The Mental Health Crisis for Healthcare Workers Is Not So Clear
Third in a series about criticism of mental health research during COVID-19
Posted Dec 02, 2020
Many journalists have sounded alarms about a mental health crisis for healthcare workers. It has been called a “devastating mental toll of COVID-19” as healthcare workers claim “I’m broken” (CBS News, 2020). The Washington Post warned the pandemic was “pushing doctors to the brink” (Choo, 2020). Scientists sounded alarms too; one journal concluded already there was a “crushing mental health toll on health care workers” because “the pandemic has unleashed a mental health crisis marked by anxiety, depression, posttraumatic stress disorder, and even suicide” (Nelson and Kaminsky, 2020).
Healthcare workers face psychological stressors that the general population does not. Most of these stressors by themselves, however, are not new to healthcare workers. What is different is the pace with which they all happened at the same time.
What Is the Research Saying?
There have been dozens of studies already published on the mental health status of healthcare workers. I looked at 14. As I mentioned in a previous post, there is no way I can keep up with all of them, but it probably doesn’t matter because most use the same methods.
For anxiety, the average percentage of healthcare workers who scored above validated cutoffs on anxiety measures from 10 studies was 34% (ranging from 8.7% to 58.6%). Prior to COVID-19, the average in the general population was 18.1% according to the Anxiety and Depression Association of America (ADAA 10/18/2020).
For depression, the average percentage of healthcare workers who scored above validated cutoffs on depression measures for eight studies was 24% (ranging from 5.3% to 50.4%). Prior to COVID-19, the average in the general population was 7.1% according to the National Institute of Mental Health (NIMH 10/18/2020a).
For posttraumatic stress disorder (PTSD), the average percentage of healthcare workers who scored above validated cutoffs on PTSD measures for eight studies was 31% (ranging from 3.8% to 71.5%). The pre-COVID average in the general population was 6.8% (NIMH 10/18/2020b).
The studies were from China, France, India, Israel, and Singapore. My numbers agree pretty well with more systematic meta-analyses (de Pablo et al., 2020; Pappa et al., 2020).
If we are to believe these studies, the rate of anxiety disorders has doubled, the rate of depression has more than tripled, and the rate of PTSD has more than quadrupled all in the space of less than six months.
Can We Believe the Studies?
I ask this with all sincerity out of concern for anyone dealing with stress and also for being fair about hype and poor research. In my opinion, no, we cannot believe the studies that report higher than average rates of disorders of anxiety, depression, and PTSD in healthcare workers.
There is a difference between being more stressed (i.e., sleep-deprived, emotionally-exhausted, and overwhelmed) versus disordered (i.e., function is impaired in work or in relationships). While these alarms in the media and journals are exaggerated, many of the alarms about healthcare workers were relatively less hyperbolic than the alarms about the general population. For example, the New York Times called the mental health toll on healthcare workers “more ripple than tsunami” (Carey, 2020).
Common sense and poor-quality of the studies argue against mental health devastation, crushing tolls, crises, or tsunamis of psychological problems. In my previous post on the general population, I explained the main concerns for how this body of research has likely artificially inflated the rates of disorders: self-administered checklists are unreliable, self-selected sampling bias will inflate rates of disorders, cross-sectional designs have no causal explanatory power, a lack of functional impairment measures in all of the studies, and relaxed peer-review allows poor-quality research to be published. The editors of a living systematic review stopped tracking these types of studies in September because there were so many low-quality studies (The DEPRESSD Project, 2020).
What It Means
I think we can conclude the same thing I concluded about the general population: Some healthcare workers will become impaired due to work-related stress during the pandemic, but the majority who report excessive psychological stress during the pandemic probably do not qualify as impaired, disordered, or require clinical intervention. The high rates of anxiety, depression, and PTSD reported in research studies reflect these stressed-but-not-impaired individuals. This seems consistent with what Chen and colleagues reported in China: Healthcare workers generally refused psychological help when offered (Chen et al., 2020).
That makes sense. Individuals who self-selected themselves to work in this field with sick patients are not likely to suddenly become so overwhelmed psychologically that they could not function well. Plus, generally speaking, humans are built for stress. Human ancestors survived more stressful living conditions for millions of years. Surviving stress is literally baked into our DNA. Research on psychological trauma victims is consistent with the idea that most people are resilient. Only about 30% of trauma victims are vulnerable to developing PTSD. The other 70% of trauma victims do not develop PTSD and are quick to recover from that form of stress.
ADAA (10/18/2020), Anxiety and Depression Association of America. Facts & Statistics. https://adaa.org/about-adaa/press-room/facts-statistics. Accessed 10/18/20.
NIMH 10/18/2020a. Major Depression.
https://www.nimh.nih.gov/health/statistics/major-depression.shtml. Accessed 10/18/20.
NIMH 10/18/2020b. Posttraumatic Stress Disorder (PTSD). https://www.nimh.nih.gov/health/statistics/post-traumatic-stress-disorder-ptsd.shtml. Accessed 10/18/20.
CBS News (2020). Health care workers share the devastating mental toll of COVID-19: "I'm no hero, I'm broken" https://www.cbsnews.com/news/covid-19-health-care-workers-ptsd-depression/; posted online 9/22/20.
Carey B (2020). The Pandemic’s Mental Toll: More Ripple Than Tsunami. New York Times; posted online 6/21/2020.
Chen Q, Liang M, Li Y, et al. (online 2/18/2020). Mental health care for medical staff in China during the COVID-19 outbreak. The Lancet.
Choo E (2020). Covid-19 is pushing doctors to the brink. Medicine needs to recognize they’re human and need help. Washington Post; posted online 7/20/2020.
de Pablo GS, Vaquerizo-Serrano J, Catalan A, Arango C, et al. (2020). Impact of coronavirus syndromes on physical and mental health of health care workers: Systematic review and meta-analysis. Journal of Affective Disorders 275 (2020) 48–57.
Nelson B, Kaminsky DB. COVID-19’s crushing mental health toll on health care workers. Cancer Cytopathology. 128(9):597-598, 2020 09.
Pappa S, Ntella V, Giannakas T, et al. (2020). Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain, Behavior, and Immunity 88 (2020) 901–907.
The DEPRESSD Project (2020). Living Systematic Review of Mental Health in COVID-19. https://www.depressd.ca/covid-19-mental-health. Accessed 10/18/20.