Key points • During the COVID-19 pandemic, healthcare professionals (HCPs) have suffered high levels of anxiety, insomnia, depressive and trauma-related symptoms. • Although most HCPs will be able to recover from these stressful circumstances, it is known that the prevalence of mental disorders among them during similar epidemic outbreaks increases in the short and medium term. • HCPs often have difficulty taking care of themselves and if they eventually develop mental disorders they are reluctant to seek appropriate help. • While affective and anxiety disorders are the most common mental disorders among HCPs, others, such as addictive disorders, not only worsen their well-being but also pose a risk to the safety of their practice. • This new post-COVID-19 scenario becomes an opportunity to promote a new culture of professionalism in which the care of caregivers becomes a priority at both a personal and institutional level. |
A high proportion of health professionals (HCPs) neglect their self-care, a phenomenon that has popularly been reflected in the old saying: “the shoemaker always wears the worst shoes” and, consequently, they find it difficult to ask for help when their distress results in a mental disorder. Their sense of duty leads them to maintain a high level of arousal and commitment and can help delay seeking help when they suffer from a mental disorder. Although HCPs’ attitudes toward self-care are slowly changing, they are still consciously or unconsciously trained to care for others and put their patients’ needs before their own. This is even more accentuated in circumstances such as emergencies, disasters, or life-threatening experiences, such as the recent COVID-19 pandemic.
HCPs also have to deal with non-occupational stressors related to time imbalance between work and home and other personal, financial, and contextual factors. Although most of the evidence on the well-being of HCPs has focused on doctors and nurses, others (such as psychologists, dentists, social workers or pharmacists) are also exposed to similar work-related stressors and tend to ignore care. staff.
Health professionals are still reluctant to recognize it and ask for professional help.
Interest in the well-being of HCPs has increased in the last 2 decades. Concern about the suffering of HCPs has been transformed into a proactive movement among professional associations and some institutions to raise awareness about the importance for HCPs of maintaining healthy habits, achieving good work integration and promoting resilience despite the adversities that they face. They find themselves in an increasingly overloaded environment. work environment. It is crucial to emphasize that not all mental disorders become psychiatric illnesses. However, when this happens, HCPs are still reluctant to acknowledge it and ask for professional help. In addition to the negative implications of this attitude on your well-being, in some cases, such as addictions or severe mental disorders, the safety of your practice may be compromised.
A general perspective on this phenomenon may ignore the role of some idiosyncratic factors associated with the emergence of mental disorders and the way they manifest among PS. Some of them are related to: age ( younger PS are more likely to suffer from psychological disorders), gender ( women still face difficulties in reconciling work and family, they are more likely to develop affective and anxiety disorders in compared to men and have less difficulty seeking help), occupation (doctors, nurses and other HCPs have specific work stressors), organization of the public and private health system of each country/region, type of mental health resources provided to them offer and other psychosocial determinants.
The impact of COVID-19 on health professionals
Prior to the COVID-19 pandemic, healthcare professionals (HCPs) were known to have higher rates of job distress in the form of burnout. Work-related mental stress increases the risk of developing mental disorders, although its etiology is linked to a complex interaction of personal and contextual factors. Among HCPs, the most prevalent diagnoses before the pandemic did not differ from those of the general population. Therefore, depressive and anxiety disorders were the most common diagnoses, followed by substance use disorders, some of which were related to easy access to medications.
HCPs, especially in countries that had not experienced recent epidemic outbreaks, faced unexpected and highly stressful experiences during the initial waves of the COVID-19 pandemic and before vaccines were available to a large number of developed countries. Researchers have extensively analyzed the mental health consequences of this epidemic crisis in HCPs and their findings have been publicized in traditional and social media around the world.
Previous research on other infectious diseases, including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and Ebola virus disease, consistently showed that many HCPs reported symptoms of anxiety and depression and were more likely to develop mental disorders. disorders, including addictions , both during and after the outbreak, causing a severe impact on their coping skills, in some cases with long-lasting effects.
Many public health systems in Western societies initially faced this extraordinary situation with significantly reduced material and human resources as a result of the economic cuts that followed the Great Recession (2008). This added to the insecurity inherent in the lack of knowledge about the virus and the absence of effective treatments. Health workforce capacity was further reduced during the early waves of the COVD-19 pandemic after many HCPs became infected and had to be quarantined.
