The COVID-19 pandemic has brought on an unprecedented surge in critical care patients admitted to acute hospitals. Consequently, staff working in intensive care units (ICUs) have been overwhelmed with increased workloads and a variety of challenges.

Frontline healthcare workers have to face extended periods of potential exposure to the virus, alongside fears of contracting and spreading it to their loved ones (Hu et al., 2020; Urooj et al., 2020). Furthermore, they have to face the unpleasant reality of working so closely with the virus – the high mortality rate amongst COVID patients (WHO, 2020) and difficulty in providing adequate end of life support to patients and their loved ones are understandably distressing (Mohsin et al., 2020; Maguen & Price, 2020).

However, while we know of the psychological distress frontline workers experience from their work within the context of the pandemic (Greene et al., 2020; Lai et al., 2020; Rossi et al., 2020) we still don’t know how often this manifests into mental health disorders within ICU staff. Greenberg and colleagues (2020) aimed to fill this evidence gap by investigating the rates of probable mental health disorders in ICU and anaesthetic staff.

Methods

As part of a service evaluation, Greenberg et al. (2020) collected data in June and July of 2020 via an anonymised brief online survey from ICUs across 6 NHS hospitals with a bed occupancy ranging from 10-75 critically ill COVID patients. The ICUs included were identified through ICNARC (Intensive Care National Audit and Research Centre) data and local ICU reporting systems. The survey included questions from an array of standardised questionnaires, including:

• The Generalised Anxiety Disorder (GAD) Scale to measure anxiety
• The Patient Health Questionnaire (PHQ-9) to measure depression and thoughts of self-harm/suicidal ideation
• The Post-traumatic stress disorder checklist (PCL-6) civilian version to measure PTSD
• The AUDIT-C to measure alcohol consumption
• The Warwick Edinburgh mental wellbeing scale (WEMWBS) to examine both feelings and functioning aspects of mental wellbeing.

The authors conducted bivariate correlations to examine the relationship between different mental health measure scores. They also used logistic regression analyses to investigate differences in scores across the different professions in the ICU (e.g., doctors vs. nurses).

Results

The sample included 709 healthcare professionals. Of those, 291 (41%) were doctors, 344 (48.5%) were nurses and 74 (10.4%) were in other clinical roles.

While the majority of participants (N=415; 58.8%) reported good wellbeing, almost half (N=322; 45.4%) met the criteria for at least one of the following mental health disorders: PTSD (39.5%), severe anxiety (11.3%), problem drinking (7.2%) or severe depression (6.3%). 13.4% of the sample also reported having experienced thoughts of self-harm or sentiments of being “better off dead” within the past two weeks.

The authors also state that while doctors were more likely to report good wellbeing, nurses were more likely to meet the thresholds for PTSD, anxiety, and depression. Thoughts of self-harm and suicidal ideation were also reported in a significantly higher proportion of nurses compared to doctors or other clinical staff (19.2% vs 7.6% and 9.5% respectively).

In their investigations of the relationship between different mental health measure scores, the authors reported that higher scores on the WEMWBS, which measures mental wellbeing, were significantly associated with lower scores on all other outcome measures. They also found that measures of anxiety, depression, and PTSD symptoms were all significantly correlated with each other. However, there were no significant associations between any measure of poor mental health and alcohol consumption.

Conclusions

Staff working in ICUs reported high rates of probable mental illness and thoughts of self-harm, with 45% reporting symptoms of PTSD, severe depression, or a severe anxiety disorder. These mental health difficulties were especially prevalent in nurses. Those that met the threshold for one probable mental disorder were also considerably more likely to meet the threshold for another.

