UK military doctors; stigma, mental health and help-seeking: a comparative cohort study

Health service and psychotropic medication use for mental health conditions among healthcare workers active during the Spain Covid-19 Pandemic - A prospective cohort study using web-based surveys

Little is known about healthcare workers' (HCW) use of healthcare services for mental disorders. This study presents data from a 16-month prospective cohort study of Spanish HCW (n = 4,809), recruited shortly after the COVID-19 pandemic onset, and assessed at four timepoints using web-based surveys. Use of health services among HCW with mental health conditions (i.e., those having a positive screen for mental disorders and/or suicidal thoughts and behaviours [STB]) was initially low (i.e., 18.2 %) but increased to 29.6 % at 16-month follow-up. Service use was positively associated with pre-pandemic mental health treatment (OR=1.99), a positive screen for major depressive disorder (OR=1.50), panic attacks (OR=1.74), suicidal thoughts and behaviours (OR=1.22), and experiencing severe role impairment (OR=1.33), and negatively associated with being female (OR = 0.69) and a higher daily number of work hours (OR=0.95). Around 30 % of HCW with mental health conditions used anxiolytics (benzodiazepines), especially medical doctors. Four out of ten HCW (39.0 %) with mental health conditions indicated a need for (additional) help, with most important barriers for service use being too ashamed, long waiting lists, and professional treatment not being available. Our findings delineate a clear mental health treatment gap among Spanish HCW.

The First Attempt to Apply an Online Mindfulness Program to Nursing Staff in a Traditional Korean Medicine Clinic in COVID-19 Era: A Case Series

The importance of medical personnel's mental health is emphasized in the COVID-19 era. The characteristics of traditional Korean medicine (KM) may affect the mental health of nursing staff working at KM clinics. In this case series, we report the first attempt to apply an online mindfulness program to the nursing staff in a KM clinic in Korea. For three female nursing assistants, an online mindfulness program consisting of five sessions was offered for two months. After the program, a decrease in emotional labor was observed in two participants, and a decrease in the level of burnout was observed in all participants. One participant showed an increase in their emotional labor level, which was associated with an increase in deep acting. The participants expressed a high level of satisfaction with this program in terms of recommendations for peers and willingness to participate again. As this report is a case series, larger studies are needed to fully evaluate the benefits of the program on emotional labor and burnout of KM clinic nursing staff. However, the potential benefits of emotional labor and burnout, high satisfaction, and some challenges identified in this case series can be considered in future extensions and modifications of the program.

Lack of Interventional Studies on Suicide Prevention among Healthcare Workers: Research Gap Revealed in a Systematic Review

Addressing the mental health needs of healthcare workers (HCWs), who are at high risk of suicide, is an important public health issue. Therefore, this systematic review investigated the effect of psychosocial intervention targeting suicidal behavior (i.e., suicidal ideation, attempt, or fulfillment) of HCWs. Five electronic databases were searched for interventional studies reporting HCWs' suicidal behavior outcomes. Only two interventional studies were included in this review, and no consistent conclusion was drawn from the existing literature regarding the psychosocial prevention strategies focusing on the suicide risk of HCWs. The results indicate that compared with numerous observational studies reporting poor mental health and/or severity of suicidal risk among HCWs, intervention studies using psychosocial strategies to reduce the risk of suicide are relatively scarce. Although the insufficient number and heterogeneity of the included studies leave the results inconclusive, our findings emphasize the need to fill the research gap in this field. The causes of the gap are further explored, and suggestions for future research are provided.

What are the barriers and facilitators to seeking help for mental health in NHS doctors: a systematic review and qualitative study

BACKGROUND

The mental health of healthcare professionals is reaching a breaking point, and the COVID-19 pandemic has exacerbated current mental health issues to unprecedented levels. Whilst some research has been carried out on the barriers that doctors face when seeking mental health help, there is little research into factors which may facilitate seeking help. We aimed to expand the research base on factors which act as barriers to seeking help, as well as gain insight into facilitators of help-seeking behaviour for mental health in NHS doctors.

