stress are well demonstrated,Reference Ma, Qiao, Qu, Wang, Huang and Cheng27 social distancing deprives the individual of a crucial buffer against mental health difficulties precisely when they are at greater risk of stress.Reference Huremović and Huremović28

Research from previous epidemics/pandemics (such as the SARS outbreak from 2003, the MERS epidemic from 2012 or Ebola outbreaks in West Africa) shows that healthcare professionals can experience a broad range of psychological morbidities, including trauma,Reference Styra, Hawryluck, Robinson, Kasapinovic, Fones and Gold29,Reference Sim, Chong, Chan and Soon30 which might endure for many months after the outbreak.Reference Maunder, Lancee, Balderson, Bennett, Borgundvaag and Evans31,Reference Su, Lien, Yang, Su, Wang and Tsai32 The relationship between traumatic life events and suicide is well documentedReference McFeeters, Boyda and Siobhan33 and trauma from disaster events can increase suicidal ideation in emergency workers.Reference Stanley, Hom and Joiner34 Fears over risk to health and social isolation contribute to psychological distress,Reference Maunder, Lancee, Rourke, Hunter, Goldbloom and Balderson35 as do perceptions of ‘infection stigma’ from the community.Reference Bai, Lin, Lin, Chen, Chue and Chou36 However, the negative effects on mental health can be found in doctors irrespective of whether or not they worked directly with infected patients.Reference Um, Kim, Lee and Lee37 Although the strains of front-line healthcare during an infectious outbreak can lead to sickness absence and higher staff turn-over,Reference Shiao, Koh, Lo, Lim and Guo20,Reference Goulia, Mantas, Dimitroula, Mantis and Hyphantis38 most evidence suggests that doctors and nurses feel a strong professional obligation to continue working in spite of the danger.Reference Wong, Wong, Lee, Cheung and Griffiths39,Reference Khalid, Khalid, Qabajah, Barnard and Qushmaq40 However, given the pressures of needing to maintain high-quality healthcare provision during a pandemic, combined with doctors’ reluctance to seek help or disclose their difficulties, it is possible that this kind of professional commitment might relate strongly to presenteeism. Indeed, a recent review reported that physicians were at the highest risk of ‘infectious illness presenteeism’ when compared with a range of other occupational groups.Reference Webster, Liu, Karimullina, Hall, Amlôt and Rubin41

Having to balance their own safety with the needs of patients, family and employers and in the face of limited resources can lead to distressing ethical dilemmas for doctors and, potentially, to moral injury. Moral injury can arise when one feels compelled to make decisions that conflict with one's ethical or moral values.Reference Litz, Stein, Delaney, Lebowitz, Nash and Silva42 The effect of moral injury on subsequent mental health can depend on the quality of support provided to employees during and after such events.Reference Greenberg, Docherty, Gnanapragasam and Wessely43

Managing doctors’ stress at the organisational level during the outbreak

There is evidence that employer support for healthcare professionals during pandemics and disaster management can be very protective. Such support should include safeguards such as care for those doctors and nurses who become ill, in addition to medical and financial support for their families and protection from malpractice threat. Healthcare professionals’ motivation and morale are significantly improved when they perceive that their efforts are recognised and reciprocated by employers and authorities in these ways.Reference Damery, Draper, Wilson, Greenfield, Ives and Parry44,Reference Imai, Matsuishi, Ito, Mouri, Kitamura and Akimoto45 An important part of this support is the perceived efficacy of the training and personal protective equipment that healthcare professionals receive as well as the general quality of organisational leadership and communication.Reference Devnani22,Reference Aiello, Young-Eun Khayeri, Raja, Peladeau, Romano and Leszcz46,Reference Cates, Gomes, Krasilovsky, Hewlitt and Murthy47 These factors are important not just for motivation – they are also associated with better psychological outcomes in healthcare professionals on the front line during epidemics.

