For the last few nights, Ilene Wong has woken up troubled by dreams of going into a supermarket and not being able to find anything. Wong, a urologist in private practice in Chester County, knew three months ago that the COVID-19 outbreak in Asia was serious, but seeing the numbers of positive cases rise each day in the Philadelphia region has increased her anxiety.
“We are at the bottom of the curve,” she said. “There’s the anxiety, the anticipation, the feeling of dread knowing that you can see the tsunami coming from miles away, but feeling helpless that you’re not going to be able to protect yourself or your family. It’s really frightening to see the trajectory and raise all these concerns and feel like your voice isn’t being heard.”
Wong has been taking refresher courses on intensive care unit (ICU) procedures, as most of her elective surgeries have been rescheduled and hospitals where she has privileges have called for volunteers to help with the expected surge in coronavirus patients. Wong is facing economic stress as well — revenue at her practice is down from 50% to 70%, she estimates.
Health-care workers already deal with disproportionately high rates of depression — about three times higher than the general public. But the strain of treating coronavirus patients, and the impossible decisions many doctors and nurses are being forced to make, will likely worsen their mental health, experts say.
According to a study published in JAMA Network Open this week, health-care workers in China reported experiencing declining mental health as a result of treating patients with COVID-19. The study measured 1,257 responses to surveys and found that approximately 50% of participants experienced depressive symptoms; 45% experienced anxiety; 34% experienced insomnia; and 72% experienced distress.
Health-care workers based in Wuhan, the epicenter of the pandemic, reported the most severe symptoms across all categories. Nurses and women reported more severe symptoms than others, possibly because they have the highest risk of infection due to their “close, frequent contact” with patients. Reasons for these outcomes included loss of control, concern about their own health, supply shortages, spread of virus, health of family members and others, changes in work, and isolation.
‘An ethical and moral violation’
Even in normal times, doctors have the highest suicide rate of all professions, according to a 2018 review.
“This is not easy work at baseline,” said Pamela Wible, a family physician based in Oregon who runs a suicide prevention hotline for doctors and medical students. “You have a group of people who are exposed to a lot of trauma, and that’s a lot of pressure.”
But in the midst of the coronavirus pandemic, long hours and shortages of personal protective equipment (PPE) have left doctors feeling desperate and unprepared.
“From the very beginning, you have doctors saying, ‘This is not right, this is not the way we want to do this, we can’t take care of people the way we want to,’” said Allen Miller, program director at the Beck Institute for Cognitive Behavioral Therapy in Bala Cynwyd. “That’s an ethical and moral violation of the way doctors think, the values they have, and it challenges what they think it means to do a good job.”
Miller said that for most physicians, to do a good job is to be able to take care of patients the best they can. Not being able to do that because they are overworked and lacking resources causes stress and can lead to depression, he said.
And the way that patients are dying from COVID-19 is “quite different,” Miller said.
“They’re dying while isolated, alone, begging and pleading with professionals to pass on messages to their families,” Miller said. Health-care workers "have to make tough choices, and there’s no visible endpoint to this. They can’t help everybody, and so the repeated feedback from their environment is that they’re not doing a good job.”
How to support health-care workers
Many physicians and nurses are also worried about bringing the virus home to their families. Some are immunocompromised themselves, Wible said.
“Physicians are completing their wills, letting their friends know they want to be cremated,” she said. “This is a group of people who were already exposed to an immense amount of trauma with no mental-health care, working the equivalent of two full-time jobs ... and they’re now having their life placed at risk of an infectious disease.”
Due to shelter-in-place orders, doctors are also unable to wind down and process what they’ve seen in ways that they may be used to, such as going out for a drink with a colleague, Miller said.
“Worlds are getting very small,” he said. “Physicians are cut off from their support networks, and that’s when you get a vicious cycle of depression and anxiety playing off each other.”
But there are ways for people to help, Miller said. Donations of PPE are greatly needed, because those resources can make health-care workers feel safe when working in high-risk situations. But even kind messages that acknowledge the sacrifices physicians are making to keep people healthy are appreciated.
“Those are things that come pretty inexpensively,” Miller said. “Yet it’s not something that’s done at sufficient volume.”
Wong said that one of the most encouraging things that people can do for doctors is to “just stay home, so [we] know our sacrifice is not in vain.”
“Don’t contribute to the problem,” she said. “And continue to educate the skeptics out there, because that empowers doctors with the feeling that what they’re doing is worth it. Doctors are used to making sacrifices physically and emotionally, but it’s devastating to go on social media and see people who are elevating fake news. If doctors feel that people are ungrateful for what they’re doing, more and more of them are going to feel like it’s not worth that sacrifice anymore.”