METHODS

We conducted a systematic literature review which identified the barriers and facilitators to seeking help for mental health in healthcare professionals. Following this, we conducted semi-structured interviews with 31 NHS doctors about their experiences with mental health services. Finally, through thematic analysis, key themes were synthesised from the data.

RESULTS

Our systematic literature review uncovered barriers and facilitators from pre-existing literature, of which the barriers were: preventing actions, self-stigma, perceived stigma, costs of seeking treatment, lack of awareness and availability of support, negative career implications, confidentiality concerns and a lack of time to seek help. Only two facilitators were found in the pre-existing literature, a positive work environment and availability of support services. Our qualitative study uncovered additional barriers and facilitators, of which the identified barriers include: a negative workplace culture, lack of openness, expectations of doctors and generational differences. The facilitators include positive views about mental health, external confidential service, better patient outcomes, protected time, greater awareness and accessibility, open culture and supportive supervisors.

CONCLUSION

Our study began by identifying barriers and facilitators to seeking mental health help in healthcare workers, through our systematic literature review. We contributed to these findings by identifying themes in qualitative data.. Our findings are crucial to identify factors preventing NHS doctors from seeking help for their mental health so that more can be done on a national, trust-wide and personal level to overcome these barriers. Likewise, further research into facilitators is key to encourage doctors to reach out and seek help for their mental health.

Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.

Towards Designs of Workplace Stress Management Mobile Apps for Frontline Health Workers during COVID-19 and Beyond: A Qualitative Study

Background

In recent years, mobile apps have been developed to prevent burnout, promote anxiety management, and provide health education to workers in various workplace settings. However, there remains a paucity of such apps for frontline health workers (FHWs), even though FHWs are the most susceptible to stress due to the nature of their jobs.

Objective

The goal of this study was to provide suggestions for designing stress management apps to address workplace stressors of FHWs based on the understanding of their needs from FHWs’ own perspectives and theories of stress.

Methods

A mixed methods qualitative study was conducted. Using a variety of search strings, we first collected 41 relevant web-based news articles published between December 2019 and May 2020 through the Google search engine. We then conducted a cross-sectional survey with 20 FHWs. Two researchers independently conducted qualitative analysis of all the collected data using a deductive followed by an inductive approach.

Results

Prevailing uncertainty and fear of contracting the infection was causing stress among FHWs. Moral injury associated with seeing patients die from lack of care and lack of experience in handling various circumstances were other sources of stress. FHWs mentioned 4 coping strategies. Quick coping strategies such as walking away from stressful situations, entertainment, and exercise were the most common ways to mitigate the impact of stress at work. Peer support and counseling services were other popular methods. Building resilience and driving oneself forward using internal motivation were also meaningful ways of overcoming stressful situations. Time constraints and limited management support prevented FHWs from engaging in stress management activities.

Conclusions

Our study identified stressors, coping strategies, and challenges with applying coping strategies that can guide the design of stress management apps for FHWs. Given that the pandemic is ongoing and health care crises continue, FHWs remain a vulnerable population in need of attention.

Mental health service use and its associated factors among nurses in China: a cross-sectional survey

Background

To facilitate mental health service planning for nurses, data on the patterns of mental health service use (MHSU) among nurses are needed. However, MHSU among Chinese nurses has seldom been studied. Our study aimed to explore the rate of MHSU among Chinese nurses and to identify the factors associated with MHSU.

Methods

A self-designed anonymous questionnaire was used in this study. MHSU was assessed by the question, “Have you ever used any kind of mental health services, such as mental health outpatient services or psychotherapies, when you felt that your health was suffering due to stress, insomnia, or other reasons?” The answer to the question was binary (yes or no). Sleep quality, burnout, and depressive symptoms were assessed using the Chinese version of the Pittsburgh Sleep Quality Index , the Chinese version of the Maslach Burnout Inventory-General Survey and the two-item Patient Health Questionnaire, respectively. Chi-square tests and binary logistic regression were used for univariate and multivariate analyses.

