Abstract
Objectives. To evaluate symptomatology and clinical outcomes among treatment-seeking health care workers (HCWs). We examined engagement, presenting symptomatology, and treatment outcomes among a diverse group of HCWs in a large urban health system.
Methods. Demographic and pretreatment–posttreatment outcome data were available for 69 HCWs who sought cognitive behavioral therapy (CBT), with or without medication management, at a specialized clinical center from July 1, 2020, to April 25, 2022.
Results. Treatment-seeking HWCs predominantly identified as female (78.3%) and non-White (53.6%) and had a mean age of 36.33 ± 10.72 years. Wilcoxon signed-rank tests showed significant reductions in all symptoms and increased well-being (P < .001), with effect sizes ranging from 0.59 to 0.71.
Conclusions. Our findings replicate those of existing research on the prevalence of psychiatric distress among HCWs, uniquely focusing on those seeking care. Our outcome data suggest that short-term CBT is effective in reducing clinical symptoms and increasing HCW well-being.
Public Health Implications. Given the elevated rates of distress found in HCW surveys, evidence-based interventions such as ours are essential to ensure workforce well-being. Providing mental health care to HCWs has both individual benefits and potential implications for improved patient care and workforce retention. (Am J Public Health. 2024;114(S2):S167–S170. https://doi.org/10.2105/AJPH.2023.307435)
Studies have documented the immense psychological toll of the COVID-19 pandemic on health care workers (HCWs), including occupational burnout,1 depression, anxiety, and posttraumatic stress disorder (PTSD).1,2 Despite HCWs’ high need for mental health services, few studies have examined treatment outcomes in this population. Existing research centers on nonclinical support initiatives such as psychoeducation, peer support programs, mindfulness skills, and mobile applications,3 as well as self-guided cognitive behavioral interventions.4 Although these programs may benefit HCWs’ mental health, they lack specificity for clinical disorders and may not address the full range of mental health needs. Indeed, most of these resources recommend therapy referral in the event of suicidality or nonresponse to interventions.3,4
To fill this gap, we examined the effectiveness of clinician-delivered cognitive behavioral therapy (CBT) in a specialized HCW-centered clinical service embedded within an urban health system. As this service implements measurement-based care, data on symptoms of depression, anxiety, PTSD, alcohol use, and psychological well-being were available at multiple time points. To provide further context regarding the treatment service, we also present clinical diagnosis and engagement statistics, including no-show rates and time from initial contact to intake.
METHODS
Data were collected from HCWs receiving care in an outpatient, telehealth-based practice exclusively for HCWs employed or training at the Mount Sinai Health System, a large urban health system in New York. The Mount Sinai Center for Stress, Resilience and Personal Growth was founded in mid-2020 in anticipation of the varied mental health needs of a workforce heavily affected by COVID-19. Services include resilience-building group workshops, a Web-based app with psychoeducation and self-screening tools, and a clinical service that provides confidential behavioral health care.
HCWs seeking care were offered an initial telephone screening within 1 business day and an intake appointment within 1 calendar week of screening. Although there were no strict exclusion criteria for receiving services, HCWs seeking care for severe substance use disorders, active mania, or acute risk factors requiring a higher level of care were referred to other psychiatric programs within the same health system.
Treatment options were CBT provided by a licensed clinical social worker or a licensed clinical psychologist and, if indicated, psychiatric medication management with a psychiatrist. All clinicians participated in weekly supervision sessions with faculty psychologists trained in CBT. Nearly all visits were conducted via video telehealth. The target treatment length was 14 weekly visits, although patients could terminate if they reached their goals early or extend past 14 visits when clinically indicated.
Data Collection
Self-report measures were administered at intake, session 5, session 10, and session 14 to monitor clinical progress and treatment outcomes; completion was not mandatory but encouraged. We included in our study all patients who completed self-report measures at both intake and session 14 (the target termination session).
We used standardized self-report measures of depression (9-item Patient Health Questionnaire [PHQ-95]), thoughts of suicide or self-harm (PHQ-9 item 9), anxiety (7-item Generalized Anxiety Disorder Assessment [GAD-76]), PTSD anchored to COVID-19 (PTSD Checklist-5, Specific Version [PCL-57]), alcohol use (Alcohol Use Disorders Identification Test-Consumption [AUDIT-C8]), and emotional well-being (5-item World Health Organization Well-Being Index [WHO-59]). All measures were readministered regardless of intake score except the PCL-5, which was readministered only to those who screened positive at intake. Measures were administered via Research Electronic Data Capture (REDCap), a secure Web-based software platform.10
Statistical Analysis
Because the GAD-7, PCL-5, AUDIT-C, and WHO-5 were not normally distributed at intake, nonparametric tests were used. Wilcoxon signed-rank tests were conducted to examine differences in pretreatment and posttreatment scores. McNemar’s test was used to examine changes in suicidality from intake to session 14.
RESULTS
The median time from initial contact to intake was 8 business days. Of the 380 patients who entered treatment during the study period, 137 (36.1%) were still completing treatment, 202 (53.2%) had completed treatment (mean number of visits: 12.63 ± 4.96), 27 (7.1%) had dropped out (mean number of visits: 4.74 ± 2.82), and 14 (3.7%) were referred out before completing treatment (mean number of visits: 6.53 ± 6.57). Among the patients who entered care, 145 (38.2%) completed 14 visits by the end of the window. Of those 145, 69 (47.6%) completed measures at intake and session 14 and were thus included in our analyses of symptom change. No-show rates for all patients and those who completed the measures were 2.8% and 1.4%, respectively.