Health provider organizations and the socioeconomic and political context changed during the pandemic, and the responses of HCPs and the general population evolved accordingly. While at the beginning of COVID-19, the most frequent responses were related to hyperactivation of the mind-body system of activation and survival , various types of loss, fatigue, exhaustion and skepticism became predominant after the implementation of the vaccines. when the pandemic became apparently less severe despite the emergence of new variants of the virus.
A recent meta-analysis of 40 systematic reviews, including data from 1828 primary studies and 3,245,768 participants, estimated that anxiety (16%–41%), depression (14%–37%), and stress/post-traumatic stress disorder (18.6%–56.5%) were the most common mental health conditions during the COVID pandemic affecting HCPs. Other studies also included high prevalences of insomnia, exhaustion, fear, obsessive-compulsive disorder, somatization symptoms, phobia, substance abuse, and suicidal thoughts . When comparing countries and regions, the highest rate of anxiety was recorded in the United Kingdom, the highest rates of depression were recorded in the Middle East, and stress-related symptoms were most common in the Eastern Mediterranean region. The estimated prevalence figures varied depending on epidemiological variables such as: number of cases per 100,000 inhabitants, specific stage of the COVID-19 pandemic, characteristics of health services and vaccination rates.
Unfortunately, information on maladaptive coping strategies , such as alcohol consumption or self-prescription of sedatives, is less available. Most studies do not specifically detect potential substance use disorders, although experience from previous pandemics points to an increase in the incidence of alcohol consumption and self-medication among HCPs that may result in medium- and long-term addictive behavior. term. In accordance with the increased prevalence of mental disorders among HCPs in this new scenario, an increased risk of suicide is also expected to occur among them.
Most of the research evidence was collected at the beginning of the pandemic and then evaluated in several reviews and meta-analyses. During the early stages of COVID-19, HCPs, especially those on the front lines of care, faced unexpected traumatic experiences that were more intense and frequent than the general population. Women, nurses, and front-line HCWs have developed anxiety and depression more frequently compared to men, doctors, and second-line staff. In some studies, younger and less experienced HCPs have also been reported to be at higher risk while resilience, perceived intimate and public support, and positive coping styles have been identified as protective factors .
After analyzing the narratives of health professionals (HCPs), their main sources of anguish at that time of the pandemic were related to fear of contagion (both in themselves and in family members), the lack of protective measures, social stigma associated with exposure to COVID, ethical dilemmas, information and training, and aspects related to perceived support from families, colleagues, institutions and society . The most reported coping strategies included: individual/group psychological support, family/family support, training/counseling, and ensuring adequate personal protective equipment .
Difficulties in seeking appropriate help and its consequences
Certain aspects of the prevailing culture of HCP professionalism, especially among physicians and other caregivers with very demanding jobs and responsibilities, have been associated with resistance to seeking appropriate help when needed. These include: (1) the construction of their professional identity, with an exaggerated sense of duty combined with a greater sense of invulnerability and perfectionism; (2) his propensity to try to fend for himself; (3) your survival mentality; and (4) their high level of doubt, stigma, and insecurity regarding mental distress; and (5) fear of licensing issues when addictions or other serious mental disorders are present.
Although some coping strategies for working as a PS that are initially adaptive , can become unhealthy defense mechanisms (denial, minimization, and rationalization) when unable to cope with mental distress. Self -medication can also become a maladaptive strategy for coping with distress. In this situation, the course and prognosis of mental disorders are likely to worsen and, if left untreated, the risk of developing addictive behavior and, in some cases, suicide increases.
The stigma and self-stigma associated with mental disorders is even greater among healthcare professionals than in the general population.
It is known that self-stigma can lead to a delay in seeking help, a tendency to self-medicate, and a worse prognosis when suffering from a mental disorder. However, the stigma associated with mental disorders cannot be conceptualized as a dichotomous variable (yes/no), but as a spectrum in which stigma is inversely correlated with social acceptance.
The social recognition that the efforts of HCPs have received during this pandemic and the media dissemination of their testimonies about psychological suffering can help reduce their internal psychological barriers to seeking help. Therefore, it may be easier for HCPs to admit to anxiety or depressive symptoms if they are triggered by stressful life events, such as those triggered during the COVID-19 pandemic.
