Butler Center for Research / December 2021 Download the Health care Professionals and Mental Health Research Update Introduction Every day, health care professionals (HCPs) are tasked with performing lifesaving actions and guarding the well-being of our communities. HCPs carry a tremendous weight of responsibility to perform at a high level, which can come with repercussions regarding their own mental health. Research shows that HCPs suffer from mental illnesses such as depression, anxiety, stress and substance abuse at a greater rate than that of the general population.1, 2, 3, 4, 5 With HCPs working tirelessly to provide care to victims of the COVID-19 pandemic, on top of the demanding needs of their own specialties, it is even more evident that HCPs are in great need of mental health support. As one article remarks, HCPs "will be the heroes of the day, but we will need them for tomorrow."6 Poor Mental Health in HCPs vs. the General Population Recent research has documented the prevalence of poor mental health trends in HCPs. It is evident that they suffer from stress, anxiety, depression, PTSD and substance abuse at a higher rate than the general population of the United States.7 A number of studies have found: In a survey of U.S. physicians, 87% of respondents report they are severely burned out or stressed.7 In comparison to the 3.1% of the U.S. population who report experiencing anxiety, 52% of emergency medical professionals have varying degrees of anxiety.2, 8 The average prevalence of depression among physicians is estimated to be 28.8%, ranging from 20.9% to 43.2%, depending on specialty and field.3 This can be compared to the estimated 7.1% of all U.S. adults who suffer from depressive symptoms.9 The prevalence of PTSD in U.S. adults is estimated to be 3.8%. PTSD among emergency physicians was found to be 15.8%.4 Lastly, while the rates of substance abuse for HCPs and the general population were fairly similar, it should be noted that prevalence of substance abuse among HCPs is particularly disturbing as they are the caregivers responsible for the health and wellbeing of the general population.5 Therefore, while substance abuse severely affects any individual, the repercussions of substance abuse among HCPs have the potential to cause much more harm. How Is COVID-19 Affecting This Trend? While the pandemic has proved to be challenging for everyone, it should be noted that HCPs are particularly vulnerable to emotional distress in the current pandemic due to their close proximity to the disease and the high demand for their services.10 HCPs may experience a range of stressors during this time such as uncertain prognoses, shortages of protective resources, conflicting messages from authorities, the anxiety around the risk of contagion, and concern about infecting and caring for their loved ones.10, 11 Perhaps overlooked may be the psychological stress related to the ambiguity of COVID-19. As one study remarks, HCPs are neither prepared nor trained to let people die whom they could save under normal circumstances.10 The great volume of traffic in hospitals—combined with shortage of materials and overworking—prevents HCPs from performing at their highest quality. These factors may lead to incidences of moral injury, or the psychological distress that results from actions, or the lack of them, that violate a provider's moral or ethical code.6 While COVID-19 is a new and not yet fully understood disease, it is not our first pandemic. A study that tracked the mental health of HCPs after the SARS outbreak found that hospital workers, particularly doctors and nurses, were more susceptible to psychological disorders after participating in the treatment of SARS patients over a decade ago. This suggests that their participation in fighting a pandemic may have weakened and worsened their mental health in the long run.12 A similar study showed that HCPs who worked in SARS units and hospitals during the outbreak also reported depression, anxiety, fear and frustration as a result of the stressful environment they were working in.13 This research indicates that the effects of the current pandemic are likely to continue affecting HCPs long after the pandemic has slowed. Based on experience from past viral epidemics, the development and implementation of mental health assessment, support, treatment and services are crucial and pressing goals for the health response to the COVID-19 outbreak.13 What Is Causing Poor Mental Health in HCPs? Occupational factors central to any career in the health care field present obstacles to positive mental health in HCPs. The very characteristics that make an HCP successful in their role—such as conscientiousness, obsessiveness and perfectionism—may also increase their risk of developing mental health problems and increase their inability to unwind and replenish their inner resources.14 Furthermore, the lifestyle of an HCP itself may be a source of poor mental health. Several studies suggest that poor mental health in HCPs is exacerbated by:15, 16 Extensive workload and long hours Over-demanding patients Scanty resources Ethical and legal issues Constant exposure to stressful situations and the need for critical decision-making Fear of failure These stressors not only appear once an HCP is steadily employed in a hospital or specialty; rather it has been found that the root of such tensions often originates in medical school. A study of medical students in Ethiopia found that one in two students struggle