Results

A total of 10.94% (301/2750) of the nurses reported MHSU. 10.25% (282/2750) of the nurses had poor sleep quality, burnout and depressive symptoms, and only 26.95% of these nurses reported MHSU. Very poor sleep quality (OR 9.36, 95% CI [5.38-16.29]), mid-level professional title (OR 1.48, 95% CI [1.13-1.93]) and depressive symptoms (OR 1.66, 95% CI [1.28-2.13]) were independent factors associated with MHSU.

Conclusions

Most of the nurses have experienced burnout, poor sleep quality or depressive symptoms and the MHSU rate among them was low. Interventions to improve the mental health of nurses and to promote the use of mental health services are needed.

Rapid Design and Delivery of an Experience-Based Co-designed Mobile App to Support the Mental Health Needs of Health Care Workers Affected by the COVID-19 Pandemic: Impact Evaluation Protocol

BACKGROUND

The COVID-19 pandemic has highlighted the importance of health care workers' mental health and well-being for the successful function of the health care system. Few targeted digital tools exist to support the mental health of hospital-based health care workers, and none of them appear to have been led and co-designed by health care workers.

OBJECTIVE

RMHive is being led and developed by health care workers using experience-based co-design (EBCD) processes as a mobile app to support the mental health challenges posed by the COVID-19 pandemic to health care workers. We present a protocol for the impact evaluation for the rapid design and delivery of the RMHive mobile app.

METHODS

The impact evaluation will adopt a mixed methods design. Qualitative data from photo interviews undertaken with up to 30 health care workers and semistructured interviews conducted with up to 30 governance stakeholders will be integrated with qualitative and quantitative user analytics data and user-generated demographic and mental health data entered into the app. Analyses will address three evaluation questions related to engagement with the mobile app, implementation and integration of the app, and the impact of the app on individual mental health outcomes. The design and development will be described using the Mobile Health Evidence Reporting and Assessment guidelines. Implementation of the app will be evaluated using normalization process theory to analyze qualitative data from interviews combined with text and video analysis from the semistructured interviews. Mental health impacts will be assessed using the total score of the 4-item Patient Health Questionnaire (PHQ4) and subscale scores for the 2-item Patient Health Questionnaire for depression and the 2-item Generalized Anxiety Scale for anxiety. The PHQ4 will be completed at baseline and at 14 and 28 days.

RESULTS

The anticipated average use period of the app is 30 days. The rapid design will occur over four months using EBCD to collect qualitative data and develop app content. The impact evaluation will monitor outcome data for up to 12 weeks following hospital-wide release of the minimal viable product release. The study received funding and ethics approvals in June 2020. Outcome data is expected to be available in March 2021, and the impact evaluation is expected to be published mid-2021.

CONCLUSIONS

The impact evaluation will examine the rapid design, development, and implementation of the RMHive app and its impact on mental health outcomes for health care workers. Findings from the impact evaluation will provide guidance for the integration of EBCD in rapid design and implementation processes. The evaluation will also inform future development and rollout of the app to support the mental health needs of hospital-based health care workers more widely.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26168.

Emotional intelligence, cortisol and α-amylase response to highly stressful hyper-realistic surgical simulation of a mass casualty event scenario

Lifetime exposure to stress leads to risk of suffering from cumulative detrimental physiological and psychological ailments. Due to the nature of healthcare and exposure to trauma, medical professionals are particularly susceptible to the negative impacts of high stress environments. emotional intelligence plays a role in ameliorating the risk of being negatively impacted by these stressors. As such, there is special interest to develop and implement training interventions for medical personnel that would allow them to improve emotional intelligence potential with the goal of enabling them to handle stress better and mitigate burnout. A hyper-realistic surgical simulation training session, replicating the intensity of a Mass-Casualty Event scenario, was implemented to allow medical professionals to experience this in real time. Overall, the training led to increased emotional intelligence, correlating with decreased hypothalamus-pituitary-adrenal axis and sympathetic nervous system stress biomarkers, cortisol and α-amylase. This novel training provides, at least, short-term improvements in emotional intelligence that is reflected with a physiological response. These results guide the ongoing effort to develop therapeutic tools to improve long term stress management, mitigate burnout and reduce post-traumatic stress risk after an exposure to a Mass-Casualty event scenario.

