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Mental Health Treatment for Front-Line Clinicians During and After the Coronavirus Disease 2019 (COVID-19) Pandemic: A Plea to the Medical Community

The COVID-19 pandemic has placed front-line health care professionals—who were already at higher risk for negative effects of chronic stress before the pandemic—at even greater risk for depression and anxiety. This article reminds us of the importance of mutual support and caring for our own mental health, including seeking help from our mental health colleagues when needed.

is an unprecedented health care crisis that is challenging and overwhelming both institutions and individuals. The pandemic has created anxiety and fear in health care providers, from physicians and nurses to allied professionals and first-line responders. We fear for our safety and the safety of our families and patients. We grieve for those who have died. We feel guilt for not being able to save all of our patients, for getting sick ourselves, and for abandoning our families. Many have adopted the phrase "We will get through this together," but none of us will survive unscathed.
Regardless of our training, backgrounds, or personal strength, we are all human and are affected by pain and loss. These experiences make us susceptible to fear, anxiety, and stress-emotions sharing a neurobiological cascade that prepares a physiologic response for our body to respond and adapt to challenges. Stress exposure alters the function of brain circuits involved in fear detection, mood regulation, cognitive performance, and decision making. These changes shift our systemic physiology, altering autonomic, endocrine, and immune system function (1). For short periods, these changes are adaptive. However, for some, these changes persist after the danger has passed and become maladaptive. Under conditions of chronic stress, our brains undergo structural and functional changes in an attempt to adapt to the changing circumstances. Such shifts include plasticity changes in brain regions, including the hippocampus and amygdala; disruptions in the circadian system; and persistent epigenetic changes to regions of the genome affecting these neural and physiologic systems, such as glucocorticoid receptor expression (1). Although health-promoting behaviors can reduce the negative effects of chronic stress, in times of crisis the extent of the trauma may overwhelm our ability to cope. Longer-term physiologic changes contribute to immune suppression, cardiac disease, and obesity while also increasing the risk for burnout, depression, posttraumatic stress disorder, and addiction.
Unfortunately, evidence suggests that health care professionals are already at higher risk for negative effects of chronic stress. Even before the pandemic, physicians exhibited higher rates of depression and anxiety than other professional groups (2). Although the physician suicide rate has decreased in the past 30 years, female physicians remain at higher risk for suicide than other women (3). Early evidence from China found that 70% of physicians and nurses reported high levels of distress during the pandemic, with approximately 50% reporting significant depressive or anxiety symptoms, and the greatest symptom burden was reported on the front lines (4). The United Nations recently highlighted front-line health care workers as being particularly vulnerable to developing mental health needs during the pandemic (5). For front-line clinicians, sheer force of will cannot sustain us in the months ahead.
The good news: We can decrease our risk for burnout and long-term negative consequences. First, we must practice self-care by taking time to eat, sleep, and rejuvenate (6). Intentionally creating even brief moments of lower stress through mindfulness meditation can reduce both physiologic stress markers and depressive and anxiety symptoms (7,8). To make the time required to recover, we need to lean on our social supports, including our colleagues, coworkers, teammates, friends, and families. They will understand because they have the same fears, challenges, and needs. Second, social distancing cannot mean social isolation. Support groups of peers (6) or informal opportunities to share our experiences are invaluable. Third, monitoring and early detection of potential problems is crucial. Look for warning signs in yourself and others. Monitor for maladaptive behaviors, such as sleep disturbances, increases in drinking or smoking, use of illicit drugs, or feelings of hopelessness or helplessness (5). Fourth, if you are struggling, ask for help early. Psychiatrists and psychologists have a range of effective treatments, including brief, focused psychotherapy; group therapy; and, if needed, prescription medication. Many medical centers have employee assistance programs primed to provide assessments and support. If you are in a smaller program or team, look to the burgeoning community efforts, where psychiatrists, psychologists, and other providers are offering assistance. Finally, do not ignore these signs in your colleagues. They may be struggling and need your concern and support.
Health care workers, particularly physicians, are often reluctant to seek mental health care. Reasons are often related to stigma, including fears of discrimination in credentialing or licensure, negative effects on career advancement, consequences to liability insurance, and a medical culture that can view help-seeking behavior as a sign of weakness (9). Although this stigma discourages seeking care, the consequences for untreated mental health disorders are substantial. Beyond increasing risk for addiction or suicide, physicians with untreated mental health disorders provide lowerquality care, exhibit reduced productivity, and report lower work satisfaction (10). Asking for help should not This article was published at Annals.org on 26 May 2020.

IDEAS AND OPINIONS
be a source of shame but rather an acknowledgment that you are as vulnerable as everyone else to tragedies and stress. As difficult as it can be to ask for help, do it for those around you. Do it for your patients. Do it for your colleagues and teammates who care for you and depend on you. Most important of all, do it for yourself and your families. Ask for help before stress, anxiety, and depression become entrenched and injure those you care the most about. Do not let this moment destroy all that you are fighting for.
The public is showing how they value the contributions and sacrifices of the health care community. It has been generations, if ever, since we have seen the outpouring of love and gratitude that we are witnessing today. We see applause and cheers directed to frontline personnel spanning the balconies of New York to hospital parking lots to individual neighborhoods as providers return home after long shifts.
As mental health professionals, this is our plea: If you are struggling, let us help you. Front-line clinicians, emergency department and intensive care unit teams, first responders, and EMS units all face unprecedented challenges. We must support each other. If you need help, please allow mental health professionals the privilege of supporting you.