Larry Catá Backer's comments on current issues in transnational law and policy. These essays focus on the constitution of regulatory communities (political, economic, and religious) as they manage their constituencies and the conflicts between them. The context is globalization. This is an academic field-free zone: expect to travel "without documents" through the sometimes strongly guarded boundaries of international relations, constitutional, international, comparative, and corporate law.
Tuesday, March 31, 2020
COVID-19 and Suicide--The Dark Side of Narrative and the Agony of Pandemic
Hysteria, obsession, and what feels like the inescapable reality of a pandemic served up in a never ending stream of exclamation points. Thsi si what surrounds the masses in thsi era of pandemic:
The COVID-19 pandemic brings suffering, and instability, and dislocation, and trauma, and loss. And it brings death. It brings the death of individuals, it brings the statistics of death, it brings the ratings of death, it brings accountability for death. It brings a constant chatter about death--death that has come, death that is here, death that is yet to come.
Death is both a physical manifestation of personal tragedy and loss; death is an abstraction that is used as an illustration, as a sign, as the symbol and harbinger of this or that. Death becomes the marker because of the identity between pandemic and death. This is not the orderly death that can be understood by the application of the metrics of the cycle of life, a production line in the factory ordering undifferentiated passages from birth to death, nor is this death that is positioned at the end of ordinary medical protocols for the ordinary experiences of life. It is the ultimate terror--it brings with it the potential of death, where everyone is potentially marked even as only some suffer directly or indirectly. But in the process death becomes the air we breathe, it becomes the substance of the information we receive. It is the subtext of all communication and the excuse for every action. We are choking on the fumes of death and touched by its drama as it is played out in personal tragedy projected through the miracle of technology to all corners of the earth.
Every one of us experiences death, engages with it, and participates in its passage from a potentiality on the horizon, to the whirlwind that uproots everything, to the detritus of an engagement around us that is indifferent to the way in which we clean it up. Death comes in the petri dishes that cruise ships have sometimes become; it surrounds islands of isolation like the rising sea, always threatening to overwhelm those islands of isolation situated precariously between the satisfaction of prevention and the guilt of as passive witness of the flows of death swirling about them. witness. To avoid testing is to tempt Death, to test positive is to acquire a marker of death's potential.
The last three paragraphs are histrionic; they read like a bad poem; they are suffocating. They mean to convey intensity, panic, emotion, alarm, and all of the other reactions appropriate to a crisis of this kind. They are meant to contribute to a narrative that is useful for getting people to take the pandemic seriously, and to treat institutional instructions with even greater seriousness. News reports, governmental statements, the analysis of experts, the attention of social media--all of these add layers that in the end read like a constantly reinforcing reminder of societal distress at a macro and micro level.
But the effects of these narratives are not necessarily always positive. In its more negative forms it may be possible to surmise that these pandemic narratives spread death beyond the effects of the COVID-19 virus and its attacks on the human body. It penetrates the human psyche and insinuates itself as a point of ecstasy of pandemic, of a euphoria that moves from light to darkness. The frenzy of death that throbs through the reporting of the pandemic and through the responsibility borne by those who confront the physicality of death, is both a great molder of societal response, of popular feeling, and when it manifests as despair, in suicide.
Suicide is worthy of far greater attention in the midst of the many challenges of the pandemic. It is an expression of personal agony, of illness, of despair, and of the power of the narratives of pandemic--and its expression through mechanisms of societal communication, policy and management--that is likely a far more powerful factor in the framework of epidemic response than one might gather from the single minded focus on the narratives of state and of those who seek to use their voices to move discourse towards particular ends. It kills as surely as the virus at the heart of the pandemic. "Crisis hotlines nationwide are surging with calls from Massachusetts to Oregon, both of which are states with “shelter-in-place” orders implemented, keeping people out of work and isolated at home. In Portland, Police Chief Jami Resch said Tuesday suicide threats or attempts are up 41 percent from this time last year and have jumped 23 percent since 10 days before a declared state of emergency" (More People Died From Suicide Than Coronavirus In Tennessee This Week).
