From Anxiety To PTSD: The Psychological Toll of The Front Line


An NYU Langone psychiatrist on efforts to help healthcare workers cope amid hospital war zones

Hospitals have turned into war zones. Although the enemy, Covid-19, is invisible, healthcare personnel are experiencing emotions familiar to soldiers in battle — think grief, loneliness, hopelessness, and even guilt. I turned to Dr. Charles Marmar, Chairman of the Department of Psychiatry at NYU Langone Health, to understand the psychological impact of the pandemic on these workers and what’s to come.

Katie Couric: From the very beginning, I’ve been very concerned about the mental health of these frontline medical workers. Can you just tell me kind of in a nutshell from a mental health perspective, what dealing with this pandemic has been like day in and day out for the medical community?

Dr. Charles Marmar: Well, it’s been extraordinarily challenging, stressful, heartbreaking, and super demanding. While many of our frontline healthcare workers are caring for patients, some of them are dying in much larger numbers at a pace that’s emotionally very difficult.

I work at NYU Langone Health. We usually have the lowest mortality of any major academic center medical center in the country, and now, we’ve had a huge number of deaths. So you can imagine it’s shocking.

We’ve also had to redeploy a large number of staff, who are now working outside their normal comfort zones. The shifts are long.They’re only beginning to fully understand Covid-19’s complications and how to treat them. And on top of that, they worry about bringing the disease home with them or falling ill themselves.

What are some of the psychological symptoms of working under these circumstances?

The first is exhaustion. The second is insomnia, and behind that, are a series of psychological symptoms. But first, let’s talk about some of the common reactions people have to these kinds of disaster situations. The reactions include such things as grief, loss, fear, isolation, loneliness, feeling guilty that you can’t do more to save people, and feeling responsible for those who die. It’s a combination of reactions and then over time, in a minority of frontline workers, we do see significant symptoms of acute stress disorders, depression and anxiety disorders.

Isn’t it too early to say that the majority of healthcare providers are going to be fine, because we haven’t gotten to the other side of this pandemic?

Many, with great courage and strength, have been able to work through this and perform amazingly well under extreme stress. But I think you’re correct, we don’t yet know the outcomes of this new disease and we don’t know the true psychological cost to the frontline.

A lot of people have likened this to a war and you’re an expert in PTSD. When things calm down, what kind of psychological ramifications and symptoms might some of these front frontline workers exhibit?

We’ve learned a lot from the war zone that applies here. First, in fairly large numbers of frontline healthcare workers, we have some symptoms of acute stress reaction. That means exhaustion, insomnia, difficulty relaxing, some sense of burnout and feelings of guilt and anxiety.

When people become troubled repeatedly by thoughts, images, and memories of their frontline experience, develop persistent insomnia, and more, those are symptoms of early post traumatic stress disorder, depression or generalized anxiety.

What is being done for these frontline workers to ensure that they are staying strong psychologically in addition to physically to contend with all the pressures this pandemic is posing?

When this pandemic seriously erupted in New York, our first step was to work with our colleagues in Child and Adolescent Psychiatry to build a website with educational information and support resources.

Anyone can quickly go there and learn about common acute stress symptoms and how to manage them. The next thing we did was create 40 support groups to serve general faculty and particularly high-risk groups — like emergency medicine personnel, frontline nurses that are dealing with death. And the support groups are ongoing. We have 500 NYU employees in them.

We set up something that we call gravity rounds. We’ve redeployed very experienced, psychiatric nurses from our inpatient psych unit, and deployed them to the frontline. They walk through the hospital and spend time huddling and touching base with the frontline personnel in a non-stigmatizing way.

We also developed expert psychological and psychiatric treatment services for those who need them.

Is there still a stigma among medical professionals about asking for help?

The stigma for mental health services remains profound at every level of society. In the general community, we’ve made enormous progress in understanding, diagnosing and treating psychiatric disorders, and yet so many people do not seek care.

Particularly one of the groups that’s most difficult for us to engage are the front line physicians. Anyone who goes into fields like emergency medicine, law enforcement, and the military service, is usually highly self-reliant. They have a culture in which they don’t want to acknowledge their own vulnerabilities, for a fear that it undermines their sense of ability to cope with the challenge.

They also want to be able to present themselves as strong to their patients, their colleagues and their families.

How do you de-stigmatize this? These medical professionals are not only trying to save lives, they’re trying to connect patients with their families and then having to be grief counselors for families. They must feel so terribly inadequate in this setting. Medical workers are supposed to heal, but there’s so many things that are demanding their time and energy. It must be so overwhelming.

And there are some practical things we can’t ignore. We’re lucky at this hospital that all of our frontline personnel have had very good protective equipment. They have ventilators, and other tools to fight the war. That isn’t true in all settings.

You have to realize people have different skill sets, and you want them in different roles performing different functions. If you have a particularly empathetic emergency room physician, they spend more time with the families, while someone else might be better working out technical parameters.

The medical community and the world at large was shocked to learn that an NYC ER doctor, Dr. Lorna Breen, took her life when she was home in Charlottesville, Virginia. Are you worried that other medical personnel are at risk for this kind of thing?

It’s heartbreaking. She was a leader in her field, and mentored and trained a number of the excellent emergency room doctors at NYU, so we felt a loss very directly that way.

It’s a real concern and intensifies all of our efforts to provide more real time support and our own team has made a special outreach to our emergency doctors. At NYU, we’re going to provide them with a very simple set of questions. If they screen positive for stress, anxiety, and depression, it links them to further resources. We would like anyone who’s felt stressed by this situation to seek care sooner, rather than later.

We’ve also been learning more and more about the impact of Covid-19 and I don’t think there’s been a lot of discussion about the neurological impact of the virus.

Can you elaborate on that for us?

There’s data from China that says at least one third of the more serious hospitalized Covid-19 cases have some significant neurological involvement. This virus affects the brain — probably subtly in many, but fairly dramatically in a minority. It can rarely cause significant strokes.

It’s not limited to respiratory environments. It attacks the kidneys, the liver, the gastrointestinal tract, and it can certainly attack the brain. And that is very concerning.

What about the deeper psychological problems like depression or anxiety that can be the result of a chemical imbalance — have you seen Covid-19 have an impact on some of those psychological conditions?

It’s too soon to know for sure. But we know other viral infections, in the same family, are known to trigger biological depression, particularly in individuals who may have some genetic predisposition.

It’s unclear about the psychological impact on many of these frontline workers. Should there be a more coordinated response to ensure that there is some standard of care for all these people who may find themselves extremely vulnerable once they let that let down their guard and things start to return to normal?

Yes. And that process has started. I’ve been a member of the American Psychiatric Association’s Committee for the Psychiatric Dimensions of Disaster, and we’re developing policy statements to distribute nationwide. We’ve been dealing with a whole range of issues: Who should be selected for the front line? How should they be prepared? Who is greater at risk for psychiatric difficulties?

Our nation failed to respond to the enormous psychological and psychiatric needs of the Vietnam generation for more than a decade. Those lessons have been learned and can be quickly applied in this context.

There will unfortunately, to some extent, be a wave of psychiatric and psychological difficulties. What we don’t want is for those to lead to tragic consequences.

This interview has been edited and condensed.

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