Fear and isolation drives PTSD among health/social workers in COVID-19

The load on health and social care workers (HSCWs) has been high, and sometimes overwhelming, during the course of the current COVID-19 pandemic. A new study, published on the preprint server medRxiv* in October 2020, identifies the factors that predict distress in HSCW and emphasizes the importance of adequate supplies of personal protective equipment (PPE).

HSCWs Are A High-Risk Group

The toll on the emotional and physical health of HSCWs was inevitable, considering the higher-than-usual risk of contagion to them and more challenging work conditions requiring a more demanding schedule as well as more extraordinary efforts. Moreover, it exposes them to the pain of watching suffering and death on a scale far more extensive than usual, which is likely to arouse anxiety and stress.

Supportive interventions require knowledge of the risk factors for such anxiety peaks during future pandemics, including which category of HSCWs is at the highest risk. A general overview of risk factors operating on HSCWs is also useful.

Causes of Stress

Historical evidence demonstrates the higher risk of post-traumatic stress disorder (PTSD), depression, and anxiety, among other mental conditions, during HSCWs involved in the care of patients during a pandemic. This is so with those who work with potentially infectious patients, the nursing occupation, younger age, having dependent children, and female sex.

New evidence suggests that mental ill-health due to such fears is on the rise in many countries during the current pandemic, especially with higher infection rates and severe disease among healthcare workers.

Stress could be exacerbated by the inability to provide the desired level of care. This type of distress is called 'moral injury.' It is especially keen in areas such as Northern Italy where there was a need to select patients who would receive medical treatment due to the overwhelming health services.

High Rate of Infection of HSCWs Linked to Distress

About 10% of COVID-19 cases in England at the peak of the pandemic's first wave were in frontline HSCWs. This is linked to the perceived deterioration in the mental health of HCSW in the UK, as reported in an April 2020 survey, including the onset of depression, anxiety, and stress, and mental health problems.

Among UK nurses, too, according to an August 2020 survey, over three-quarters said they had higher stress levels since the beginning of the pandemic, with half expressing anxiety about their mental state.

Broader Spectrum of Study

The current study aims to examine risk factors for mental ill-health among HSCWs in the UK. In contrast to earlier studies, which have mostly explored medical professionals and some allied paramedical workers, the current study identifies risk factors for and compares rates of PTSD, depression, and anxiety in auxiliary hospital workers like cleaners, porters, and receptionists. It also looks into the impact of the pandemic on the mental health of social care workers.

The current study data comes from the Frontline-COVID study, which collated online survey data from May 27 to July 23, 2020. The average age was ~42 years, with over 90% being white and female.

Rates of Distress

Over three-quarters were in frontline health or social care for COVID-19 patients. Of these, ~18% had a history of confirmed COVID-19. Another ~13% suspected they had had it. This means almost one in three HSCWs were under stress from the feeling of having contracted a potentially deadly infection.

About a third reported resorting to alcohol or other drugs to ease their stress, more often than normal. At the same time, almost the same proportion said they could not express their fear or insecurity to their supervisor or another figure in authority.

Overall, ~58% met the diagnostic criteria for clinically significant distress for PTSD, depression, and anxiety, indicating that these disorders were prevalent among HSCWs during this pandemic phase.

Risk Factors: Lack of Support at Work

The researchers found that all HSCWs had the same levels of these disorders or symptoms, with the only significant differences between allied healthcare professionals and clinical support staff. The latter were consistently more affected.

They identified three variables that significantly predicted the occurrence of distress. Firstly, a third of HSCWs reported being unable to tell a manager about their inability to cope with the situation. This was linked with the highest rates of distress.

Strategies to train managers in healthcare to be more sensitive to and supportive of workers in distress are slowly entering the scene, and not too soon. Such interventions, including bringing in mental health professionals, are likely to be even more urgent for redeployed staff who were wrenched away from their old support systems. Other reasons for the perceived rift between workers and managers in healthcare should be examined in future studies.

Social Isolation

A second risk factor was the fear of carrying contagion. HSCWs who feel unprotected against infection are more likely to keep away from their loved ones to avoid transmitting infection.

Well over half of them indicated they were moderately to extremely worried about the risk of getting infected, while almost 80% were very anxious about the risk of transmitting the infection to others.

This agrees with earlier studies, which show that many more people are worried that they will transmit the infection to others than that they will catch it.

Social Stigma

The third risk factor was the feeling of being stigmatized due to the social perception (in over a third) that their role exposed those in contact with them to infection.

In addition to self-determined isolation, others may avoid interactions with HSCWs to minimize the chances of catching COVID-19 from them. This may hurt all the more because the HSCWs are putting themselves at risk for the sake of caring for other segments of society. The combination of poor social support and higher stress/distress levels is a well-known recipe for mental ill-health.

High PTSD Risk

PTSD was more likely among reassigned participants, as well as nurses and midwives. It was higher among individuals who feared becoming infected and among the group with the lowest household income (between £30,000-59,999).

Unlike earlier studies, all categories seemed to have an equally high risk of having PTSD symptoms, depression, and anxiety compared to nurses. However, most groups were too small to be separately assessed and were thus clubbed together in the heterogeneous "Others" group.

The Importance of PPE

Almost a third of HSCWs were frustrated by unreliable PPE supply, and this group had much higher rates of both anxiety and depression were in this group. The same was true of those who had any illness.

Nurses and midwives were at the highest risk for any illness than caregiving staff or allied healthcare professionals, doctors, or non-clinical staff. Finally, those with the highest income had the lowest chances of PTSD, anxiety, or any clinical illness.

The researchers point out, “These results indicate that it is paramount to provide adequate PPE to HSCWs throughout an infectious disease outbreak not only to protect their physical health but in order reduce the likelihood of mental distress.”

Implications and Future Directions

Further research will be required to explore the rates of COVID-19-related distress among all HSCWs. This group's predominant white female composition mandates more study on the potential for disproportionate impact on HSCWs identifying as Black, Asian, or other ethnic minority since other recent studies seem to indicate that this is the case.

The study's generalizability is limited by the self-reported nature of the data, as well as the convenience sampling and should be addressed in future studies.

Much of the observed distress is bound to decrease over time in the absence of any intervention for most participants. Therefore strategies should consider this factor. At the same time, it is necessary to identify those who will need care lest their symptoms become chronic or severe. This differentiation is, therefore, a priority. When the potential for future pandemics, and future waves of the current one, is considered, the need for such studies and targeted interventions is clear.

*Important Notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Journal reference:
Dr. Liji Thomas

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.

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