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Establish psychological screening and support programmes for health workers: Psychiatrists

21 Jun 2021

By Ruwan Laknath Jayakody   Systematic psychological screening and mental health support programmes should be established across the country in order to address the high prevalence of psychological distress among healthcare workers, especially nurses and others who are at greater vulnerability due to pre-existing psychiatric disorders and their exposure to Covid-19 patients owing to their work in treatment units. This proposal was put forward by P.S. Alles, Y.M. Rohanachandra, and L. Amarakoon (all attached to the Sri Jayewardenepura University’s Medical Sciences Faculty’s Psychiatry Department) and S. Prathapan (attached to the same Faculty’s Community Medicine Department) in an original paper titled “Psychological distress, challenges, and perceived needs among doctors and nurses during the Covid-19 pandemic, in a tertiary care hospital in Sri Lanka” which was published in the Sri Lanka Journal of Psychiatry recently. Presently, owing to the third wave of the Covid-19 global pandemic and national (Sri Lanka) epidemic, healthcare workers are working with limited resources (C. Carter, N. ThiLanAnh, and J. Notter note in “Covid-19 Disease: Perspectives in Low and Middle Income Countries” that Sri Lanka’s healthcare system experiences a critical shortage of intensive care beds and personal protective equipment [PPE]) in high-pressure and high-risk environments and adverse work conditions, putting in long hours, and as a result are isolated from their family and friends, which in turn is likely to cause psychological distress. As explained by M.S. Spoorthy, S.K. Pratapa, and S. Mahant in “Mental health problems faced by healthcare workers due to the Covid-19 pandemic – a review”, such difficulties are exacerbated by factors such as quarantine, uncertainties about the mode of transmission of the infection, the rapidity of its spread, and the lack of definitive treatment protocols or vaccines. Studies such as J. Lai, S. Ma, Y. Wang, Z. Cai, J. Hu, N. Wei, J. Wu, H. Du, T. Chen, R. Li, H. Tan, L. Kang, L. Yao, M. Huang, H. Wang, G. Wang, Z. Liu, and S. Hu’s “Factors associated with mental health outcomes among healthcare workers exposed to the coronavirus disease 2019” have found the pandemic to be significantly associated with high levels of psychological morbidity in healthcare workers, with stress disorders affecting around 71%, roughly half experiencing depression, and 44% having anxiety.  Furthermore, those who are the most affected by such and are at higher risk of developing more psychological consequences including distress, according to studies (Lai et al., A. Babore, L. Lombardi, M.L. Viceconti, S. Pignataro, V. Marino, M. Crudele, C. Candelori, S.M. Bramanti, and C. Trumello’s “Psychological effects of the Covid-19 pandemic: Perceived stress and coping strategies among healthcare professionals”, H. Cai, B. Tu, J. Ma, L. Chen, L. Fu, Y. Jiang, and Q. Zhuang’s “Psychological Impact and Coping Strategies of Frontline Medical Staff in Hunan Between January and March 2020 During the Outbreak of the Coronavirus Disease in Hubei, China”, Z. Zhu, S. Xu, H. Wang, Z. Liu, J. Wu, G. Li, J. Miao, C. Zhang, Y. Yang, W. Sun, S. Zhu, Y. Fan, Y. Chen, J. Hu, J. Liu, and W. Wang’s “Covid-19 in Wuhan: Socio-demographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers”, L. Kang, Y. Li, S. Hu, M. Chen, C. Yang, B.X. Yang, Y. Wang, J. Hu, J. Lai, X. Ma, J. Chen, L. Guan, G. Wang, H. Ma, and Z. Liu’s “The mental health of medical workers in Wuhan, China, dealing with the 2019 novel  coronavirus”, and W.R. Zhang, K. Wang, L. Yin, W.F. Zhao, Q. Xue, M. Peng, B.Q. Min, Q. Tian, H.X. Leng, J.L. Du, H. Chang, Y. Yang, W. Li, F.F. Shangguan, T.Y. Yan, H.Q. Dong, Y. Han, Y.P. Wang, F. Cosci, and H.X. Wang’s “Mental health and psychosocial problems of medical health workers during the Covid-19 epidemic in China”), are females and nurses and frontline workers.  The higher psychological impact on female nurses may be due to, C.Y. Liu, Y.Z. Yang, X.M. Zhang, X. Xu, Q.L. Dou, W.W. Zhang, and A.S.K. Cheng’s “The prevalence and influencing factors in anxiety in medical workers fighting Covid-19 in China: A cross-sectional survey” observed, the higher probability of exposure to Covid-19 owing to longer work hours and more direct contact with patients. Hence, Alles et al. conducted a cross-sectional descriptive study among the healthcare workers of the Colombo South Teaching Hospital in Kalubowila from May 2020 to August 2020. In April 2020, a separate unit was established for patients suspected of having Covid-19, and doctors and nurses from all units of this tertiary care hospital were assigned to it on a roster basis. Only three confirmed cases were detected during the period of the study. A total of 394 healthcare workers including 200 nurses and 194 doctors were randomly selected as participants from the staff register. A questionnaire was used to collect data.  