When the World Health Organisation (WHO) declared the spread of the severe acute respiratory
syndrome-coronavirus 2 (SARS-CoV-2) a global pandemic on March 11, 2020, there were
approximately 147,000 confirmed cases worldwide. Just one month later, the COVID-19
disease had spread dramatically; the number of cases had increased ten-fold (1), with
15% of infected patients requiring hospitalization and 5% in intensive care units
(3). This meteoric rise in cases resulted in an overloaded demand for medical resources,
often exceeding the available resources of healthcare systems around the world.
Although we often conceive of healthcare systems in terms of the physical hospital
beds and medical equipment, the system’s most fundamental, valuable, and vulnerable
assets are, undoubtedly, its manpower resources. Medical doctors, nurses, physiotherapists,
technicians, and countless other professionals must all come together for the system
to work effectively. Indeed, in order to buffer the effect of the pandemic on our
healthcare systems and society as a whole, we rely heavily on the extent to which
these individuals can function in a cohesive, effective manner (5).
Healthcare workers are being impacted by the current pandemic on two fronts. Like
all of us, they are navigating social distancing, school and day care closures, the
economic crisis, concerns about the health of their loved ones, and general uncertainty
about the future. Also, because of their profession, they are likely to be exposed
to overloaded working hours and a higher risk of infection amidst potential shortages
of adequate personal protection equipment (PPE) and other supplies. Further stressful
factors include feeling a lack of control or sense of helplessness, daily contact
with suffering and death, as well as the need to communicate bad news and establish
new communication strategies with family members who cannot visit hospitalized patients.
In addition, concerns about infecting their families has resulted in many professionals
leaving their homes and sheltering elsewhere, which may further worsen their psychological
well-being. Finally, they are worried about whether they will be prioritized in care
if they become ill and whether they will face ethical dilemmas such as those reported
in other countries where the health system has collapsed (7).
Clearly, this pandemic is exerting great stress on the personnel working on the front
line of efforts to control the virus in the healthcare system (5). Studies have already
shown that most health care providers are exhibiting stress-related symptoms such
as anxiety, depression, sleep disturbances, and emotional distress, and around 50%
of them will fulfil criteria for a mental disorder (6). It is still not completely
clear who among us is at a higher risk. As an example, early data suggest that females
nurses may be particularly vulnerable (6,8), especially those working in direct contact
with infected patients for longer hours. Also, anyone with a pre-existing chronic
disease or mental health condition is at greater risk (5,6).
These data demonstrate that we are facing a situation in which the backbone of our
health system, our personnel, is highly exposed, both physically and psychologically.
The relevance of that unfolds in the consequences: if care providers are hampered
by mental health and psychosocial issues, infection rates will increase (due to lower
compliance with safe practices), which, in turn, would reduce staff numbers and amplify
emotional distress in a vicious cycle. Indeed, this pandemic has already resulted
in soaring rates of absenteeism, medical leaves, and even resignations.
For these reasons, any strategy to combat the COVID-19 crisis must take the mental
health and psychosocial aspects of its healthcare workers into consideration. The
strategy should be established at several levels: governmental, institutional, and
individual. In fact, recent studies show that governmental and institutional attitudes
toward the pandemic can directly increase motivation and performance levels of healthcare
personnel, thereby protecting against negative mental health effects (8). Simply put,
our healthcare professionals must feel that the government and medical institutions
understand how stressful the current situation is and that they are taking actions
to take care of them. This includes clear communication with the staff, provision
of protective measures and PPEs, and sensitive administration of work shifts. Governments
should also establish public policies that allow institutions to guarantee health
care assistance, social (e.g. childcare needs, paid time off) and financial support
to the health care professionals and their families. In addition, open access to mental
and psychosocial support and treatment is critical and must be taken into account.