The mean age of the 69 patients included in the analyses was 36.33 ± 10.72 years. Most of these patients (78.3%; n = 54) identified as female. Although White-identified patients were the largest single racial group (46.4%), the majority (53.6%) of participants identified as non-White. Additional demographic details, including data on HCW occupational groups, are provided in the appendix (available as a supplement to the online version of this article at http://www.ajph.org). Patients who completed session 14 measures did not differ from those who did not in terms of race/ethnicity, gender, symptom severity at intake, diagnosis, occupation, or treatment modality (see the appendix).
Within the analyzed sample, adjustment disorders were the most prevalent clinical diagnosis (42.0%), followed by generalized anxiety disorder (23.2%), major depressive disorder (15.9%), and PTSD (13.0%). Just over half (n = 37; 53.6%) of the patients received therapy with medication management, and 32 (46.4%) received psychotherapy alone.
Wilcoxon signed-rank tests were used to compare score changes among all patients from intake to session 14. The results showed increased well-being and significant reductions in all symptoms (P < .001), with effect sizes ranging from 0.59 to 0.71 (Table 1). Supplementary mixed analyses of variance showed a slight advantage of combined therapy and medication for anxiety and well-being (see the appendix). McNemar’s test showed a significant decrease in the percentage of patients who endorsed suicidality from intake (15.9%) to session 14 (2.9%; P = 0.01). Additional details on categorical analyses of outcomes are available in the appendix.
TABLE 1—
Results of Wilcoxon Signed-Rank Tests for Treatment Outcome Measures From Intake to Session 14: New York City, July 2020–April 2022
| Measure | No. | Intake Median |
Session 14 Median |
Median Difference | Test Statistics | ||
| Z a | P | r b | |||||
| PHQ-9 | 68 | 10.00 | 5.00 | −5.00 | −5.83 | < .001 | 0.71 |
| GAD-7 | 68 | 11.00 | 6.50 | −4.50 | −5.77 | < .001 | 0.70 |
| PCL-5 | 11 | 41.00 | 32.00 | −11.00 | −2.41 | < .001 | 0.73 |
| AUDIT-C | 69 | 2.00 | 1.00 | −1.00 | −3.48 | < .001 | 0.42 |
| WHO-5 | 69 | 36.00 | 56.00 | 20.00 | 4.87 | < .001 | 0.59 |
Note. AUDIT-C = Alcohol Use Disorders Identification Test-Consumption; GAD-7 = 7-item Generalized Anxiety Disorder Assessment; PCL-5 = PTSD Checklist-5, Specific Version; PHQ-9 = 9-item Patient Health Questionnaire; WHO-5 = WHO-5 Well-Being Index.
For Wilcoxon signed rank test.
Measure of effect size.
DISCUSSION
The onset of the pandemic’s demands and safety limitations necessitated the rapid creation of supportive virtual interventions for distressed HCWs. Many of these interventions have been self-guided and app based, with limited outcome data.3 To our knowledge, the present study is the first to examine more traditional behavioral health service outcomes among COVID-19-era HCWs.
Our results demonstrate high commitment to care, as evidenced by low dropout and no-show rates. After 14 visits, HCW patients evidenced significant decreases in reported symptoms of depression, suicidality, anxiety, PTSD, and alcohol use and increased psychological well-being. These findings suggest that immediately accessible short-term CBT is effective in this population, with effect sizes comparable to those found in randomized controlled trials.11 However, more research is needed on mechanisms of change and pretreatment predictors of response. The ongoing burden of the COVID-19 pandemic on HCWs makes this finding particularly compelling, as it suggests that skill building is effective amid ongoing chronic stressors. Incorporation of coping skills may be especially important for HCWs exposed to known contributors to psychological distress such as limited staffing and resources, poor support,1 and workplace violence.12
There are several limitations of our study. The self-report measures were voluntary, and approximately half of the participating patients did not complete their session 14 measures. However, there were no significant demographic or symptom differences between patients who did and did not complete measures. In addition, although a CBT-based approach was reinforced in supervision and didactics, adherence checks and therapy process outcomes were not implemented, nor were sessions recorded for later coding owing to the sensitive nature of the treatment sample. Finally, because of the limited sample size, we were unable to examine potential moderating factors such as occupation, medication type, and race/ethnicity; this may thus limit the generalizability of our findings to any single occupational group. Our practice continues to collect data with the aim of deepening understanding of effective, targeted treatments for HCWs.
PUBLIC HEALTH IMPLICATIONS
Given the elevated rates of distress found in HCW surveys, evidence-based interventions such as ours are essential to ensure workforce well-being. Providing evidence-based psychotherapy to HCWs has both individual benefits and potential implications for improved patient care and workforce retention.
ACKNOWLEDGMENTS
This study was partially supported by a Health and Public Safety Workforce Resiliency Training Program grant from the Health Resources and Services Administration (U3NHP45398); additional support, including for the REDCap research infrastructure, was provided by a grant from the National Institutes of Health National Center for Advancing Translational Sciences (1UL1TR004419-01).
Data from this study were previously presented in symposia at the Anxiety & Depression Association of America annual conference in Washington, DC (April 2023) and the American Psychiatric Association annual conference in San Francisco, CA (May 2023).
CONFLICTS OF INTEREST
Jonathan M. DePierro, Vanshdeep Sharma, and Deborah B. Marin are named as co-inventors on a patent application for a technology related to supporting mental health and improving resilience that has yet to be licensed. Jonathan M. DePierro receives book royalties from Cambridge University Press and honoraria from Springer Press.
HUMAN PARTICIPANT PROTECTION
The Mount Sinai Program for the Protection of Human Subjects reviewed and approved this study, including a waiver of informed consent for the use of deidentified retrospective data.
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