The Pandemic’s Psychological Toll

Physicians often don’t get treated for mental illness because they fear stigmatization. Emergency physician Lorna Breen, MD, who worked on the front lines, got sick with the coronavirus and went right back to work, only to kill herself shortly thereafter. Her survivors want to eliminate the stigma associated with mental illness. So do the psychiatrists behind a new hotline for physicians.

Dr. Breen saved lives not only inside New York–Presbyterian Allen Hospital in Manhattan, where she was the clinical director of the emergency department (ED), but also beyond hospital walls. A few years ago at the Denver airport, Dr. Breen was traveling along a people mover when she spotted a man going in the other direction who’d turned blue. “She jumped over the people mover, performed [cardiopulmonary resuscitation], and saved his life,” said her sister Jennifer Feist. But 49-year-old Dr. Breen—who died by suicide on April 26, at the height of the ongoing mass casualty event that was the coronavirus disease 2019 (COVID-19) outbreak in New York City—was no mere adrenaline junkie. She dedicated herself to improving the ED experience for patients from start to finish: She learned medical Spanish in Central America to help Spanish-speaking patients; she was developing a protocol for the treatment of autistic patients; and she was also pursuing an MBA at Cornell University’s New York City campus, with the goal of helping to streamline the patient admission process.

When COVID-19 hit New York this spring, the crisis swept Dr. Breen away with it. In late March, she became sick with the virus and took time off to recuperate—although she never gave herself a complete break from the stress. “She was texting her colleagues the whole time to make sure they had enough [personal protective equipment] and were feeling okay,” said Feist. As soon as her fever was behind her, Dr. Breen asked to get back on the schedule. Two days later, she returned to Allen, a 200-bed hospital that at times had as many as 170 COVID-19 patients. Scheduled for 9 shifts during the next 11 days, Dr. Breen stayed at the hospital past the 12 hours she was supposed to work each day. “Nobody else was leaving and she couldn’t leave her peers,” said Feist. And yet Dr. Breen didn’t seem fully recovered from her sinister illness. “The scene was overwhelming. People were dying everywhere. There weren’t enough oxygen hookups, so they were using tanks, but the tanks would run out of oxygen and the patients would die while waiting to be seen,” added Feist. Angela Mills, MD, chair of emergency medicine at Columbia University Irving Medical Center (CUIMC), which includes Allen Hospital and several other New York–Presbyterian campuses, said, “Many of our physicians saw more deaths in a week than they would have seen in a lifetime.”

Dr. Breen was not someone short on physical stamina or courage: an avid runner, she was competing in a half marathon years ago when, during the first mile, she began having trouble breathing. She fought through the difficulty and completed the race, only to receive a diagnosis the following day of bilateral pulmonary embolisms. Neither was Dr. Breen unaccustomed to the intensity of a New York City ED. “Lorna worked in the ER for 16 years in Manhattan, and she’d seen a lot of stuff,” Feist said. As Lawrence A. Melniker, MD, MS, vice chair for quality care at the New York–Presbyterian Brooklyn Methodist Hospital, told The New York Times, “You don’t get to a position like that at Allen without being very talented.”

Shortly after returning to work, Dr. Breen’s mental health appeared to decline, although she had no previous record of mental health problems. When she told her sister she couldn’t get out of her chair, Feist became so concerned that she and Dr. Breen’s friends worked together to transport Dr. Breen to Feist’s hometown of Charlottesville, VA; once Dr. Breen arrived, Feist took her sister to UVA Health, the local hospital. Dr. Breen was kept in the psychiatric unit there for 11 days and was released on April 21. Five days later, she died by suicide.

Dr. Breen’s death devastated the New York–Presbyterian community, in particular CUIMC, where she was a member of the faculty. “Nobody expects something like this,” said Lourival Baptista Neto, MD, vice chair for Clinical Services in the Department of Psychiatry at Columbia University. “People were shocked, sad, angry, confused. It was really hard to make sense of it.” Part of the anger and fear caused by Dr. Breen’s suicide, he said, was a widespread perception that she was in good health, and that the trauma of COVID-19 alone brought her down. But even such extreme and unusual stress does not, on its own, typically predict death by suicide. “When we look at suicide research, the majority of the cases are multifactorial,” said Baptista Neto, noting that most suicides are associated with a preexisting psychiatric condition.

