Although epicenters like New York have started to see a decline in cases, the coronavirus pandemic has not gone away; cases are continuing to increase in states across the country. Meanwhile, much of what has been seen or experienced during this first wave of COVID-19 cannot be readily unseen or forgotten. And given what we know about disaster-related post-traumatic stress disorder, the mental health aftermath of this pandemic may devolve into its own version of a crisis.
At the end of April, Lorna Breen, an emergency room doctor at NewYork-Presbyterian Allen Hospital, died from self-inflicted injuries. But though her death certificate will not officially list the coronavirus as the cause of death, "she’s a casualty just as much as anyone else who has died,” her father said.
Given what we know about disaster-related PTSD, this mental health aftermath of the pandemic may devolve into its own version of a crisis.
Breen had been treating COVID-19 patients for weeks in one of New York City’s overrun emergency rooms before contracting the infection herself. Though she took a week and a half off to recover, Breen did not convalesce physically or mentally. After returning home to Virginia at the behest of family, Breen, who had no history of mental illness, died by suicide shortly after a hospitalization for exhaustion.
Earlier that same week, John Mondello, a 23-year-old Bronx EMT who had been on the job for less than three months, died from a self-inflicted gunshot wound. Described by a friend as “always very peppy, very happy,” the fledgling EMT was working in the city’s busiest emergency areas. “He told me he was experiencing a lot of anxiety witnessing a lot of death. He’d feel it was a heavy experience when he’d fail to save a life,” said friend Al Javier.
The stories of Breen and Mondelo did not unfold in a vacuum. Though, as physician Dhruv Khullar wrote in the New Yorker, “adrenaline, duty, and fear have motivated an impassioned response” from front-line health care workers, the sustained deluge of morbidity and mortality wrought by the coronavirus has caused psychological trauma and moral injury to many of them.
There is trouble in anointing health care workers heroes. Heroic acts become expected of them and the traumatization endured is seen as part of the self-sacrifice. The pain and fear of those on the medical front lines are thus lost in the 7 p.m. cheers. As Dahlia Lithwick observes in Slate, “The cost of being a hero today is that in return you are meant to accept your halo and wings and then die quietly.”
But underneath all the PPE (personal protective equipment), these health care heroes are suffering. As scores of them work extended hours to provide care daily for suffering patients, they also harbored fears about their personal health and the health of their colleagues and families. This psychological distress is compounded by co-workers who become critically ill or die.
Celia Marcos was a nurse in Los Angeles. When a patient with COVID-19 stopped breathing, she rushed to him despite only wearing a thin surgical mask. She soon tested positive for the virus and died 14 days later. “What we've been dealing with has been absolutely, incredibly emotionally hard for us," Devika Wijesinghe, a Los Angeles hospice nurse, told Fox 11.
And there are deep scars that form each time a nurse or doctor comforts a dying patient who is all alone in the end.
Michelle Au, an anesthesiologist in Atlanta, refers to herself as being “radioactive” after intubating COVID-19 patients and perpetually worries about the “invisible risks that trail you” after a patient encounter. While some physicians are writing their wills, others are living in isolation from their families. At the same time, many doctors have been thrust into unfamiliar clinical roles to fill shortages.
This is in addition to the dire shortages of PPE that left those on the front lines highly vulnerable to coronavirus exposure and to the lack of medical devices (ventilators) needed to keep the severely ill alive.
A survey of 1,257 health care workers across 34 hospitals in China found that 72 percent had experienced symptoms of distress by the early part of February.
Some early data from pandemic hotspots highlights a concerning pattern. A survey of 1,257 health care workers across 34 hospitals in China found that 72 percent had experienced symptoms of distress by the early part of February. Half of respondents reported depression and anxiety while slightly more than one-third noted insomnia.
Similar findings were observed in a study of 1,379 health care workers in Italy. Half of the participants self-reported PTSD symptoms. Severe depression or anxiety was described by 20 percent of those surveyed.
And though this pandemic is nascent and long-term data on mental health is not yet available, the 2003 SARS epidemic offers clues. A follow-up study of 549 hospital employees who were exposed to the epidemic in Beijing revealed that moderate to severe depressive symptoms persisted three years later in 23 percent. A similar study done two years after the epidemic abated in Toronto showed that health care workers there had appreciably higher than normal levels of psychological distress, burnout and post-traumatic stress.
Even before this current pandemic, burnout was already significant among U.S. doctors and nurses. It has pushed doctors to commit suicide at double the rate of the general population. Worryingly, they are loath to seek help for any underlying mental health disorders due to the stigma, insufficient time and concerns that any frank admission may affect their ability to procure a medical license.
Given these pre-existing psychological vulnerabilities, the virulence of all this newfound fear, anxiety and depression on the medical front lines cannot be understated. As Andrew Schwehm, a clinical psychologist and PTSD specialist at Bellevue Hospital in New York City told me in an email: “During COVID, we have a more complex form of trauma in that the event continues to happen potentially daily, especially for health care workers. After exposure to trauma, our brain is trying to make sense of what's happening. This is a potentially critical moment. If these emotions and trauma-related memories are left unprocessed, they may come back around.”
We have seen this happen before. During the Ebola outbreak, doctors lost colleagues, ignored their grief and emotions and lacked support systems because of self-quarantine.
We have seen this happen before. During the Ebola outbreak, doctors lost colleagues, ignored their grief and emotions and lacked support systems because of self-quarantine. In the aftermath of 9/11, disaster responders were most scarred by exposure to death and human remains. And post-Hurricane Katrina, it was found that the psychological toll was disproportionately higher for hospital workers who cared for patients from indigent and marginalized communities.
Because it will be difficult to minimize exposure to recurring trauma, health care systems must institute other sustainable measures to blunt the psychological effects. In the short-term, reactions and performance of staff must be closely monitored, procurement of PPE needs to be prioritized, 24/7 psychosocial support from trained professionals should be readily accessible, and false reassurances laced with euphemisms about what employees should expect in the trenches have to be shed. In the long-term, there must be continued professional support and psychological treatment, as needed, to help vulnerable personnel process and cope with its grief, loss and moral injury.
These measures will be necessary to flatten a mental health curve that is growing. As Bellevue's Schwehm added, “Again, the issue here is that there is a culture that exists in the medical community around not complaining, doing what is told, and not necessarily expressing feelings.” For doctors, nurses and other health care workers who have long deferred or temporarily bandaged their psychological wounds, this may be a watershed moment.