What to Do About Pandemic PTSD

When the COVID-19 pandemic engulfed the nation well over a year ago, Rebecca Hendrickson, MD, PhD, immersed herself in the shell-shocking revelations that clinicians began posting on social media. The accounts offered just a snapshot of the pandemic’s heavy psychological toll, and Hendrickson, a psychiatrist at the University of Washington School of Medicine in Seattle and an expert in posttraumatic stress disorder (PTSD), wanted to know more.

She and her colleagues devised a survey to assess the impact of several pandemic-related factors, including increased work hours, social distancing restrictions, and lack of adequate personal protective equipment.

What began as a survey of healthcare workers soon expanded in scope. Of the more than 600 survey respondents to date, healthcare workers account for about 60%, while the rest are first responders — police officers, firefighters, paramedics, and emergency medical technicians — and nonclinical personnel, such as security guards and office staff, in healthcare settings. The respondents range in age from 19-72, and hail from all regions of the country. 

“Our findings were really striking,” Hendrickson said, “including very high rates of thoughts of suicide and thoughts of leaving one’s current field, which were both strongly linked to COVID-19-related occupational stress exposure.”

The distress stemmed from a multitude of factors. Among the most demoralizing: witnessing patients die in isolation and being stretched thin to provide optimal care for all patients amid an unrelenting onslaught of COVID-19 cases, she said. For some healthcare workers, living in the garage or basement — to avoid infecting family members with the virus — also wore on their psyche.

Of all healthcare workers in the study, more than three quarters reported symptoms that fell within the clinical range for depression (76%) and anxiety (78%). More than 25% noted that they had lost a family member or close colleague to the virus.

Hendrickson, who also works with military veterans at the VA Puget Sound Hospital System’s Mental Illness Research, Education and Clinical Center and their PTSD Outpatient Clinic, hadn’t expected the experience of loss to be so pervasive. She said the sheer number of people who “crossed the threshold” into despair concerned her deeply.

Signs and Symptoms of PTSD

PTSD’s prevalence among healthcare workers has always been variable, said Jessi Gold, MD, assistant professor and director of wellness, engagement, and outreach in the Department of Psychiatry at Washington University School of Medicine in St. Louis, Missouri.

As a psychiatrist who sees healthcare workers in her clinical practice, Gold has noted poor baseline mental health, including depression and trauma. Significant data have also pointed to a relatively higher suicide rate among physicians than the general population. These problems have been compounded by COVID-19.

“It has been an unrelenting series of new stressors,” she said, citing lack of resources; a feeling of being unable to help; and the high frequency of risk of death to patients, family and friends, and the caregivers themselves as just as few examples. “It is very likely going to increase our baseline trauma, and honestly, I don’t know that we can predict how. To me, trauma has no real timeline and can show up months or even years after the pandemic.”

PTSD can manifest itself in healthcare workers in several different ways. A few commonalities Gold has observed: sleep disruption (including insomnia and nightmares), work avoidance by taking disability or quitting, irritability or other changes in mood, trouble concentrating, and hypervigilance.

She also has seen physical manifestations of trauma — such as body pain, stomachaches, and teeth grinding, which “you might not realize are at all related to trauma but ultimately are.” Sometimes, she added, “people have panic attacks on the way to work or right when they get to work, or are thinking about work.”

Gold noted that different types of treatment, such as cognitive behavioral therapy and Eye Movement Desensitization and Reprocessing (EMDR), can be effective for PTSD. Medication is often necessary due to comorbid anxiety, depression, or eating disorders, said Gold, who is conducting a study on the pandemic’s effects on medical students.

The Difficulties in Isolating COVID as a Contributor

Not all researchers are convinced that a causal relationship has been established between the pandemic and worsening mental health among those in the healthcare sector.

With provider burnout being a long-standing concern in medicine, Ankur A. Butala, MD, assistant professor of neurology, psychiatry, and behavioral sciences at the Johns Hopkins University School of Medicine, Baltimore, Maryland, said he remains a bit skeptical that acute stressors during the pandemic amounted to a uniquely potent driving force that can be extrapolated and quantified in a study.

“It’s hard to interpret a chronic, rolling, ongoing trauma like COVID-19 against tools or scales developed to investigate symptoms from a singular and acute trauma, like a school shooting or a [military] firefight,” Butala said.

In addition, he noted a reluctance to generalizing results from a study in which participants were recruited via social media as opposed to research methods involving more rigorous selection protocols.