There are also many ways to tackle mental health stigma in the workplace. The foundation for this is creating a culture that encourages open communication and seeks to reduce the stigmatisation of psychological vulnerability.Reference Halpern, Gurevich, Schwartz and Brazeau48 This may include devising activities that challenge unhelpful attitudes and that instead promote desired values, as well as expanding knowledge and encouraging positive behavioural change.Reference Hanisch, Twomey, Szeto, Birner, Nowak and Sabariego49 The anti-stigma project Time to Change,Reference Henderson and Thornicroft50 provides a suite of simple interventions for implementation in the workplace.51 Elsewhere there is good evidence for peer support training in health crises or disaster management. One example is the Trauma Risk Management programme (TRiM), where non-clinical personnel are trained to assess peers following traumatic events and provide short-term support or access to professional care if required. Mental Health First Aid (MHFA) operates on a similar model and both it and TRiM can be effective in reducing mental health stigma in the workplace.Reference Imai, Matsuishi, Ito, Mouri, Kitamura and Akimoto45,Reference Cates, Gomes, Krasilovsky, Hewlitt and Murthy47

Stress management at the individual level

There is evidence that psychological interventions for work stress can be effective in healthcare professionals.Reference Ruotsalainen, Verbeek, Mariné and Serra52 Recent reviews attest to the effectiveness of mindfulness-based interventions for work stress and suicide ideation;Reference Burton, Burgess, Dean, Koutsopoulou and Hugh-Jones53Reference Williams, Duggan, Crane and Fennell57 mindfulness-based interventions also have a sound theoretical basis.Reference Hayes58,Reference Kabat-Zinn59 Mindfulness skills are particularly suited to high-stress work settings, in that they can be practised privately or in groups, in almost any environment and can be conducted as briefly as time permits. Negative automatic cognitions are a key trigger in stress reactions.Reference Feldman, Greeson and Senville60 Mindfulness interventions encourage us to ‘notice’ our thoughts and to view them as objective events that happen to us. This enables us to objectify our own negative thoughts, gaining a new perspective on how those thoughts influence our emotions and behaviour and enabling better management of the distress that would normally accompany them. The effectiveness of online mindfulness courses also has a good evidence base.Reference Spijkerman, Pots and Bohlmeijer61

Conclusions

Healthcare executives and managers should be aware of the potential for the COVID-19 outbreak to elevate the risk of psychological distress and suicidal ideation in doctors. The literature shows that, although healthcare professionals place high value on provision of training and equipment during such pandemics, effective leadership and managerial support for clinicians and their families are also highly protective against negative psychological outcomes. One of us (T.H.) is involved in setting up a support network of psychiatrists with the sole aim of supporting all physicians during this unprecedented event. Managers and clinicians might also remember that many doctors are reluctant to reveal their difficulties even when experiencing significant psychological distress. Workplace interventions that reduce mental health stigma and promote sharing and support for colleagues with psychological difficulties might improve help-seeking behaviour and attitudes. Mindfulness practice has versatility and a strong evidence base in workplace stress reduction and is therefore a viable technique for groups or individual clinicians to manage stress during the COVID-19 outbreak.

About the authors

Niall Galbraith, Reader in Health Psychology, Department of Psychology, University of Wolverhampton, UK. David Boyda, Senior Lecturer in Psychology, Department of Psychology, University of Wolverhampton, UK. Danielle McFeeters, Senior Lecturer in Psychology, Department of Psychology, University of Wolverhampton, UK. Tariq Hassan, Associate Professor, Department of Psychiatry, Queen's University, Providence Care Hospital, Kingston, Ontario, Canada.

Author contributions

All authors contributed to the design, analysis of literature, writing and revision of the article.

Declaration of interest

None.

ICMJE forms are in the supplementary material, available online at https://doi.org/10.1192/bjb.2020.44.

Footnotes

*

A video abstract for this article is available at https://vimeo.com/bjpsych/bjb-2020-44.

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