In terms of sex, age, work experience, and ethnicity, the majority were female (289 – 73.4%), between 25 and 34 years of age (202 – 51.3%), with less than 10 years of work experience (268 – 68%), and Sinhalese (337 – 85.5%). The majority of the staff was from the medical wards (16.2%), gynaecology and obstetrics wards (11.4%), and paediatric wards (9.4%). Only 12 (3%) participants had a pre-diagnosed psychiatric illness. The majority (207 – 52.5%) had dependent children. The challenges that healthcare workers faced that were considered in this study included the lack of the availability of PPE, the lack of transport to get to work, difficulty in obtaining food, problems with accommodation, and difficulties in assisting their children with their distant learning activities. The perceived care needs of the healthcare workers that were considered in this study were the availability of better PPE, the availability of transport facilities to and from work, the grant of provisions to purchase food and essential items within the hospital, the provision of additional financial benefits for working during the pandemic, the availability of accommodation within or near the hospital, and flexible working hours being allowed in order to assist with their children’s distance learning activities.  Depression was assessed for dysphoria (a profound state of unease or generalised dissatisfaction with life), hopelessness, devaluation of life, self-deprecation, the lack of interest or involvement, anhedonia (the inability to feel pleasure in normally pleasurable activities), and inertia (resistance to change and tendency to maintain the status quo). Anxiety was assessed for autonomic arousal, skeletal muscle effects, situational anxiety, and the subjective experience of the anxious effect. Stress was assessed for chronic nonspecific arousal, difficulty in relaxing, nervous arousal, and being easily upset or agitated, irritable, or being over reactive, and being impatient. The scores for depression (mild, moderate, severe, extremely severe), anxiety (mild, moderate, severe, extremely severe), and stress (mild, moderate, severe, extremely severe) were calculated by summing up the scores for the relevant items including high or elevated levels of depression, anxiety, and stress.  The findings were thus:
  1. i)                The majority did not feel safe when working during the pandemic (295 – 74.9%).
  2. ii)              The majority were not satisfied with the availability of PPE (273 – 69.3%).
iii)             Nearly half (194 – 49.2%) were worried about getting infected with Covid-19 (those who denied being worried about contracting Covid-19 had higher rates of depression and stress, which Alles et al. elaborated, may indicate that the use of denial as a coping mechanism is associated with higher rates of psychological morbidity).
  1. iv)             The majority (215 – 54.6%) were worried about being a carrier of Covid-19.
  2. v)              Doctors were more likely to be worried about contracting the infection and being a carrier.
  3. vi)             A significantly higher number of nurses, compared to doctors, had difficulty in obtaining food and essential items, finding transport during the lockdown and in homeschooling children.  
The findings with regard to mental health were thus:
  1. i)                A total of 117 (29.7%) experienced stigma due to their work in healthcare in the form of not being accepted into supermarkets (32 – 8.1%) and being asked to leave their place of accommodation (12 – 3%), while 61 (15.5%) felt that their family was discriminated against, and perceived stigma did not differ between doctors and nurses (S. Bagcchi’s “Stigma during the Covid-19 pandemic” and V. Menon, S.K. Padhy, and J.I. Pattnaik’s “Stigma and Aggression Against Healthcare Workers in India Amidst Covid-19 Times: Possible Drivers and Mitigation Strategies” noted stigma and discrimination against healthcare workers during the pandemic).
  2. ii)              Anxiety being the common psychological sequelae, with high levels being present in 62 (15.7%) and in severe form in 19 (4.8%).
iii)             High levels of depression were seen in 55 (13.9%) with 17 (4.3%) showing severe symptoms.
  1. iv)             Elevated stress was seen in 45 (11.4%) with 10 (2.6%) experiencing severe stress.
