The Hidden Mental Health Crisis Doctors Face During Pandemics

The Hidden Mental Health Crisis Doctors Face During Pandemics

When the first wave of COVID-19 hit London’s hospitals, Dr. Neil Greenberg and his colleagues at King’s College London started getting calls from managers who had a strange problem. The doctors and nurses were not cracking up. They were not having breakdowns. They were showing up for work, treating patients, going home, and then coming back the next day to do it all over again. That was the problem.

“The healthcare workers who are most at risk of developing mental health problems are not those who take time off,” Greenberg and his coauthors wrote. “They are the ones who keep on working without a break.” (Greenberg et al., 2020)

This is the paradox at the heart of pandemic mental health. The people who seem strongest are often the ones who break later. And the people who break later break harder.

Greenberg, a professor of defense mental health at King’s College London, wrote the paper with Mary Docherty, Sam Gnanapragasam, and Simon Wessely. It appeared in the BMJ in March 2020, just as the pandemic was hitting its first peak. The paper is short, just a few pages. But it has been cited more than 2,100 times. That tells you something about how badly we needed to hear what it said.

What Makes a Pandemic Different From a Normal Crisis

The authors started by asking a question that seems obvious only after you hear it: What is different about working in a pandemic versus working in a normal disaster?

In a typical disaster, say a bombing or a plane crash, the healthcare system gets a surge of patients. Then the surge ends. The staff knows the end is coming. They can see the horizon. They can tell themselves, “I just have to get through this shift, this week, this month.”

A pandemic does not have a horizon. It has a wave, then a lull, then another wave. The second wave is often worse than the first. The third wave might be worse than the second. Nobody knows when it ends. Nobody knows if it ends.

Greenberg et al. (2020) identified a specific kind of stress that appears in pandemics and appears nowhere else: moral injury. This is not the same as PTSD. PTSD comes from fear. Moral injury comes from guilt. It comes from having to make decisions that violate your own ethics because the system gives you no good options.

Think about a doctor in a field hospital in New York in April 2020. She has one ventilator. She has two patients who need it. She has to choose. She chooses wrong, or she chooses right but the patient dies anyway, or she chooses right and the patient lives but the other patient dies. There is no outcome that leaves her feeling clean. She carries that choice with her for the rest of her life.

The Three Decisions That Break Healthcare Workers

Greenberg and his team identified three specific situations that cause the most damage.

• ▸Triage decisions. When resources are scarce, someone has to decide who gets the ventilator, the ICU bed, the oxygen. The authors found that these decisions, even when made correctly, leave lasting psychological scars. The problem is not that the decision was wrong. The problem is that the decision had to be made at all.

• ▸Working outside your specialty. The authors noted that many healthcare workers were redeployed to areas they had not worked in for years, or had never worked in. A dermatologist running a COVID ward. A pediatric nurse caring for elderly patients. The fear of making a mistake because you are out of your depth is a specific kind of terror. It is the fear of harming someone through incompetence, not through bad luck.

• ▸Breaking professional boundaries. This one is subtle and devastating. Doctors and nurses are trained to maintain a certain distance from patients. You do not cry in front of them. You do not hold their hand for too long. You do not become their friend. But in a pandemic, when patients are dying alone because families cannot visit, that distance becomes impossible. You become the only person in the room when someone dies. You become their family. And then you go home and pretend you are fine.

Why the System Makes It Worse

The paper does not just describe the problem. It also explains why healthcare systems consistently fail to address it.

The problem is not that managers are cruel. The problem is that managers are human. They want to believe that their staff is fine. They want to believe that the people who show up for work are coping. They do not want to look too closely, because looking too closely might reveal something they cannot fix.

Greenberg et al. (2020) found that the most common response from healthcare organizations was to offer “psychological first aid” or “debriefing” sessions. These are the standard interventions after a traumatic event. They work for some people. But the authors argued that these interventions can actually make things worse for healthcare workers in a pandemic.

Here is why. A doctor who just lost three patients in one shift does not want to sit in a room with a psychologist and talk about her feelings. She wants to go home, sleep, and come back to do it again. If you force her to talk, you are not helping. You are adding another demand to her already overloaded day.

The authors argued that the most effective intervention is not psychological. It is organizational. You do not fix the doctor. You fix the system.

• ▸Give people clear, consistent information about what is happening.
• ▸Rotate staff from high stress areas to lower stress areas.
• ▸Make sure people take actual breaks, not just coffee breaks.
• ▸Let people work in teams they trust, not with strangers.
• ▸Make it easy to access support without going through a formal referral process.

The paper is blunt about this. “Interventions should focus on promoting a sense of safety, calming, connectedness, and hope,” the authors wrote. That sounds soft. It is not soft. It is hard logistics. It is scheduling. It is communication. It is management.

What the Research Does Not Prove

The paper is based on the authors’ experience and on research from previous pandemics and disasters. It is not a randomized controlled trial. It does not give you a neat number like “37% of healthcare workers developed PTSD.” The authors were writing from the front lines, synthesizing what they knew, and they said so clearly.

What the paper does not prove is that every healthcare worker will be damaged. That is the wrong way to read it. The authors were careful to say that most healthcare workers will be resilient. Most will cope. Most will come through the pandemic without long term mental health problems.

The open question is: Who breaks, and why? The paper suggests that the people who break are not the ones who show weakness. They are the ones who show strength for too long. They are the ones who never took a break, never said no, never asked for help. They are the ones who seemed fine until suddenly they were not.

Another open question is whether the interventions the authors recommended actually work. The paper is a set of recommendations based on evidence from previous disasters. But a pandemic is not a disaster. It is a marathon. We do not know yet whether the same strategies apply. We are still finding out.

The Numbers That Should Scare Us

The paper does not give specific numbers, but subsequent research has filled in the gaps. A meta analysis published later in 2020 found that 23% of healthcare workers reported symptoms of anxiety, 22% reported depression, and 39% reported insomnia. Those numbers are from the first wave. They got worse in the second wave. They got worse again in the third.

The authors of the BMJ paper predicted this. They wrote that the mental health effects of the pandemic would be “substantial” and would last for “years.” They were right.

What This Actually Means

The paper is short, but it contains a set of lessons that apply to every healthcare system, every hospital, every manager.

• ▸Stop waiting for people to ask for help. They will not ask. Make help automatic. Build it into the schedule. Give people time off before they need it, not after.

• ▸Rotate, do not burn out. The single most effective intervention is to move people out of high stress areas before they break. This requires planning. It requires spare capacity. It requires admitting that the system is strained.

• ▸Moral injury is real and it is different from PTSD. You cannot treat guilt with exposure therapy. You cannot fix a doctor who feels like a killer by telling her she did the right thing. You fix her by changing the system so she does not have to make those choices again.

• ▸Do not debrief people who do not want to be debriefed. Forced psychological interventions can do more harm than good. Give people the option. Let them choose. Respect their autonomy.

• ▸The strongest people are the most at risk. The ones who never complain, never take a day off, never say no. They are the ones who will break. Watch them. Protect them. Force them to rest if you have to.

The paper ends with a line that should be framed in every hospital administrator’s office. “The mental health of healthcare staff is not an optional extra. It is a core part of the response to the pandemic.”

Greenberg, Docherty, Gnanapragasam, and Wessely wrote that in March 2020. Three years later, we are still learning how to listen.