That said, even during more normal times, research indicates that physicians have the highest suicide rate of any profession, more than twice that of the general population. What’s more, physicians who have been on the front lines, even those who don’t come down with COVID-19 themselves, appear to be at heightened risk for depression, anxiety, insomnia, and psychological distress, according to a March study in JAMA Psychiatry that assessed health care workers at fever clinics or COVID-19 wards in China. “The ever-increasing number of confirmed and suspected cases, overwhelming workload, depletion of personal protection equipment, widespread media coverage, lack of specific drugs, and feelings of being inadequately supported may all contribute to the mental burden of these health care workers,” the study’s authors wrote. They also noted that, if surveys of health care workers who experience the 2003 SARS outbreak are any indicator, fears of infecting loved ones, feeling stigmatized, and a sense of uncertainty will likely also play a role.

Aside from the mental stress, the pandemic is also physically taxing for emergency personnel, which can contribute to poor mental health. “Emergency workers and intensivists have unique skills in huge demand during this pandemic, and there is a lot of pressure to work long hours,” said Katherine Gold, MD, MSW, an associate professor of family medicine at University of Michigan Medical School in Ann Arbor who is also a mental health researcher with expertise in physician mental health and suicide. Add to that the trauma of “repeatedly seeing devastating outcomes over which they have little control,” said Dr. Gold, and it’s no surprise that many physicians in the hardest-hit areas are having trouble coping.

To help its frontline workers, a group from Columbia, led by Baptista Neto, is providing psychiatric and psychotherapeutic support for physicians at Columbia-affiliated hospitals. CopeColumbia is a collaborative effort between Columbia University’s psychiatry department and ColumbiaDoctors, an organization made up of specialists from CUIMC. Since its March 23 launch, the CopeColumbia team has provided 2 types of free counseling: group sessions, facilitated by a psychiatrist and a psychologist, and confidential, urgent-care-style concierge access to psychiatrists and psychologists by way of Zoom, 7 days a week, 8 to 12 hours a day. In the wake of Dr. Breen’s death, ColumbiaDoctors and CopeColumbia also began to provide more opportunities to attend group meetings and individual one-on-one sessions with psychiatrists and psychologists, “not as psychotherapy sessions but rather as peer-to-peer support sessions,” said Dr. Mills. “Peer debriefing sessions are important so physicians can talk and share their experiences with each other. Often physicians and health care personnel don’t feel that folks outside of health care can understand what they’re going through.” These conversations were scheduled proactively so that physicians could opt out, but didn’t have to opt in. “We wanted to remove any potential stigma for those who may want to schedule,” said Dr. Mills. “We also know that sometimes those who are in greatest need have difficulty scheduling and wanted to make it as easy as possible while allowing people to opt out.” Dr. Gold agreed peer discussions are key. “Feeling that you are not the only one struggling goes a long way in reducing the shame that we so often feel,” she said. The proactive scheduling seems to have been effective, too; in the week after Dr. Breen’s death, more than 70% of the faculty from Columbia’s emergency medicine department met with the CopeColumbia volunteers.

What should other hospitals and managers do to help preserve and protect the mental health of their emergency physicians? “[Emergency] physicians specifically should have defined breaks between shifts or groups of shifts to be able to regroup and take a break from caring for very ill patients,” said Dr. Gold. She pointed out that having adequate personal protective equipment is also crucial because it helps physicians feel safe and reduces feelings of helplessness. Perhaps as important is that supervisors need to strive to make sure their staff feels appreciated for their work. “This helps physicians gain a sense of meaning and importance for their contributions,” said Dr. Gold, “an important way of coping with the stress.”

Physicians can also help one another. “It is important that if you think a colleague may be struggling that you privately let them know you’re concerned,” said Dr. Gold. “If you’re worried a colleague is suicidal, you need to ask the hard questions. You need to say something like, ‘Are things getting so bad that you’re thinking of hurting or killing yourself?’”

