In April, a report highlighted the “catastrophic toll” on the mental health of NHS staff as a result of the Covid-19 crisis. It came from the respected Institute of Public Policy Research (IPPR), and was based on a specially commissioned YouGov poll. Not only did half of those sampled have symptoms indicating poor mental health, one in five “could quit after the pandemic”, they said.
Speaking as a clinical psychiatrist with an academic training in epidemiology, the study of disease and populations, I have a few words of caution. Polling data can be fickle, and the questions asked were not sufficient to differentiate between normal emotional reactions and mental health disorders that might require treatment. But given that the NHS workforce is facing unparalleled pressures, findings like this are hardly a surprise. This is not business as usual. We know from SARS and Ebola that being a healthcare worker in a pandemic comes with risks. As I write, more than 130 healthcare staff have died, of whom about 25 were doctors. General Medical Council data shows that about 50 doctors die in any normal month, but although the final mortality rates for exposed NHS staff will not be known for some time, this figure will be elevated. This among other reasons contributed to the proven increases in mental disorders in staff after SARS and Ebola. Particularly troubling is that those from ethnic minority backgrounds seem already to be experiencing worse outcomes.
If history repeats itself, the mental health pressures on staff may not be confined to familiar conditions such as post-traumatic stress or depressive disorders. Writing in the British Medical Journal recently, my colleague Neil Greenberg and I drew attention to another concern: what the military calls “moral injury”. This is emotional disturbance that results from actions, or the lack of them, which violate someone’s moral or ethical code. In the current situation this might refer to feelings of anger, shame or guilt arising from being unable to deliver the kind of care that would have been possible before the crisis.
That healthcare workers are under pressure is not news. Pressure can be a challenge, and the opposite of pressure for some is boredom. There are few roles in the NHS that do not involve some exposure to stress. Jenny Firth-Cozens, a psychologist who has been studying the mental health of doctors for three decades, wrote in the BMJ that when she published her first study in 1987, the “press coverage picked up the high levels of distress in junior hospital doctors of 30-50 per cent” – similar to the IPPR figures. This was during the period in which junior doctors regularly worked punishing hours of 60-80 hours a week, sometimes longer. Back then she found that “access to meals and hours of sleep mattered more to young doctors than the number of hours worked”. We see echoes of this in the reactions of healthcare workers in Wuhan during the Covid-19 epidemic, whose priority was adequate rest and PPE. They were rather dismissive of interventions from mental health professionals, as research has shown. The issue of PPE was not around when Firth-Cozens started her work, but the principles have not changed – the first mental health interventions involve equipment, training, meals, supervision and sleep. Cohesive teams with good leadership remain vital. Mental health professionals should be in the background for some when needed.
But it is not all bad news. I have spoken to juniors who report that while they have never been as challenged as they are now, they also appreciate that once basics such as PPE and sleep are taken care of, they take satisfaction from saving lives, receiving levels of supervision that were rare before the current crisis, appreciating the team spirit and esprit de corps more familiar to older generations of staff. They are confident that they will emerge from this better professionals. We call this “post-traumatic growth”, just like we found in surveys of the Armed Forces on their return from Iraq or Afghanistan, the results of which were published in 2010. One of the most endorsed item on the list of legacies of their recent deployment was: “I can now handle stress better than before”.
It is too early to know just what will be the long term impacts on the health and wellbeing of NHS staff after this pandemic. It also seems that the unprecedented speed and scale of the NHS response has not, as yet, created a tide of moral injury. In fact, the Practitioner Health Programme, which provides a service for doctors with mental health problems, is seeing more people who feel a sense of moral injury from not being on the front line than those who are. But all this is still anecdotal. In April, my colleagues at King’s College London launched a major long-term study – NHS Check – of 60,000 healthcare staff in three major London trusts and including the new Nightingale hospitals to address that question properly.
The mental health consequences of the current general lockdown, even if it was to end tomorrow, remain uncertain. We can expect an increase in mental health issues in the coming months. We know that the longer and deeper the economic depression, the greater the cracks to the social cohesion, the longer the disruptions to schooling, and much else besides, the greater the cost will be to our future physical and mental health. Some say we will live in a kinder, gentler, greener world. Others predict more dystopian outcomes. Ultimately it is not for boring boffins like me, nor even those who are leading our health response, to decide when, if ever, the cure becomes worse than the disease – that will be the task for our leaders.
Simon Wessely is professor of Psychological Medicine at King’s College London