Correspondence Address:
Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India

Full Text



The SARS-CoV-2 (COVID-19) pandemic has emerged as a global health problem.^[1],[2] The landscape of coronavirus is changing rapidly, with new hot spots emerging across the world, and currently, the entire world had succumbed to the clutches of the deadly virus. The infection is very contagious, with a high rate of person-to-person transmission.^[3] This has led to strict quarantine measures and adaptation of social distancing across the globe. The number of confirmed cases and mortality associated with the COVID-19 infection is increasing day by day.^[2] The pandemic has led to significant fear and uncertainty, as there is a threat to one's own survival.

The physical outcomes of COVID-19 infection among people vary from being asymptomatic to severely ill people, requiring ventilatory support. However, the proportion of people requiring the ventilatory support or oxygen support is much less than those with minor symptoms or those being asymptomatic. At this moment, the major emphasis is on the diagnosis, management, and prevention of COVID-19, to minimize the mortality.

The COVID-19 pandemic had proved to be one of the deadliest fear of the humankind and had given a severe blow to the health-care system of the modern world. It has evolved as a major crisis for health-care workers (HCWs).^[3] The HCWs are the frontline warriors facing the COVID-19 crisis tirelessly since the outbreak of the illness in different capacities and caliber. Along with working in adverse circumstances, they have to protect and safeguard themselves from getting infected as well as have to take care of the ailing patients infected by COVID-19. The pandemic has broadened the role of HCWs from just managing patients to doing the contact tracing, managing people during the quarantine, ensuring proper quarantine, and taking care of the needs of people under quarantine. In addition, other issues which have cropped in due to lockdown include the mental health issues of migrant laborers,^[4],[5] mental health crisis during lockdown^[6] and deterioration of preexisting medical conditions^[7] in a significant proportion of the population. This has further led to an added burden on the existing health-care services.

However, while carrying out these activities, the HCWs are have been found to be subjected to violence, ridicule, and stigmatization by the patients, their family members, people in the society, police, bureaucrats, politicians, and their own colleagues.^[8] The HCWs handling the administrative issues are under a lot of pressure from the first-line workers and also from the policymakers, to ensure proper care of patients and, at the same time, take care of the economic issues. The HCWs not involved directly in the care of patients with COVID-19 infection are under pressure to provide services to patients with other ailments. The HCWs involved in the care of people without COVID-19 infection are, in fact, under much more stress than others, because they do not have adequate personal protective equipment (PPEs)/protective gear, and are not sure about the COVID-19 status of the patient.

HCWs involved directly in the care of people with COVID-19 infection are always under a constant fear of contracting the infection either due to possible breach in the PPEs or due to inadequate PPEs to safeguard themselves during different procedures.^[9] Across the world, the infectivity rates in the HCWs and subsequent deaths in the HCWs are alarming.^[10],[11] Some of the HCWs are posted in isolation areas/wards, and intensive care units are with inappropriate training and experience.^[12],[13] Moreover, some of the HCWs have difficulty in using the PPEs, because of lack of experience of using the same in the routine practice. The use of PPEs is also associated with a sense of suffocation and physical discomfort.^[14] The use of PPEs takes away the usual communication and empathy between the doctor and the patient. The HCWs involved in the care of people with COVID-19 are also facing deaths, situations which require ethical and legal decision-making, prioritization of resources, staying away from their families, isolation, and loneliness. In addition, the HCWs are facing significant burnout^[15] and are overworked, and all these issues are taking a heavy toll on the mental health of HCWs.^[16]

Among the medical student population, the issues are much more varied. Besides carrying out the care of patients with COVID-19 patients, the trainee residents are at the forefront and are the actual first-line workers involved in screening, triage, and providing care to patients visiting any hospital. Hence, they are at the maximum risk of exposure to COVID-19 infection. There are media reports of resident doctors, removing their PPEs and face shields to save the life of patients with COVID-19 infection.^[17] Further, accidental exposure is leading to havoc among the HCWs. At places, the trainee residents are under pressure to continue with their academic schedules and, at the same time, carry out with their duties. Some of the students, who are supposed to complete their thesis/dissertation in the near future, are at a loss, as they had planned to complete their research data intake and write the thesis/dissertation during this time. The pandemic has disrupted their data intake and led to a situation, where many studies have to revise the number of participants committed for their research work.

As the pandemic is evolving, some of the faculty members and the trainee residents have also got involved in the COVID-19 research and are facing a pressure to complete the research work rapidly, because they are not sure about the value the research will have once the pandemic is under control.

