Responding to the hidden pandemic for healthcare workers: stress

Healthcare workers are having to work under incredibly stressful conditions. Videoconferencing can be harnessed to provide mental-health support, but some report ‘tele-health’ fatigue. To protect public health, prepare for the mental-health surge among healthcare workers.

In the COVID-19 pandemic, frontline healthcare workers are having to work under particularly intense stress levels. They must work in makeshift settings created to handle the overflow of patients from intensive care units, sometimes with inadequate access to optimal protective equipment. They often need to cover additional shifts to compensate for the absence of their colleagues who have become ill or who are quarantined. They must quickly adapt to medical interventions as they are asked to intervene outside of their typical area of medical expertise. Day after day, they must optimize the treatment of patients with COVID-19 and make complicated clinical and ethical decisions that affect the mortality of their patients, at unprecedented rates.

Credit: John Krystal

It will be important to identify and support healthcare workers who are struggling in the context of the pandemic1. Experience with the Ebola virus suggests that healthcare workers experience extremely high stress2. In the case of COVID-19-related stress, one would expect symptoms that include preoccupation with the risks of COVID-19, compulsive attention to COVID-19-related news, insomnia, healthcare work–related anxiety, guilt, bereavement, avoidance of returning to the healthcare setting, irritability, intrusive thoughts, nightmares and depression.

For most people, these symptoms will resolve without intervention. However, if not addressed urgently, these symptoms may contribute to burnout and functional impairment among healthcare workers.

Moreover, natural disasters both cause post-traumatic stress disorder and increase the rates of other psychiatric disorders, including mood and anxiety disorders and addictions, which may cause another wave of stress-related difficulties for healthcare workers and others profoundly affected by the pandemic.

Thankfully, this pandemic has arrived in the digital age, which provides some avenues for remote mental-health support. At Yale School of Medicine, for example, under the leadership of Jack Tebes, we created ‘Stress and Resilience Town Halls’ that are provided virtually and without charge to faculty, staff and trainees twice each day, Monday through Friday. These town halls are led by experienced faculty members and psychiatry residents who donate their time. The Yale Stress Center, led by Rajita Sinha, is leading web-based courses on mindfulness meditation and is staffing virtual sessions focused on the COVID-19 pandemic. The programs developed and implemented at Yale are mirrored by similar initiatives at other institutions across the country. An array of digital applications, ranging from actigraphs to mobile phone–related heart-rate monitors, could be used to provide feedback on the stress levels and disruption of circadian rhythms of workers.

Recently, videoconferencing platforms have also been harnessed for the delivery of mental-health treatment, and this move has been quite well received overall. Previously, ‘tele-mental health’ was the province of large healthcare systems, such as the US Department of Veterans Affairs medical centers. However, there has been a revolution in remote behavioral-health care, seemingly overnight. At Yale, as with the psychiatry departments of Columbia University, Johns Hopkins University, McLean Hospital, Massachusetts General Hospital, the University of California San Francisco, etc., nearly all ambulatory mental healthcare has been converted to virtual meetings. Although tele-mental health has already been implemented in many parts of the world, the COVID-19 pandemic has revealed its feasibility and utility on an unprecedented scale. These insights may help to reduce disparities in access to mental healthcare across the globe. Having participated in one form of the future of mental healthcare, it is unlikely that it will fully return to the earlier status quo.

Paradoxically, this has created some new stresses. Some healthcare workers are beginning to complain of ‘videoconferencing fatigue’. During this crisis, they find themselves in virtual meetings on a nonstop basis from early in the morning until the evening. Some mental-health workers complain of isolation from their colleagues or of feeling detached from their patients. Other clinicians have reported surprise that the high rate of adherence to virtual treatments has robbed them of breaks they used to recoup their emotional equilibrium. HHealthcare workers providing treatment or teaching from home must also manage childcare and other family responsibilities.

Societies around the world are counting on their healthcare workers to meet the medical challenges presented by COVID-19. The frontline healthcare workers are heroes who are putting themselves at risk for the sake of others. But this puts those healthcare workers at enormous risk of stress-related symptoms and even persisting adjustment-related problems. Our healthcare providers should be able to count on the healthcare systems in which they work to protect their mental health as well as their medical health. Providing mental-health support to healthcare workers is a crucial part of the overall mobilization of healthcare systems to combat COVID-19. During this pandemic, as in everyday life, there is no health without mental health.


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Supported by a National Institute of Health Grant, Yale Clinical & Translational Science Award (5UL1TR0018663; J.H.K. and R.L.M., co-directors).

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Correspondence to John H. Krystal.

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Krystal, J.H., McNeil, R.L. Responding to the hidden pandemic for healthcare workers: stress. Nat Med 26, 639 (2020).

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