At the same time there are stories. And these stories of those who in the face of epidemic chose that path are worthy of retelling. A few of those stories follow. Suicide is an an abstraction; it is the sum of the stories of individuals confronted by a context of meaning, of significance, we have all helped to build.
Last week, 34-year-old nurse Daniella Trezzi, who worked in the
COVID-19 intensive care ward of San Gerardo hospital at Monza, near
Milan, learned that she had been infected with the disease. Distraught
at the idea that she could have spread the coronavirus to others before
she learned that she carried the disease, and facing the relentless
working conditions at a hospital in the epicenter of the pandemic in
Europe, Trezzi tragically committed suicide.
The National Federation of Italian Nurses (FNOPI) said in a brief
statement about her death that Ms. Trezzi and many nurses treating
quarantined patients showing COVID-19 symptoms feel “heavy stress for
fear of having infected others.” The Federation noted the “pain and
dismay” of its members “at the news of her death.”
Trezzi had studied at the Università degli Studi di Milano-Bicocca
and lived with her dog in Brugherio. She leaves behind a brother and
many friends and colleagues. Her Facebook page, which was still
accessible yesterday, made clear her love of nature and travel and her
dedication to her chosen profession.
Daniela Trezzi
In the wake of Trezzi’s suicide, the FNOPI implored: “Each of us has
chosen this profession for good and, unfortunately, also for bad: we are
nurses. And nurses, all nurses, never leave anyone alone, even at
risk—and this is evident—of their own lives. But that’s enough: we must
not, we cannot, abandon the nurses.”
This tragedy points to the terrible human cost not only of the
COVID-19 pandemic, but of decades of social austerity policies that have
left hospitals across Europe understaffed, overworked and without
life-saving protection equipment like masks to shield medical staff from
the contagion.
Now, amid the greatest global pandemic since the Spanish flu of
1918–1919, millions of nurses and medical professionals internationally
are working around the clock with little or no protective gear. Across
Europe tens of thousands of medical staff have contracted the disease,
and health workers represent a staggering one in eight of Spain’s now
85,195 COVID-19 cases. They share images of exhausted colleagues, as
hospitals buckle under the stress of treating thousands of COVID-19
intensive care patients each day.
Medical staff undergo unbearable stress, helplessly watching COVID-19
patients die alone. Dr. Francesca Cortellaro, head of the emergency
room of the Borromeo hospital, told Euronews: “Do you see the emergency
room? COVID-19 patients enter alone, no relatives can attend, and when
they are about to leave they sense it. They are lucid, they do not go to
narcolepsy.”
The stress is intensified by the contradictory messages and policies
from European governments, which repeatedly made false comparisons of
COVID-19 to seasonal flu to downplay the illness and try to force
workers back to work to boost corporate profits in the middle of the
pandemic.
Monica Trombetta, a nurse working in Como, near Monza, told the
press: “We’re very tired and afraid. Government decrees change every
day. Personnel does not have clear guidelines for dealing with this new
virus and feel a little abandoned—not by our hospital, but it’s just as a
general feeling. Nurses are afraid to go home and potentially infect
their relatives.”
Nurses—who by the very nature of their job, spend the most time with
patients—are particularly vulnerable to suicidal feelings. Nurse
suicides have become a global epidemic, with US female and male nurses
committing suicide at rates of 11.97 and 39.8 per 100,000 respectively
last year, even before the COVID-19 pandemic. In their extremely
high-pressure environment, demands for optimal performance are a
decisive factor in intensifying feelings of distress and depression.
In Britain, a young nurse in her 20s working at King’s College
Hospital in London took her own life while treating COVID-19 patients
last week. Her colleagues found her unresponsive in her ward, and
doctors were unable to resuscitate her. Her next of kin have been
notified, but the hospital did not release her identity.
Several British hospital trusts are reporting that up to 50 percent
of their medical staff are at home, sick with COVID-19, leaving
remaining staff wondering who will look after them and the massive daily
influx of COVID-19 patients if they too fall ill with the virus.
