HCFI Dr KK Aggarwal Research Fund

12^th June, 2021, Saturday, 9.30am-10.30am

Key points from the discussion

• A presentation on “COVID-19 and mental health of healthcare workers” was given by Dr Avinash Hosanagar, Assistant Professor, Michigan Medicine and Staff Psychiatrist, Ann Arbor VA
• Several studies have shown high prevalence of mental health problems in healthcare workers (HCWs) such as distress, depression, anxiety, insomnia; also, HCWs who feared infection of their close ones experienced high levels of stress, anxiety and depression. About one-third of HCWs experienced burn out syndrome (emotional exhaustion, sense of low personal achievement).
• Anxiety disorder and depression was highest among frontline HCWs and more so in those with clinical responsibilities. Nurses and female HCWs had more moderate to severe somatic symptoms.
• Gender and occupational differences were observed in a systematic review and meta-analysis with female HCPs and nurses showing higher rates of mood and anxiety symptoms than the male HCWs.
• When the cases are going up in the early phase, there is fear for basic needs, especially among the HCWs. As the situation plateaus, there is uncertainty of how things will evolve and when the situation shows a decline, we feel better but there is a need for processing of all traumatic experiences that people have undergone. 
• People go through emotional highs and lows. During the initial period, there is lot of heroism and people come together (resilience). As the pandemic continues, a period of disillusionment sets in; emotional lows occur during this period. This is followed by a very gradual period of restoration, where people work through their grief and adjust to their new lifestyle and situation and rebuilt. People experience negative emotions during the disillusionment period, lot of trigger events and anniversary reactions happen leading to psychological trauma manifesting as anxiety and depression.
• During a pandemic (disaster), people may have distress reactions in the form of sleep difficulties, decreased sense of safety, irritability, anger, distraction, isolation. They may also engage in risky behaviors such as alcohol, tobacco to cope with the stress. Family distress, interpersonal conflict/violence, disrupted work-life balance especially in the context of restricted activities.
• The challenges faced by HCWs are unprecedented during this covid times such as a high demand for medical services over a long period of time, HCWs have been forced to step up into roles outside of their areas of expertise, covid-19 management protocols are uncertain and still evolving, fear of contracting the infection and spreading it family members and coworkers. HCWs who get infected or experience burn out due to the high volume of the work may result in absenteeism and staff shortage.
• A survey of HCWs undertaken to identify their sources of anxiety revealed the following eight sources: Access to the right PPE; exposure to Covid at work and taking the infection home to their families; lack of fast access to testing if symptoms develop and fear of spreading the infection at workplace and uncertainty whether their organization will support and take care of their personal and family needs if they develop infection; support for transportation, food and family needs as work hours and demands increase; access to childcare when working extra hours and schools are closed; having the right skills if sent to work in a new area and lack of access to up-to-date information and communication. 
• APA experts committee has suggested that it is important to recognise that exposure to death (especially in high volumes) with ongoing risk for HCW for families is an extreme stressor. HCWs face challenges of workers with less experience of intensive care settings like ICUs, inadequate evidence base for treatment, insufficient resources including lack of optimal self-protection, obstacles to meaningful connection with patients and diminished access to HCWs support system such as families.
• Principles of psychological first aid have been advised, which include promoting a sense of safety as much as possible, helping them use self-calming techniques, promoting basic self care during the pandemic, encourage use of prior helpful coping mechanisms, access to stress reduction resources, create a sense of team, promote social support, monitor those in high distress and get appropriate additional mental health team support.
• It is important to be mindful of individual differences in response to death. One must focus on what we can control and accept what we cannot.
• Factors like the heavy workload, high death rates, and inability to follow usual routines increase the stress. Talking about these can help the HCWs. Their efforts during these times should be regularly recognised and honoured. 
• The leadership should actively respond to the needs and concerns of the HCWs, which include working without needed PPE or safeguards, witnessing human suffering, making life and death decisions, fear of infecting family members, separation from family, fear of getting sick and mental exhaustion.
• How can leaders help? By leading them with model behaviors (e.g. wearing masks at all times so that the rest of the team can follow), listen to them, protect them, prepare them (to be proactive when numbers come down), support them and care for them.
• Things that will help in this direction: Talk directly with your staff and listen, walk the floors weekly to show your support for workers, model the right way to put on and take off PPE, set up a buddy system, post or share tools and resources, give support to HCWs, communicate clearly, as often as possible and let teams know. Keeping them informed is critical. The more you talk to your team, the better prepared they will be to manage your patients.
• A new phenomenon of moral distress leading to moral injury in healthcare workers and its implication in work life has been described in this pandemic. Moral injury is known in psychiatry as occurring in military persons and is now being identified in HCWs.
• Moral injury is worsened when the healthcare system is overwhelmed when decisions have to be made about allocation of scarce medical resources to patients.
• All HCWs experience moral injury but in different domains. Moral injury will lead to burn out and ultimately poor productivity. 
• A “posttraumatic embitterment disorder” (PTED) has also been recognised.
• This moral distress would be carried over even beyond the pandemic as well.
• Toxic stress is related inflammatory processes and oxidative stress.
• There are no studies that have examined the impact of burn out syndrome on families and rest of the society specifically in terms of the current Covid-19 pandemic, but there are enough studies on the impact of burn out on work and productivity in a hospital system.
• Burn out results in smaller work force, people choosing other professions outside of medicine, less productivity in work on a day to day basis. All these affect the number of patients seen, the quality of care provided and the patient outcomes. Burnout has a huge economic impact.
• We need to learn from this pandemic and prepare the next generation for this. We must take note of what happened including mistakes that happened. This pandemic has exposed the fragility of healthcare systems. It is our responsibility to get the health care system where it needs to be for future situations.
• As leaders of NMAs, we have to make sure that we are heard. This is a time for advocating for healthcare resources that we need. We need to be more proactive.

Participants

Member National Medical Associations

Dr Yeh Woei Chong, Singapore, Chair CMAAO 

Dr Ravi Naidu, Malaysia, Immediate Past President CMAAO

Prof Ashraf Nizami, Pakistan, First Vice President CMAAO

Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer, CMAAO 

Dr Marthanda Pillai, India, Member World Medical Council

Dr Salma Kundi, Pakistan 

Dr Qaiser Sajjad, Pakistan 

Dr Angelique Coetzee, South Africa

Dr Akhtar Hussain, South Africa

Dr Md Jamaluddin Chowdhury, Bangladesh 

Invitees

Dr Russell D’Souza, Australia UNESCO Chair in Bioethics

Dr Shashank Joshi, Endocrinologist, Mumbai, India

Dr Monica Vasudev, Allergist-Immunologist, USA

Dr Nidhi Aggarwal, Pathologist, USA

Dr Mulazim Hussain Bukhari, Pakistan

Dr S Sharma, Editor IJCP Group

Dr Meenakshi Soni Barnwal, HCFI

Moderator

Mr Saurabh Aggarwal