with depression, one in three reported anxiety and one in five reported comorbid depression and anxiety.17 These statistics indicate that medical school represents the beginning of poor mental health trends for HCPs. The study hypothesized that a new environment, new friends and being apart from family could be central to the higher rates of anxiety in medical students.17 What Are the Consequences of Poor Mental Health for HCPs? The personal and professional repercussions of poor mental health on HCPs are well documented in research. A study of burnout in physicians in the U.S. found emotional exhaustion, depersonalization and a sense of reduced accomplishment to be highly prevalent across specialties.18 Furthermore, a survey of nearly 5,000 U.S. physicians showed that 43.9% reported at least one symptom of burnout, which is emotional exhaustion due to constant exposure to stressful situations in the workplace. This study indicated that burnout in HCPs manifests personally and professionally.19 In terms of professional consequences, burnout may cause:18 Increased medical errors Risk of malpractice Reduced patient satisfaction Failure of interpersonal relationships The untimely departure of physicians from their jobs With regard to personal consequences, burnout may lead to:18 Increased incidence of stress Increased odds of substance abuse and dependence Increased risk of depression An increase in suicidality and suicidal ideation A study of the professional consequences of poor mental health in HCPs found that in a population of 7,905 surgeons, 8% committed major medical errors due to lapses in judgment, and both burnout and depression were independent risk factors for major medical errors.20 Research evaluating occupational stress among physicians identified that the majority of physicians in their study admitted that patient care is affected negatively by their stress at work.21 Thus it is clear that HCPs will not be able to deliver the highest quality of care they can if they are struggling with poor mental health. This indicates that while HCPs would benefit greatly from mental health support and resources, so would patients. Support for HCPs through Programs and Interventions Some hospital administrators have implemented programs to target stress reduction among their HCPs. A research review of interventions designed to improve the well-being of general practitioners found that cognitive, behavioral and mindfulness-based interventions significantly reduced stress in doctors when implemented by hospital staff.22 This study concluded that, after the implementation of a 10-week mindfulness-based intervention, a significant reduction in stress and anxiety was reported in general practitioners and persisted at a six-month follow-up.22 Other researchers have pointed to resources outside of work as being crucial to positive mental health in HCPs. For example, one study found that the family environment is an important protective factor against the development of depressive disorders, and therefore, seeking support at home could halt the growth of poor mental health trends.16 Another study found that prevention of burnout and stress disorders requires rest and disconnection.10 While these relaxation and disconnection opportunities could be provided by the hospital or organization, they could also be explored outside the workplace with family or friends.10 In a recent research review, six studies exploring mental health interventions mainly focused on individual approaches, most often requiring health care workers to initiate contact. Proactive organizational approaches could be less stigmatizing and more effective; more research providing evidence on the efficacy of interventions/strategies is needed.23 While many health organizations have committed resources to the well-being of HCPs, only a few have published their protocols of intervention. The majority opted for helpline services, usually applicable and effective for urgent social and psychological problems.24 The scientific community has pointed out that there is a need to develop tailored mental health interventions for HCPs.25 Yet current findings of emotional distress among health care workers might indicate that the health care system is not able to effectively help the helpers.23 Understanding the risks and mental health impact(s) that health care workers experience and identifying possible interventions to address adverse effects are invaluable.23 Conclusion HCPs carry immense responsibility in their day-to-day work, which may have detrimental effects on their mental health. Excellent professional performance as an HCP is often synonymous with managing the taxing aspects of the job such as long work hours, constant exposure to stressful situations and the pressure to make split-second decisions with an individual's life weighing in the balance. Because of these factors, HCPs face mental illness at a higher rate than the general population; however, few resources are made readily available to them. While this dilemma was present before the current pandemic, COVID-19 has only exacerbated the stress and pressure on HCPs, and it threatens to have long-term effects on frontline workers. Programs have been implemented to improve the mental health of HCPs and have shown success in reducing stress, anxiety and depression. However, the research community has pointed out that there is a need to develop more mental health interventions tailored to health care professionals.