Although Hendrickson acknowledged the study’s limitations, she said her team nonetheless found strong correlations between COVID-19-related stressors and self-reported struggles in completing work-related tasks, as well as increasing thoughts of leaving one’s current field. They adjusted for previous lifetime trauma exposure, age, gender, and a personal history of contracting COVID-19.

The underlying premise of the study could be confirmed with repeated surveys over time, Butala said, as the COVID-19 pandemic evolves and the vaccination effort unfolds.

Follow-up surveys are being sent to participants every 2 weeks and every 3 months to gauge their mood, for a total follow-up period of 9 months per individual. New participants are still welcome. “We will continue to enroll as long as it seems relevant,” Hendrickson said.

Carol S. North, MD, MPE, who’s added to the growing research on the pandemic’s toll on mental health, noted that because symptom scales do not provide psychiatric diagnoses, it is difficult to attribute the prevalence of psychiatric disorders to the pandemic. North is chair and professor of crisis psychiatry at UT Southwestern Medical Center in Dallas, and director of the Program in Trauma and Disaster at the VA North Texas Health Care System.

The DSM-5 criteria exclude naturally occurring illness, such as a virus (even during a pandemic) as a qualifying trauma for the diagnosis of PTSD. According to current criteria by the American Psychiatric Association, COVID-19 and the pandemic are not defined as trauma, North said, while noting that “just because it’s not trauma or PTSD does not mean that the pandemic should be discounted as not stressful; people are finding it very stressful.”

Identifying the exact source of distress would still be difficult, North said, as the pandemic has produced severe economic consequences and prolonged social isolation, as well as occurring alongside nationwide protests over racial and ethnic divisions. Studies to date haven’t effectively separated out for these stressors, making it impossible to weigh their relative impact.

Furthermore, “most of us face many other stressors in our daily lives, such as grief, losses, broken relationships, and personal failures,” she said. “All of these may contribute to psychological distress, and research is needed to determine how much was a product of the virus, other aspects of the pandemic, or unrelated life stressors.”

A Rallying Cry for New Interventions

Despite such doubts, a growing number of studies are reporting that healthcare workers and first responders are experiencing intensified PTSD, depression, anxiety, and insomnia as a result of the pandemic, said Hrayr Pierre Attarian, MD, professor of neurology at Northwestern University Feinberg School of Medicine in Chicago, Illinois. These results should act as a rallying cry for implementing more policies tailored to prevent burnout, he adds.

“What we are seeing during this terrible pandemic is burnout on steroids,” said Attarian, who is also medical director of Northwestern’s Center for Sleep Disorders. There are already high burnout rates, “so this should be doubly important.”

Rooting out this problem starts at the institutional level, but merely advising providers to “be well” wouldn’t make inroads. “There needs to be fluid dialogue between healthcare workers and the leadership,” he said.

Among his proposed remedies: access to confidential and free mental health resources; increased administrative support; flexible hours; respect for work-life balance; and forgiveness for occasional errors that don’t result in harm. 

“Sometimes even the perception that a mistake has been made is taken as proof of guilt,” Attarian said. “It is not conducive to wellness. Extra income does not replace a nurturing work environment.”

Furthermore, “as a profession, we must stop glorifying ‘overwork.’ We must stop wearing ‘lack of sleep’ as badge of honor,” he said. “Sleep is a biological imperative like self-preservation, hunger, and thirst. When we don’t sleep anxiety, pain, and depression get amplified. Our perception of distress is off, as is our judgment.”

The Federation of State Physician Health Programs provides a directory of programs that physicians can use to be referred to confidential consultation or treatment.

Christopher Bundy, MD, MPH, executive medical director of Washington Physicians Health Program in Seattle, has been following Hendrickson’s longitudinal study with keen interest. As president of the Federation of State Physician Health Programs, he hopes to translate the findings into practice.

“Obviously, the COVID-19 pandemic has been a ‘black swan’ in terms of workforce sustainability issues,” Bundy said, citing “high rates of burnout, disillusionment, and dissatisfaction.” He sees some similarities with his former role in treating war veterans.

“The invisible wounds of combat, the psychological scars don’t really become apparent until after you’re out of the war zone,” said Bundy, who is also a clinical associate professor of psychiatry at the University of Washington School of Medicine.

Likewise, he expects the “emotional chickens will come home to roost as the pandemic subsides.” Until then, “people are just focused on survival, and in doing their jobs and protecting their patients.” Eventually, “their own wounds inside the pandemic will take hold.”

Susan Kreimer is a New York-based freelance health journalist.

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