COVID-19–Associated Psychiatric Symptoms in Health Care Workers: Viewpoint From Internal Medicine and Psychiatry Residents

To the Editor:

Introduction

The physiological impacts of COVID-19 are beginning to be understood. However, the psychological impacts of COVID-19, especially among the health care workers who work with COVID-19 patients, are not well described. We assess data available from China on the impact of COVID-19 on psychiatric symptoms among health care workers to highlight the challenges currently faced by health care workers in the United States. We incorporate our viewpoints from our internal medicine and psychiatry residency programs.

Methods

We reviewed available literature as of March 25, 2020. We used the MeSH term “covid AND (psychiatry OR mental health)”. We searched PubMed, Ovid Medline, and PsycInfo. As our purpose was to survey all the current literature on this topic, we did not have any exclusion criteria. The initial search resulted in 52 articles. After duplicates were removed, there are 32 articles remaining. Three articles discussed our topic of concern.

Frontline Health Care Workers

Frontline health care workers are those who interact directly with COVID-19–positive, or potentially positive, patients. These frontline health care workers are not simply working extremely hard, they are struggling to treat a new viral disease that is not well understood. This situation creates a unique psychiatric burden.

Lai et al.¹ enrolled 1257 health care workers who responded to a cross-sectional survey. General distress was present in 72% of participants, followed by symptoms of depression (50%), anxiety (45%), and insomnia (34%). Women reported more severe scores on all 4 of these categories. Nurses also reported more severe scores than physicians.¹

Huang et al.² recorded responses from 230 out of 246 medical staff on self-rating anxiety scale and posttraumatic stress disorder self-rating scale. This study revealed a strikingly similar trend in comparison to the study by Lai et al.¹ The incidence of anxiety was higher among female health care staff than among male health care staff (26%, 48/187 compared with 12%, 5/43). Because this was self-reporting of anxiety, it is possible that male participants may have minimized symptoms. The incidence of anxiety among nurses, compared with doctors, was nearly 2-fold (27%, 43/160 compared with 14%, 10/70).²

Nonfrontline Health Care Workers

For this viewpoint, vicarious traumatization refers to psychiatric symptoms experienced by nonfrontline health care workers. As delineated previously, frontline health care workers are currently at a high risk for increased psychiatric symptoms.

Li et al.³ analyzed the prevalence of vicarious traumatization by using electronic surveys to record responses from 740 people (214 general public, 234 frontline health care workers, and 292 nonfrontline health care workers). They developed a 38-item questionnaire subdivided into physiological responses, psychological responses, emotional responses, behavioral responses, cognitive responses, and life belief. Each item ranged from 0 (never) to 5 (always). Compared with frontline health care workers, nonfrontline health care workers scored higher for every single category, and each category reached statistical significance.³

Our Perspective as Frontline and Nonfrontline Resident Physicians

Our institutions have struggled to provide us with adequate personal protective equipment. We have limited masks available that must be continuously reused. Furthermore, policies change very frequently, leading to confusion. When we exhibit symptoms, we are directed to contact our employee health services. However, instructions are often vague, and there is limited testing provided to assess for COVID-19–positive status. Anecdotally, our colleagues are physically and mentally exhausted. There is overwhelming anxiety that we will contract the virus and infect our loved ones at home. Some residents have been living in hotels to avoid returning home.

We suggest that vicarious traumatization scores are higher among nonfrontline health care workers because of the following potential contributors: sympathy for COVID patients as well as for frontline health care workers (as Li et al. point out) and guilt in the avoidance of frontline work.³

At our institutions, emergency medicine physicians and internal medicine physicians are rapidly becoming ill with COVID-19 themselves. In response, the Accredited Council for Graduate Medical Education has transitioned to stage-3 pandemic emergency status, where resident physicians from other specialties will assist physicians on the frontline. In our psychiatry residency program, interestingly, residents asked to have volunteers sign up to be called to duty. This behavior underscores the prevalence of avoidance and associated guilt in nonfrontline health care workers. It is possible that those who do not volunteer, especially if they observe colleagues called to frontline duty, will develop increased vicarious traumatization scores.