To address the aforementioned issues, the University of São Paulo School of Medicine
and its Health Complex, Hospital das Clínicas, developed the program “COMVC19: The
Mental Health and Psychosocial Well-Being Personal Protective Equipment to the Health
Professionals involved in the Combat against the COVID-19 Pandemic.” This program
is designed to offer mental health and psychosocial support and psychological/psychiatric
treatment to approximately 20,000 hospital employees. It has been officially broadcasted
to members of the whole complex through electronic means (a link to the webpage) and
new information is continuously updated. Based on what we have learned from our interactions
with our professionals, teams, and their leadership, the program comprises three branches:
mental health and psychosocial support, education, and research.
The composite term ‘mental health and psychosocial support’ (MHPSS) is used in the
Inter-Agency Standing Committee (IASC) Guidelines for MHPSS in Emergency Settings
to describe “any type of local or outside support that aims to protect or promote
psychosocial well-being and/or prevent or treat mental health condition”. The global
humanitarian system uses the term MHPSS to unite a broad range of actors responding
to emergencies such as the COVID-19 pandemic, including those working with biological
approaches and sociocultural approaches in health, social, education, and community
settings, as well as to “underscore the need for diverse, complementary approaches
in providing appropriate support” (4). The IASC Guidelines for MHPSS in Emergency
Settings recommends that multiple levels of interventions be integrated within outbreak
response activities. These levels align with a broad spectrum of mental health and
psychosocial needs and are represented in a pyramid of interventions (Figure 1) ranging
from embedding social and cultural considerations in basic services to providing specialized
services for individuals with more severe conditions. Core principles include: do
no harm, promote human rights and equality, use participatory approaches, build on
existing resources and capacities, adopt multi-layered interventions, and work with
integrated support systems (4). The MHPSS branch of the COMVC19 program (Figure 1)
consists of coordinated measures that range from preventive actions and therapeutic
interventions to rehabilitation, if required. Secondary prevention encompasses the
training of members of our medical units following the “Psychological First Aid” principles
(2), as well as support groups for professionals working on the frontline - hence,
those who are more likely to develop mental disorders (6). This means that individuals
who require mental health support will have access to psychological groups acting
locally within their wards or to a hotline held by supervised residents of psychiatry
on call, 24/7. In both cases, mental health professionals will provide empathic listening
in the short term. This support stage will allow us to identify individuals who require
referral to psychiatric and/or psychological (brief psychotherapy) treatments, or
a psychiatric ER if the situation constitutes an emergency. Finally, specific occupational
therapy will be provided for those in quarantine or on medical leave.
The educational branch of the initiative focuses on the training of residents in all
these actions and will include six hours of short video-classes prepared by our group
of experienced assistants. Critically, these videos will target both health professionals
and the general public, thereby scaling up the impact of the program. They are freely
available online (https://sites.google.com/hc.fm.usp.br/comvc-19/comvc-19),
Finally, a research branch was developed to monitor our employees' mental health regularly
through an online platform. Our aim is to investigate and identify risk and devise
protective interventions for specific groups. Further, using standard instruments,
each intervention will be evaluated in real time. Hereafter, the analyses, interpretation,
and publication of these experiences will allow us to improve the whole program, as
well as share our failures and successes with the scientific community.
Specialists estimate that the world will endure a long battle against the COVID-19
pandemic and its consequences. To ensure success, it is essential to keep our healthcare
workers active, motivated, and healthy. Thus, we hereby recommend that all health
institutions pay special attention to the mental health and psychosocial well-being
of their workers. If our frontline health soldiers should suffer due to mental health
and psychosocial burdens, all our other weaponry will be compromised and the war will
be lost. These actions will mitigate a second wave of high incidence of mental health
and psychosocial problems as a sequelae of this pandemic that could otherwise be prevented
by these interventions.
AUTHOR CONTRIBUTIONS
Fukuti P, Uchôa CLM and Miguel EC were responsible for the manuscript original draft.
Mazzoco MF, Corchs F, Kamitsuji CS, Rossi L, Rios IC, Lancman S, Bonfa E and Barros-Filho
TEP were responsible for the manuscript writing, editing and review.