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This study examines the relationship between emotional intelligence and stress response.

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Higher values in self-perception and stress management correlate with lower cortisol and α-amylase values.

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Alpha-amylase is more predictive of pre-event emotional intelligence while cortisol levels are better for post-event.

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Training improves short-term emotional intelligence, that may be useful to enhance stress management and mitigate burnout.

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Monitoring α-amylase and cortisol levels may help identify individuals at risk or with lower resilience potential.

The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: A rapid systematic review

Background

As the world is battling the COVID-19 pandemic, frontline health care workers (HCWs) are among the most vulnerable groups at risk of mental health problems. The many risks to the wellbeing of HCWs are not well understood. Of the literature, there is a paucity of information around how to best prevent psychological distress, and what steps are needed to mitigate harm to HCWs’ wellbeing.

Methods

A systematic review using PRISMA methodology was used to investigate the psychological impact on HCWs facing epidemics or pandemics, using three electronic databases (PubMed, MEDLINE and CINAHL), dating back to 2002 until the 21st of August 2020. The search strategy included terms for HCWs (e.g., nurse and doctor), mental health (e.g., wellbeing and psychological), and viral outbreaks (e.g., epidemic and pandemic). Only studies with greater than 100 frontline HCWs (i.e. doctors or nurses in close proximity to infected patients) were included.

Results

A total of 55 studies were included, with 53 using quantitative methodology and 2 were qualitative. 50 of the quantitative studies used validated measurement tools while 5 used novel questionnaires. The studies were conducted across various countries and included people with SARS (13 studies), Ebola (1), MERS (3) and COVID-19 (38). Findings suggest that the psychological implications to HCWs are variable with several studies demonstrating an increased risk of acquiring trauma or stress-related disorders, depression and anxiety. Fear of the unknown or becoming infected were at the forefront of the mental challenges faced. Being a nurse and being female appeared to confer greater risk. The perceived stigma from family members and society heightened negative implications; predominantly stress and isolation. Coping strategies varied amongst the contrasting sociocultural settings and appeared to differ amongst doctors, nurses and other HCWs. Implemented changes, and suggestions for prevention in the future consistently highlighted the need for greater psychosocial support and clearer dissemination of disease-related information.

Conclusion

This review can inform current and future research priorities in the maintenance of wellbeing amongst frontline HCWs. Change needs to start at the level of policy-makers to offer an enhanced variety of supports to HCWs who play a critical role during largescale disease outbreaks. Psychological implications are largely negative and require greater attention to be mitigated, potentially through the involvement of psychologists, raised awareness and better education. The current knowledge of therapeutic interventions suggests they could be beneficial but more long-term follow-up is needed.

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Frontline health care workers (HCWs), especially females and nurses, are amongst the most vulnerable groups at risk of mental health problems, especially during severe viral epidemics.

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Fear of uncertainty or becoming infected were at the forefront of the psychological challenges faced.

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Several studies demonstrated an increased risk of acquiring trauma or stress-related disorders, depression and anxiety.

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Coping strategies varied between sociocultural settings and HCWs of different disciplines.

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Adequate psychosocial support and clear dissemination of disease-related information was consistently recommended.

Help-seeking for depression among Australian doctors

BACKGROUND

Depression is common among doctors. However, concerns remain that doctors are unlikely to ask for help when symptoms of depression arise.

AIMS

To determine rates and patterns of help-seeking for depression among doctors and to identify predictors of and barriers to such behaviour.