  2. v)              Females, nurses, and healthcare workers less than 35 years of age (C.S. Romero, C. Delgado, J. Catala, C. Ferrer, C. Errando, A. Iftimi, A. Benito, J.D. Andres, and M. Otero’s “Covid-19 psychological impact in 3,109 healthcare workers in Spain” demonstrated an inverse relationship among healthcare workers, with regard to age and psychological distress), those who did not have children (comparatively, healthcare workers with children had significantly less depression, anxiety, and stress, according to Babore et al. and Romero et al., while Alles et al. observe that children represent a break and distraction from exhausting working hours, and the frustration of dealing with patients, and fatigue), and those whose permanent residence was outside the Western Province (being away from one’s family during a stressful time makes much-needed social support less accessible, Alles et al. observe), were more likely to have depression, anxiety, and stress.
  3. vi)             Healthcare workers with no physical comorbidities had significantly higher levels of anxiety and stress, but not depression (Alles et al. explain that since physical comorbidities are likely to increase with age, older age may explain the reduced psychological distress seen in those with physical comorbidities).
vii)           Staff working in medical, paediatric, gynaecology and obstetrics, and surgical wards which have a higher risk of contact with patients had significantly higher levels of stress and anxiety compared to staff working in the blood bank and forensic medicine units (staff in the latter two units have less direct contact with patients, Alles et al. note). viii)         There were no significant differences in stress and anxiety among other units. 
  1. ix)             Rates of depression did not vary among the units. 
  2. x)               Higher levels of depression and stress but not anxiety, were associated with a past history of psychiatric illness. 
  3. xi)             Anxiety, but not depression or stress, was significantly higher in those with work experience less than 10 years, compared to those with work experience of 10 years or more (Romero et al. note that those with longer work experience are likely to have expertise and more confidence in facing unforeseen circumstances). 
xii)           The presence of perceived stigma was associated with higher levels of stress, but not with depression or anxiety.  xiii)          Depression, anxiety, or stress were not associated with marital status, ethnicity, having a partner working in essential services, or the availability of PPE.  Psychological consequences including distress were seen in, Alles et al. noted, 11% to 15%.  Explaining the findings, Alles et al. pointed out that the results may be due to the fact that the study was done during the early period of the Covid-19 first wave in Sri Lanka, when PPE was not available in adequate amounts, understanding about the modes of transmission of the infection and its prevention was poor, and there was a lack of guidelines about the management of Covid-19-positive patients and healthcare personnel. However, the reasons for the relatively high levels of psychological consequences, despite the smaller number of patients at the time of the study, requires, as pointed out by Alles et al., further study. The majority (85%) of the participants had stated that the primary need was for the availability of better PPE. Studies conducted elsewhere (Liu et al., J. Du, L. Dong, T. Wang, C. Yuan, R. Fu, L. Zhang, B. Liu, M. Zhang, Y. Yin, J. Qin, J. Bouey, M. Zhao, and X. Li’s “Psychological symptoms of frontline healthcare workers during the Covid-19 outbreak in Wuhan” and N. Shaukat, D.M. Ali, and J. Razzak’s “Physical and mental health impacts of Covid-19 on healthcare workers: A scoping review”) have linked the inadequacy of PPE with increased psychological morbidity in healthcare workers. Among healthcare workers, stigma, Alles et al. explain, increases psychological distress, stress, and burnout. Alles et al. therefore, recommended efforts to minimise the stigma against healthcare workers. Concerning the mental health of healthcare workers, in April 2020, the Sri Lanka College of Psychiatrists established a 24-hours helpline, while at the institutional level, healthcare workers have been encouraged, if required, to contact the relevant hospital’s psychiatry unit. However, Alles et al. point out that the issue with this is that the screening for psychological distress was not conducted. Therefore, the screening of healthcare workers, in particular, those serving in high-risk units, should be included in psychological support programmes, Alles et al. suggested, adding that since those with a history of psychiatric morbidity have a higher risk of developing psychological consequences, such individuals should receive additional psychological support.  It was also noted by Alles et al. that since healthcare workers who experienced difficulties in obtaining food and other essential items in turn experienced additional psychological problems, addressing their practical needs is also a need of the hour in order to alleviate the psychological distress they face. Highlighting the plight of healthcare workers in secondary care facilities which are less resourced when compared to tertiary care facilities, Alles et al. also noted that the psychological distress among healthcare workers in this study may be lower than the levels for the same experienced by healthcare workers in other settings such as secondary care hospitals due to the latter likely having substantially less resources and facilities when compared to the situation in tertiary care hospitals.


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