When Helpers Feel Helpless:
Mitigating Suicide Risk of Health Care Workers in a Pandemic
Douglas G. Jacobs, M.D. and Marci Klein Benheim, Ph.D.
The current pandemic is exacerbating a long-standing hazard for healthcare workers: suicide. Many have been saddened by the deaths by suicide of emergency room physician Dr. Lorna Breen and EMT John Mondello in New York City. In the midst of Mental Health Awareness Month and National Nurses Week, we must equip frontline health care workers with the resources necessary to protect their mental health.
Health care workers have always been at disproportionate risk. The overall suicide rate in the United States has increased by 35% since 1999, and is now at its highest rate since World War II. According to a 2019 review by Frédéric Dutheil and colleagues, physicians and nurses are 2-3 times more likely to complete suicide than the general population, with female physicians especially at risk.
Over the past few decades, American physicians have become increasingly distressed, dissatisfied, and burned out. With legal and economic pressures and mounting administrative tasks, American physicians are working more hours, spending less face-to-face time with their patients and less time with their families. This is in stark contrast to their European counterparts, whose working conditions have improved since the European Union instituted the Working Time Directive (WTD), which set out requirements for working hours, rest breaks, and annual leave, resulting in a decreased suicide rate over time.
Nurses are also known to be at high risk: they face many of the same stressors as doctors, including heavy workloads, work-family conflicts, lack of social support, and frequent exposure to illness and suffering. The lack of autonomy inherent in the nursing profession is another factor. Nurses working in emergency departments face the demands of shift work, aggressive patients, and trauma exposure. There is little data on the suicide risk of other health care workers and hospital staff, such as respiratory therapists, EMTs, and housekeepers. This oversight needs to be addressed.
In areas where sick patients are overwhelming the healthcare system, shortages of personal protective equipment (PPE) for workers and lack of effective treatment options for patients can lead to a sense of helplessness and hopelessness, factors associated with suicide risk. Health care workers are dealing with the uncertainty of daily policy changes, including reduced pay due to financial pressure on hospitals. This is on top of the stresses of managing children home from school and caring for family members.
Intensive care units usually involve frequent interactions with patients, monitoring vital signs, adjusting medications, and changing ventilator settings. Yet due to PPE shortages and the sheer number of patients, these interactions have become circumscribed. This change is unsettling to those used to working closely with individual patients. And doctors and nurses unaccustomed to emergency care are finding themselves repurposed to care for COVID-19 patients, which ironically can make them feel less adequate and competent.
Hospital staff are afraid of becoming infected and dying or passing infection on to others. Many workers are distancing from their friends and loved ones, making it difficult to maintain relationships with their usual support networks. Fear of spreading it to others can also fuel suicide rates. There are reports that one of the two infected Italian nurses who completed suicide was “terrified she had infected others in the line of duty.”
When workers get sick, they may feel helpless or guilty about being unable to perform their essential, life-saving jobs, or for contributing to staff shortages for those remaining at work. The late Dr. John Mack, a noted suicide expert, wrote, “low self-esteem results when a wide gulf is experienced between the perceived self and the ideal self.” Suicide can result when individuals judge that they do not measure up to their “ego ideal,” the person they wish to be. Health care workers are often motivated by wanting to help others. Being rendered helpless in the midst of the COVID-19 pandemic may affect their self-esteem and identity, increasing suicide risk.
At a meeting last week, Dr. Bruce Schwartz, President of the American Psychiatric Association, stated that the trauma of the pandemic will have lasting effects for many frontline responders. Nearly half of those caring for SARS patients in 2002-2003 suffered from psychological distress, burnout, and PTSD. A 2010 study of the SARS epidemic found an exceptionally high rate of suicide, arising from stress, anxiety, social disengagement, and economic disruption. While conditions are ripe for increases in suicides from COVID-19, this doesn’t have to be the result.
How do we support first responders to mitigate their suicide risk? We need to invest in “emotional” intensive care. There are warning signs for suicide, like: “I am of no use to anyone” or “I feel like such a burden.” We can educate loved ones, colleagues, and the community about these warning signs. Most people communicate suicidal intent. These should be responded to no differently than any other medical emergency.
Anyone may be suicidal, irrespective of mental health history. The CDC found that 54% of all suicide cases in 2015 were not associated with a diagnosed mental disorder. Italian psychiatrist Dr. Maurizio Pompili recently opined that we need to pay careful attention to those who are experiencing intolerable mental or psychic pain, whether or not they meet full criteria for a psychiatric diagnosis.
There are evidence-based treatments that can mitigate suicide risk. Mental health providers can use telehealth to effectively work with patients, including prescribing medications when indicated. There is a cognitive behavioral therapy app that can be effective in the absence of in-person visits. Safety plans include whom you will contact if you become suicidal and should address the availability of lethal means, including pharmaceuticals to which health care workers have access.
For these to work, we need to normalize, facilitate, and destigmatize help-seeking. When doctors become depressed and suicidal, they often do not seek treatment out of fear of being deemed incompetent and losing their positions.
There are a number of openly-available, free screening tools that can be used to detect the presence of anxiety, depression, PTSD, substance abuse, and suicide risk on the Substance Abuse and Mental Health Service Administration website. If you or someone you know is at risk for suicide, you can call the National Suicide Prevention Lifeline (1-800-273-8255). The Disaster Distress Helpline (1-800-985-5990) is another resource available for those dealing with emotions related to disasters including Covid-19. For physicians, the Physician Support Line (1-888-409-0141) is staffed by over 600 volunteer psychiatrists to provide peer support during this pandemic.
Health care institutions can also enact programs devoted to staff mental health. For example, Johns Hopkins Medicine operates a confidential support program called Resilience in Stressful Events (RISE), which provides in-person psychological and emotional support. During the pandemic, the RISE team checks on health care workers within units dealing with COVID-19 patients, or adjunctive workers in less visible units, such as EMTs, patient transport, pharmacy, laundry, and the microbiology laboratory.
Institutions need to express gratitude to health care workers for shouldering the increased demands being placed on them. This may take the form of hazard pay, increased time off, and community recognition. Unfortunately, hospital finances are being depleted due to cancellation of bread and butter elective surgeries, PT, clinic visits, and many ordinary income sources. But to reduce the risk of long-term psychological complications, including suicide, in our healthcare workers in the future, we need to support and protect their mental health now. This may require institutional change. It starts with acknowledging the need.
The National Suicide Prevention Lifeline is a hotline for individuals in crisis or for those looking to help someone else. To speak with a certified listener, call 1-800-273-8255.