On the contrary, serious disorders, such as bipolar or psychotic disorders, and addictions are experienced with shame and are often hidden. This attitude is not only internalized by PSs but is also present among their peers or in the institutions where they work. Difficulties in asking for help when suffering from serious mental disorders may increase the risk to themselves (suicide risk) and/or to others (safety of practice). Prejudices regarding serious mental disorders and addictions among HCPs may be related to the fear of possible disruptive behaviors at some point in their evolution. However, unfortunately it persists even when the HCP as a patient has consolidated psychopathological stability and is ready to safely return to work.
In some individual SPs, psychological barriers to recognizing their own vulnerability may be related to personal characteristics such as high self-criticism, low self-esteem, poor bonds with family members, and also to competitive, status-conscious, and humiliating work environments. as well as symptoms of exhaustion linked to high work demands. However, vulnerability to developing mental disorders may be linked to other specific personal and family variables along with other psychosocial determinants.
Delaying seeking help is also likely to result in HCPs trying to cope on their own and, in some cases, turning to drugs as one of their coping strategies (usually self-prescribed, such as sedatives or hypnotics, or socially accepted, such as alcohol). In fact, it is estimated that between 10% and 14% of physicians may become chemically dependent at some point in their careers.
However, trends in drug addictions are changing among new SPs and should be adequately investigated in the future. Knowledge and availability of legal drugs may partly explain the higher rates of substance use disorders among some HCPs compared to others. Potentially, this combination of factors often leads HCPs to experience both substance use and a non-addictive mental disorder, complicating their course and prognosis.
Suicide risk among HCPs is elevated compared to the general population, and suicide incidence data may underestimate the problem, in part due to difficulties related to reporting reliability. In addition to other specific psychosocial factors, delay in seeking help together with easier access and knowledge of potentially lethal methods may explain this phenomenon. The risk of suicide is higher among nurses, veterinarians, doctors, dentists, and pharmacists compared to other HCPs and other occupational groups.
Denial (conspiracy of silence ), minimization and rationalization are also common defense mechanisms displayed by HCPs when a colleague suffers from a mental disorder despite its direct or indirect signs. Box 1 offers some strategies for handling this situation.
Box 1 Promotion of appropriate voluntary help-seeking among health professionals with mental disorders • A conspiracy of silence does not help the health professional (HCP) in trouble. • Avoid “corridor or hallway” queries. • Find a quiet, private place to talk without interruptions. • Try to be empathetic and non-judgmental. • Show a non-stigmatizing attitude towards mental disorders. • Underline the benefits of seeking help early as a healthy coping strategy. • Focus on PS’s own strengths and competencies. • Offer advice on appropriate mental health treatment or help alternatives. • Free, easily accessible, and highly confidential programs can help sick HCPs overcome their initial resistance to receiving appropriate treatment. • The HCP should be encouraged to abstain from work if he or she is affected by his or her mental disorder. |
Specialized mental health treatment resources for healthcare professionals
Mental disorders have a negative effect on PS practice and can lead to both absenteeism (leaving work without giving a good reason) and poor performance presenteeism (attendance at work despite poor health). In any case, evidence shows that sick HCPs report more medication errors, patient falls, and give poorer standards of patient care. Therefore, providing adequate support to the treatment of HCWs with mental disorders is essential both for their well-being and to reinforce patient safety and societal trust, while failure to do so increases risk in these areas.
The term “impairment” refers to those situations in which HCPs are unable to adequately fulfill their professional responsibilities due to a variety of health problems, including medical illness or mental disorders. Professional impairment due to mental disorders is most frequently related to addictive behaviors . In addition to the negative consequences on their practice, when mental disorders harm HCPs, other personal and environmental problems may arise: (1) sexual, marital and/or economic difficulties; (2) driving convictions; (3) decreased participation in family activities and commitments; (4) behavioral problems of dependent children; (5) frequent arguments or unexpected mood swings; (6) social isolation and/or loss of friends; and (7) cessation of hobbies and other interests. In fact, family members or close friends may be the first to identify symptoms related to addiction or serious mental disorder and may encourage impaired HPs to seek help, although it is not uncommon for troubled HPs to ignore or reject such recommendations. .