Five psychiatrists and their team of volunteers have gone beyond helping their peers locally. Prompted by the pandemic, they launched Physician Support Line on March 30. The free and confidential hotline, started expressly to support physicians and staffed by nearly 700 volunteer psychiatrists, is available 7 days a week, from 8 am until 3 am eastern standard time. Crucially—because so many physicians are reluctant to seek help because of concerns about privacy—the volunteer group is not affiliated with any organization or health care system. “There are many hotlines for suicide prevention, veterans, etc, but this is the first one that is specific to physicians,” cofounder Suzan Song, MD, MPH, PhD, division director of Child/Adolescent and Family Psychiatry and associate professor, George Washington University, told Annals. “We chose to focus on physicians due to the higher rate of completed suicide as compared to the general community, and the physician profile of being self-reliant, wanting to help others, not ourselves, leading to a stigma against seeking mental health care.” When physicians call the support line, what issues do they need to discuss? “The most common concerns are feeling anxious and fearful of contracting COVID themselves or exposing family members, general fatigue and exhaustion, and family-related issues,” Dr. Song noted. “Most all callers at some point apologize for taking up our time, but we are here specifically for physicians!” The American College of Emergency Physicians (ACEP) also now has a chat room in which emergency physicians can confer with peers, “Let’s Talk” EngagED Forum, ACEP’s only member forum that allows anonymous posts.

Despite these efforts, many physicians still feel reluctant to seek out mental health care because of the perceived stigma associated with doing so. Indeed, Feist wonders how much fear of being ostracized factored into her sister’s death. “Even before she went into the hospital, she felt a lot of pressure to fight the fight along with her colleagues,” said Feist. “The fact that she couldn’t stay at work—she felt like that was a sign of weakness, and if her colleagues could stay, then what was wrong with her?” Dr. Breen’s brother-in-law, J. Corey Feist, JD, MBA, chief executive officer of UVA Physicians Group, the group practice of the University of Virginia, added, “She felt like being held at the psych unit was something she could never come back from, like that was effectively the end of her career.” The relevance of the Feists’ insights are underscored by what Dr. Gold knows from her research. “Physicians often feel guilty if stepping away from care as they feel huge responsibility for patients and do not want to burden their colleagues,” she said. “Even in a pandemic where the normal response would be to feel overwhelmed at times, physicians may feel shame admitting to these feelings.”

Prompted by Dr. Breen’s death, the Feists are now working to change the culture. The Dr. Lorna Breen Heroes’ Fund will raise money to help provide mental health support for health care professionals. “I would like for all physicians and health care providers to recognize that the stress of providing health care can very quickly escalate from difficult to overwhelming,” said Feist. “It is so important for all of our providers to recognize this fact, take care of themselves and each other, and to get help if they need it and when they need it. There is no shame in taking a break.” Those within the medical community should also help change the culture, Dr. Song argued. “We need to tackle the stigma around emotional distress and mental health problems by having leadership and other physicians vocalize their own stories and show how normative it is to both experience mental health problems and seek support,” she said. Beyond that, she said, more physicians should be in administrative positions so they have the power to prioritize and promote physician well-being.

Beyond the culture of medicine, many state licensing boards help to institutionalize the stigma associated with seeking care by asking about mental health diagnoses and treatments on applications. Dr. Gold argues for the elimination of all such questions, pointing out there is no evidence that a physician who seeks treatment for depression or anxiety poses a threat to patient care. “Duty for fitness should be based on behaviors and functioning, not on diagnoses,” Dr. Gold added. “States are slowly making changes, but there are too many physicians who could benefit from mental health care who still avoid it due to these questions.”

After Dr. Breen’s death, one of her senior colleagues, Lee Goldman, MD, MPH, executive vice president and dean of the Faculties of Health Sciences and Medicine, and chief executive of CUIMC, sent a letter to the CUIMC community in which he noted that Dr. Breen’s death underscored how important it is for physicians to talk openly about their mental health needs. “[N]one of us should assume that the coping mechanisms we have developed and relied upon in the past will be sufficient in these unprecedented times,” he wrote. “What many of you do every day is truly heroic, but please remember that even heroes are not invulnerable and that asking for help is not a sign of weakness but rather a sign of self-awareness.”

If you are having thoughts of suicide, you can avail yourself of the resources described above; call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK); text HELLO to 741741, the free and confidential Crisis Text Line; or go to SpeakingOfSuicide.com/resources for a list of additional resources.

Section editors: Truman J. Milling, Jr, MD, and Jeremy Faust, MD, MS