Strengths and limitations

This study has several strengths:

• Firstly, their inclusion of a range of NHS acute trusts across the UK, including both teaching and district general hospitals meant that they likely included a range of participants and experiences within their findings.
• Secondly, the anonymisation of the survey they used reduced the risk of social desirability biases affecting participants’ responses.
• Thirdly, the inclusion of a variety of ICU staff allowed the authors to briefly examine differences across professions.
• Finally, the use of validated measures to assess the mental health outcomes of interest means that we can be relatively certain that the authors are truly measuring what they set out to, and in turn, that inferences and conclusions made based on these scores are valid (Murphy & Davidshofer, 2001; Tsang et al., 2017)

However, there were also several limitations:

• The lack of demographic information means that the authors were unable to identify any other factors that may be associated with the high rates of probable mental disorders. For example, nurses in the UK are more likely to be young females (NMC, 2018), a group that is more likely to experience mental health difficulties (SAMHSA, 2020). Therefore, it’s difficult to ascertain whether these elevated rates are linked to some characteristic of the profession, or to the demographic.
• In addition, the use of self-report measures rather than gold-standard diagnostic interviews raises potential issues, such as participants misremembering their affective experiences when asked to look back on how they’ve been feeling (Lucas, 2018).
• Moreover, the lack of random selection may mean that a response bias has occurred, wherein individuals who were experiencing salient mental health difficulties were more likely to participate. It also means that these findings are not generalisable outside of this staff group.
• There is some ambiguity regarding their finding on self-harm; it’s unclear how common thoughts of self-harm are in ICU staff in general, so we can’t really tell if this is an elevated rate in comparison to pre-COVID.
• Finally, at the time this blog was written, this study was yet to be peer-reviewed, which is a process intended to ensure the quality, validity, significance, and originality of the study (Kelly et al., 2014).

Implications

Where can research go from here?

Future studies should strive to carry out random selection when conducting research of this nature, which would allow greater generalisability of the findings. Furthermore, there is a need to gather demographic information, so that we can have a better understanding of which factors really influence the rates of probable mental disorders seen in ICU staff. Lastly, to untangle why we might be seeing differences across professions in the ICU, it may be beneficial to conduct qualitative research on the matter to explore differences in their experiences. The rich nature of qualitative data allows us to gain valuable insight into the complex nature of human experiences, which can, in turn, help us to form hypotheses that can later be tested through quantitative research such as in this study (Agius, 2013). For example, in a previous blog I wrote for the Mental Elf on a study by Fox et al. (2020) on the link between PTSD and increased suicide rates in the general population, I expressed concern over potential PTSD and suicidality in frontline workers during COVID-19. This was based on qualitative research I had done with UCL’s COVID Trauma Working Response Group on frontline healthcare workers. This is now backed up by Greenberg and colleagues’ (2020) findings.

How can we use these findings in clinical practice?

The importance of providing frontline staff with appropriate and timely psychosocial support cannot be stressed enough. Although my personal belief is that we should be striving to provide support to anyone who needs it, it may be more compelling to naysayers to keep in mind that there’s evidence that poor mental health is associated with functional impairment (Tay et al., 2019; Rona et al., 2009), which can, in turn, put patients at risk. But how can we counteract this negative impact on frontline health workers’ mental health?

• Put systems in place within NHS trusts wherein managers prioritise the provision of evidence-based support for their workers.
• This should include thorough monitoring of staff mental health, which would in turn aid in the prevention of the cascade of mental health difficulties through early intervention.
• We also need to ensure that frontline workers can access formal treatment in a timely manner, rather than finding themselves stuck on never-ending waitlists.
• However, as we can’t deny the existence of long waitlists, it may be beneficial to provide staff with psychoeducation, so that they can learn the skills to monitor and manage their own mental health, as well as know where they can go for help.
• In my research with frontline healthcare workers, they have often spoken about how they tend to rely on one another for support (Billings et al., 2020), and therefore there may be value in training staff themselves in mental health first aid so that they can be better equipped to support one another.

Statement of interests

None.

Links

Primary paper

Greenberg N., Weston D, Hall C. et al. (2020). The mental health of staff working in intensive care during COVID-19. medRxiv 2020.11.03.20208322.

Other references

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Billings J., Abou Seif N., Hegarty S. et al (2020). What support do frontline workers want? A qualitative study of health and social care workers’ experiences and views of psychosocial support during the COVID-19 pandemic. medRxiv 2020.11.05.20226522.

Fox V., Dalman C., Dal H., et al.  (2020). Suicide risk in people with post-traumatic stress disorder: A cohort study of 3.1 million people in Sweden. Journal of Affective Disorders, 279, 609-616.

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Photo credits

• Photo by Vladimir Fedotov on Unsplash
• Photo by Rusty Watson on Unsplash
• Photo by Aarón Blanco Tejedor on Unsplash