People working in the private sector are facing difficulties in the form of providing services, with no governmental support for PPEs. At the time, when a number of patients are anyway less than the usual flow, the people in the private sector are facing the double jeopardy.^[18] Further, the people in the private sector have to go back home, without any quarantine, resultantly also risking their family members from getting infected. The frontline health workers, working with confirmed or suspected cases of COVID-19, reportedly have also been encountering excessive workload, inadequate testing, fear of spreading the infection, and discrimination.^[12] In addition, those doctors providing teleconsultations, as per the rules^[19] and many others, have been subjected to violence and assaults.^[8]

The additional stress for all the HCWs is the problems occurring between different groups of workers (i.e., doctors, nurses, paramedics, and hospital attendants) and also among the same group of workers (i.e., for example, doctors from different specialties are finding it difficult to work together). All these factors are leading to significant psychological strain, mental health problems, moral injury, and stigmatization, besides the fear of infection for themselves and their families.^[20] Online surveys from different parts of the world suggest that the medical professionals are at risk of and had a higher prevalence of insomnia, depression, bereavement, anxiety, fear, trauma, somatization, and obsessive–compulsive symptoms as compared to nonhealth workers.^[21],[22] The studies were done during SARS outbreak and also reported psychological distress among the HCWs.^[21],[22] Furthermore, health-care workers experience stigmatization because of the presumed association of all the HCWs with patients with COVID-19 infection.^[23],[24] Data emerging from India too suggest that a significant proportion of the HCWs are experiencing depressive and anxiety disorders^{[25],[26],[27]} and other negative emotions such as loneliness, social disconnectedness, anger, and fear of infecting their family members.^[25],[26]

Accordingly, it can be said that COVID-19 infection is emerging as a major mental health crisis not only for the general public at large but also for the HCWs. Emerging data are suggesting that increasing stress is making the HCWs vulnerable to physical enervation, insomnia, and psychological distress.^[16] A cross-sectional study of 1257 health-care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in China showed that a “considerable” proportion of health-care workers reported symptoms of depression, anxiety, insomnia, and distress with reportedly more in women, nurses, those residing in epicenter, and directly engaged with suspected or confirmed COVID-19.^[16] These mental health problems affect HCWs' attention, understanding, and decision-making ability, which can hamper the care of patients. Some of the HCWs are contemplating resignation due to stress and work overload.

Although now there are guidelines for working for HCWs, these cannot be implemented, because of a scarcity of medical staff or because of the fact that a proportion of the staff is quarantined after coming in contact with patients with COVID-19 infection.

Considering a high level of stress, there is a need to provide mental health support to all the HCWs. The training programs, which mainly focus on doffing and donning of PPEs, should incorporate the components of mental health self-care, with special focus on issues while working with patients diagnosed with COVID-19 infection. These can include how to deal with anxiety of self, suffocation while in PPEs, communicating with the patient and coworkers, taking care of the psychological needs of the aggrieved patients, dealing with issues of self after the duty hours, and maintaining own mental composure while on duty and quarantine. The HCWs are usually not very used to remain ideal for long, which itself can be very distressing while off duty and during the quarantine. Providing training with respect to how to plan the period of quarantine, with respect to engaging self in work and interaction with others using telephone or online communication methods can be helpful, as many of the HCWs are not used to these. The HCWs should be equipped with stress management techniques such as relaxation exercises, breathing exercises, skills to organize their work, and sleep hygiene measures to prevent insomnia. Depending on the availability of the workforce, all the HCWs to be posted in areas with patients with COVID-19 infection must be screened for mental health issues by using questionnaires to assess the level of stress, anxiety, depression, substance use/dependence, etc.^[3] The screening can be followed by evaluation by the mental health professionals. In addition, regular mental health crisis helplines should be made available to all the HCWs, so that they can approach the mental health professionals at the time of the need. The HCWs, who disclose their mental health issues, should not be discriminated and stigmatized as those who are trying to run away from their duties.^[3] There is a need to be sympathetic toward them.

The HCWs working in non-COVID area must be provided with proper PPEs, and if these are not required, they should be provided evidence-based information about lack of need of particular level of PPEs in their patient encounters to allay their anxiety. Although the Government of India has approved the rules for teleconsultation,^[19] at present, all the HCWs, are not much acquainted in providing teleconferencing consultations across the different specialties. Further, the public is not aware of the governmental rules and regulations about the teleconsultations. Accordingly, there is a need to develop public awareness programs about the legitimacy of the teleconsultations, especially with respect to the private practice and the associated charges. This is important because the public at large is not aware of the regulation and resultantly the doctors providing teleconsultations are being considered as “mean” in the hour of crisis, rather than being considered as people, who are providing their services and doing their duties, even in the adverse situation. Moreover, health professionals are facing social stigma and discrimination, as they are working with COVID-19-confirmed cases.^[23] People are asking them to vacate their rented accommodations and not interacting with them. Developing awareness programs to address these issues and proper legal provisions, for people indulging in discrimination, may be helpful. Possibly, after the pandemic is over, there will be a shortage of HCWs due to exhaustion and burn out.^[15],[28] Accordingly, the policymakers should start seeing beyond the pandemic to improve the workforce resources and also to keep the existing workforce intact.

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