Reply to Zijlstra: Resilience and Stress Are Heterogenic Too: We Should Act Accordingly

To the Editor:

In their letter to the editor about our cross-sectional survey on the resilience and mental health of ICU healthcare professionals (HCPs) (1), Zijlstra expressed concerns regarding the aggregation of results from physicians and nurses. The letter also highlighted the heterogeneity associated with high inter- and intrapersonal variability in ICU HCPs’ responses to specific stressors at different times.

However, as shown in Figure E1 of our paper (1), the prevalences of the symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) were not different between nurses and physicians. Interestingly, residents were the most affected. By multivariable analysis, the role in the ICU (nurse vs. physician) was not associated with any of the mental health symptoms. Male sex, however, was independently associated with fewer PTSD-related symptoms and with a higher degree of resilience. We recognize that, overall, men and women may experience different types and frequencies of traumatic events. Historically, men have been more likely to experience combat-related trauma, whereas women may be more susceptible to certain types of interpersonal trauma. Looking back at the coronavirus disease (COVID-19) pandemic, we also agree that the same trauma may have activated different coping mechanisms in men and women. Moreover, gender norms and societal expectations can influence how men and women perceive and express distress. Men may be socialized to suppress emotions or to view seeking help for mental health issues as a sign of weakness, potentially leading to underreporting of symptoms. Previous studies have reported that nurses’ assistants and medical students were at higher risk of mental health disorders (2). A recent study reported that nurses were at higher risk of developing psychological distress (3).

Our study unequivocally demonstrates the presence of heterogeneity in HCPs’ responses to stress and trauma induced by the COVID-19 pandemic. First, not all respondents presented with symptoms of anxiety, depression, or PTSD. Second, men were more resilient than women. Third, the perceived experience of the pandemic (e.g., frustration, isolation, threat), clinician ratings of end-of-life care, and exposure to the infodemic, television, social media, and reading considerably conditioned this response to stress. We then agree with Zijlstra that not all ICU HCPs need an intervention to prevent or mitigate mental health symptoms. Moreover, selecting HCPs in whom an intervention might be appropriate to alleviate the symptoms of anxiety, depression, and PTSD would need to identify phenotypes of HCPs at high risk. In those HCPs, a personalized approach to managing mental health outcomes is warranted.