In addition to the numerous strategies to promote the well-being of HCPs and the development of numerous counseling services around the world in recent decades, the negative impact of mental disorders when they ultimately affect HCPs was the main reason behind the emergence of specialized mental health programs for them. Physician health programs were first developed in the United States in the late 1970s. The goal was to identify and treat physicians with problems stemming from mental health problems, primarily substance use disorders. Since then, other specialized programs have been developed in Canada, Australia, Spain, the United Kingdom, Argentina and Uruguay.
During the COVID-19 pandemic, medical health programs in the US have adapted their service provision and protocols to both support clinicians and continue to monitor people with substance use disorders to ensure safe practice. safe. In the United Kingdom, the National Health Service (NHS) Practitioner Health Programme reported that almost as many patients presented in the 12-month pandemic period (April 2020 to March 2021) as in the first 10 years of service (4,355 in the last 12 months vs. 5000 during the first 10 years). The Comprehensive Care Program for Health Professionals in Catalonia has also experienced a significant increase in PS referrals during the pandemic, especially among doctors. 66The percentage of HP women at admission and the clinical severity of the first treatment episode remained unchanged before and after COVID-19.
Summary
The prevalence of mental disorders, including addictions, has increased during the COVID-19 pandemic and is likely to remain at high rates afterwards. Until now, SPs have been consciously or unconsciously trained to prioritize caring for others rather than caring for themselves. Difficulties in seeking help when they need it must be addressed during the undergraduate period and throughout their professional career. Various specialized mental health programs and wellness resources have been offered to HCPs around the world over the past few decades. The impact of the pandemic on the mental health of HCPs has also increased the number of initiatives to support them, although many of them may be temporary.
Mental disorders among HCPs are just the tip of the iceberg of HCP well-being. This issue must be approached with a multidimensional perspective in which both individuals and context are considered. While offering appropriate treatment programs for people with psychiatric and psychological problems should be a priority, the COVID-19 pandemic can be seen as an invaluable opportunity to begin to consider caring for caregivers not only as a moral imperative but also as an essential ingredient of professionalism and healthcare organizations.
According to Dr. Shanafelt’s proposal for physicians, we were recently moving from the era of anxiety , when the ideal HCP must be perfect , have deity-like qualities, neglect self-care, prioritize autonomous performance, and not set work limits, to the of well-being 1.0 , where resilience, connection with others, and the reconciliation of work and family life were promoted. The SPs had hero qualities , but were frustrated with the institutions in which they worked. The COVID-19 pandemic could be a turning point in promoting a new paradigm of well-being 2.0 . The human qualities and self-compassion of HPs must now be highly valued, work must be experienced as meaningful , work-life integration must be facilitated, and team interactions transformed into a collaborative model. Professional organizations, institutions, leaders, PSs and society as a whole must be involved in the transition to this new paradigm.
Box 2 The COVID-19 crisis as an opportunity to rethink the care of health professionals • A new culture of professionalism among Health Professionals (HCPs) must include self-care as a priority from undergraduate and continuing throughout their professional career. • Not all mental distress is due to individual factors: context matters. • Institutions and policy makers must work proactively in favor of the care of HCWs. • Priority should be given to having sufficient material and human resources to reduce work overload and provide a “good enough” health service. • The ideal PS leader should be competent, able to work as a team, open-minded, fair, transparent and compassionate. • Learning healthy coping strategies and compassionate self-care, promoting work-life integration, and collaborative teamwork should be encouraged throughout one’s professional career. • Peer support groups can be helpful in overcoming mental distress. • The destigmatization of mental disorders among HCPs must be addressed at the personal, academic and institutional levels. • Seeking help when mental disorders exist should be encouraged and facilitated. • Offering highly confidential, easily accessible, and free mental health services can help HCPs with mental disorders (including addictions) voluntarily seek treatment, even when disabled. |
Clinic care points • If you are a health professional (HCP), consider self-care as a priority to achieve good clinical performance. • If you or a colleague suffers from mental disorders, including addictions, do not delay in seeking help. • HCPs should avoid self-medication or the use of alcohol/drugs to cope with mental distress. • A HCP should be encouraged to abstain from work if he or she is affected by his or her mental disorder. • Specialized PS treatment programs are a good alternative if you need mental health treatment. |
