COVID-19 and the mental health of health- care workers

We read Jo Billings's Comment on our paper about the prevalence of post-traumatic stress disorder and common mental disorders in health-care workers in England during the COVID-19 pandemic with interest.1Billings J The effect of the COVID-19 pandemic on health-care workers.Lancet Psychiatry. 2023; 10: 3-5Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar We thank her for her thoughtful engagement. Billings rightly notes the limitations of our data collection periods, with screening measures completed from April 23, 2020, to Jan 15, 2021, and clinical interview data from March 1 to Aug 27, 2021. The suggestion is that because the interview data were collected after the initial peaks of the pandemic, they might show a lower prevalence of mental disorders than the screening measures, owing to natural remittance of symptoms as staff entered a recovery phase. If excess mortality were used as a proxy for the pressure experienced, this criticism might be appropriate. However, as Billings touches on, evidence suggests that instead of pressure easing after the pandemic peaks, it actually intensified as backlogs of referrals and large numbers of staff resignations occurred.2Mahase E Health leaders question absence of workforce strategy in NHS elective care recovery plan.BMJ. 2022; 376: 343Crossref Scopus (2) Google Scholar Our own data (in preparation) collected from more than 23 000 health-care workers across 18 NHS Trusts, via online survey as part of the wider NHS CHECK study,3Lamb D Greenberg N Hotopf M et al.NHS CHECK: protocol for a cohort study investigating the psychosocial impact of the COVID-19 pandemic on healthcare workers.BMJ Open. 2021; 11e051687Crossref Scopus (8) Google Scholar shows remarkably little change in the prevalence of symptoms of common mental disorders (measured via the 12-item General Health Questionnaire) when compared with substantial differences in excess mortality for the same periods. For example, from April 1 to June 30, 2020, there were 53 389 COVID-19 deaths and prevalence of common mental disorders was 55% (95% CI 52–58), while from July 1, to Oct 31, 2020, there were 7157 COVID-19 deaths but prevalence remained high at 47% (46–48). Similarly, from Nov 1, 2020, to March 31, 2021, there were 88 211 COVID-19 deaths and prevalence of common mental disorders was 55% (53–56), while from April 1 to Aug 31, 2021 there were 6969 COVID-19 deaths and prevalence again remained high at 51% (48–54). We agree with Billings about the limitations of having considered only three mental disorders (anxiety, depression, and post-traumatic stress disorder). Evidence from multiple sources (including our own NHS CHECK study) has found constructs such as moral injury to be highly salient for many health-care workers, despite not being a formal mental health diagnosis.4Hegarty S Lamb D Stevelink SAM et al.‘It hurts your heart’: frontline healthcare worker experiences of moral injury during the COVID-19 pandemic.Eur J Psychotraumatol. 2022; 132128028Crossref Scopus (5) Google Scholar, 5Hines SE Chin KH Glick DR Wickwire EM Trends in moral injury, distress, and resilience factors among healthcare workers at the beginning of the COVID-19 pandemic.Int J Environ Res Public Health. 2021; 18: 488Crossref PubMed Scopus (84) Google Scholar There is a strong argument for further research of the predictors of moral injury, and into interventions that could prevent, reduce, or mitigate the effects of morally injurious events. Finally, we concur that our findings pose important questions about how local, regional, and national NHS and government organisations should respond to substantial proportions of staff meeting diagnostic criteria for mental disorders. It also raises questions about how health-care workers can, or should, hold those in decision-making positions to account. Arguably, the recent industrial action by nurses, ambulance staff, and junior doctors suggests that, for many, a line has been crossed. While it is beyond the remit of this research to dictate solutions to these problems, we hope the evidence we have provided, as well as ongoing data collection and intervention testing, contributes to the discussion. DL is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) North Thames. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. SAMS is supported by the NIHR Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and an NIHR Advanced Fellowship. NG has been an unpaid member of two NHS England expert advisory groups; and owns the company March on Stress, which is a psychological health consultancy providing mental health training to a wide range of organisations including the NHS. All other authors declare no competing interests. The effect of the COVID-19 pandemic on health-care workersThe COVID-19 pandemic has had a profound impact on the health-care workforce in the UK and worldwide.1,2 However, in The Lancet Psychiatry, Hannah Scott and colleagues3 report the results of a two-phase epidemiological survey of health-care workers in England, which suggest that prevalence rates based on self-report screening measures might have inflated estimates of mental disorders among health-care staff during the COVID-19 pandemic. The authors report that prevalence rates from a sample of clinical interviews (conducted between March 1 and Aug 27, 2021) were lower than those obtained using screening tools (administered between April 24, 2020, and Jan 15, 2021). Full-Text PDF