METHODS

A secondary analysis was conducted on a nation-wide survey of 12 252 Australian doctors. The study sample consisted of doctors who reported having ever felt seriously depressed (n = 4154; 33.9% of total sample). Rates of help-seeking, professional help-seeking behaviours and self-reported barriers were explored. Logistic regression was used to examine the association between professional help-seeking and predetermined predictive factors.

RESULTS

Sixty percent (95% confidence interval (CI): 58.5-61.5) of doctors who have ever felt seriously depressed reported some form of professional help-seeking for depression. The most common barrier to help-seeking was 'privacy/confidentiality'. Females (odds ratio (OR) = 1.74; 95% CI: 1.50-2.01; P < 0.001), locally trained doctors (OR = 1.34; 95% CI: 1.12-1.59; P = 0.001) and senior doctors (OR = 1.35; 95% CI: 1.14-1.61; P = 0.001) were more likely to seek professional help than their counterparts. Compared with general practitioners, psychiatrists (OR = 1.565; 95% CI: 1.15-2.13; P = 0.004) were more likely to seek professional help while surgeons (OR = 0.518; 95% CI: 0.37-0.72; P < 0.001) and pathologists/radiologists (OR = 0.695; 95% CI: 0.49-0.99; P = 0.043) were less likely.

CONCLUSION

While it is reassuring that the majority of depressed doctors were able to seek professional help, many were not. Major barriers to professional help-seeking, particularly concerns about confidentiality and impact on career, remain a problem. Male, overseas-trained, junior doctors, surgeons and pathologists/radiologists were less likely to seek help for depression. Targeted interventions are required to increase appropriate help-seeking for depression in doctors.

COVID 19-Depression and Neurosurgeons

OBJECTIVE

The goal of this survey was to determine factors associated with anxiety/depression among neurosurgeons during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

An online survey was performed of neurosurgeons worldwide, conducted over 3 weeks. Depression in neurosurgeons was assessed by Self-Reporting Questionnaire-20.

RESULTS

A total of 375 responses were received from 52 countries. Among all neurosurgeons, 34% felt tense, 32.5% were unhappy, 25% experienced insomnia, almost 20% had headaches, and 5% had suicidal ideation during the pandemic. Of participants, 14% had a score on Self-Reporting Questionnaire-20 consistent with depression. The likelihood of depression was significantly higher among those who did not receive guidance about self-protection from their institutions (odds ratio [OR], 2.47), those who did not feel safe with provided personal protective equipments (OR, 3.13), and those whose families considered their workplace unsafe (OR, 2.29). Depression was less likely in neurosurgeons who had minor concerns, compared with those with significant health concerns for their families (OR, 0.36). In multivariate analysis after controlling for effects of other covariates, odds of depression were significantly higher among neurosurgeons who did not feel safe with the provided personal protective equipment (OR, 2.43) and who were exposed to a COVID-19-positive colleague (OR, 2.54). Participants who had moderate concerns for their families had lesser odds of anxiety/depression than did those with significant concerns (OR, 0.28).

CONCLUSIONS

Based on the modifiable risk factors of depression in this study, it is recommended that the safety of neurosurgeons be ensured by providing appropriate safety measures for them to regain their confidence and hence reduce the incidence of depression.

Similarities between military and medical service: stigma of seeking mental health assistance

Studies have identified that there are many barriers to treatment of mental health illnesses in military populations, including the negative-associated stigma. One such barrier includes perceptions of weakness, leading to concerns about leadership and competency and being seen as malingering. Furthermore, similarities can be seen in civilian health professionals, where concerns of negative perceptions can limit reporting and treatment of mental health illnesses. Despite the frequency of stressful events, military and health professionals do not become immune to stress and are often ill prepared to cope with acute stressors that can often build on each other until emotional exhaustion and/or crisis point. Even with targeted internal programmes, the stigma of seeking mental health assistance in the military and medicine is poor and is believed to contribute to poor outcomes, such as the potential of increased suicide prevalence.