Having infected hundreds of thousands of people, COVID-19 is ravaging
hospitals in all of Europe. This exposes the malignant neglect of
European officials for the fate of the broad mass of working people.
Chancellor Angela Merkel called for Germans to accept that 70 to 80
percent of the population would get sick, and British officials calling
for Britons to develop “herd immunity” by infecting almost the entire
population with coronavirus. Based on these policies, they pressed for
workers to continue working to churn out profits for big corporations.
Such proposals, which entail hundreds of millions catching COVID-19,
would provoke a crisis hundreds or thousands of times more severe than
the horrors already being visited on the population and health staff of
northern Italy and other hard-hit regions. That such proposals are
advanced by leading European governments make clear the political and
moral degeneracy of the existing social system, and the callous
indifference of the ruling class to the human tragedies that are
unfolding.
Also last week in Italy, a 49-year-old nurse who worked in the
COVID-19 ward of Jesolo hospital committed suicide, throwing herself
into the Piave river in Cortellazzo, in the region of Venice.
The nurse, whose initials are S.L., had courageously volunteered to
work with coronavirus patients and helped convert the Jesolo hospital
into a COVID-19-only ward. S.L. lived alone and was at home for two days
with fever, awaiting the results of a COVID-19 test, when she took her
own life.
Paying his respects to S.L., her hospital director said: “She was a
person dedicated to work, an irreplaceable resource for colleagues and
for this health authority. Not by chance, as soon as we heard the news
of her disappearance, colleagues at the hospital in Jesolo, who are busy
these days on the coronavirus front, were deeply affected and shaken by
the event. I express my deepest condolences and closeness to the family
of ‘our nurse’ S.L.”
CHICAGO
(WLS) -- Suicide prevention groups are seeing an uptick in calls during
the COVID-19 pandemic and want to remind you that help is available
while we deal with tough times.
Last
week, a 44-year-old woman took her life by jumping off of an Advocate
Christ Medical Center parking garage. During this COVID-19 crisis,
suicide prevention organizations are seeing an increase in calls.
"I
think our whole entire industry is seeing an uptick," said Jonny
Boucher, CEO of Hope for the Day. "Right now, people are reaching out
whether it's through the lifelines, our website, Instagram, Facebook,
Twitter."
Organizations
like Hope for The Day are offering many online workshops to help. The
Illinois Chapter of the American Foundation for Suicide Prevention is
calling on family and friends to reach out to loved ones who are
struggling.
"For those people who do deal with mental illnesses,
this can add a lot of stress to the managing of their condition," said
Tandra Rutledge, with the American Foundation for Suicide
Prevention-Illinois Chapter. "We want them to know we are here for them,
folks are not alone."
Experts say it's vital for people with mental illnesses to stay on medication and pursue online therapy.
For
others, depression and anxiety may be hard to avoid during this
pandemic, especially being isolated. Dr. Judy Moskowitz, a psychologist
with Northwestern University Feinberg School of Medicine, said setting a
schedule and making a list each day is key.
"Two or three things
that you can do," said Dr. Moskowitz. "And when you accomplish them and
cross them off, it a hit of positive emotion that can help you stay
engaged and avoid getting too down."
Besides setting a schedule, experts advise people to limit their COVID-19 news intake.
"Turn
it off," said Dr. Moskowitz. "If you check on it once a day that is
probably plenty, and if something really big happens, you're going to
hear about it."
Reading books, preferably fiction, playing board
games and reaching out to friends online are all ways to avoid slipping
into depression. If you are suicidal, call 1-800-273-TALK.
Panic took over a man from Andhra Pradesh, India, who assumed he had
contracted the deadly coronavirus and killed himself fearing he would
also infect his family. The new coronavirus: how it's transmitted
Balakrishnayya, 50,
had visited hospital for his heart ailment when doctors there advised
him to wear a mask as he showed symptoms of cold. The man got anxious
and quickly concluded he was infected with the novel coronavirus which
has killed over 1,000 in China and infected over 40,000 people
worldwide.
According to reports in NDTV, the man who hailed from a
village Srikalahasti in Chitoor, feared he would infect his family and
other villagers. He locked his family in the house and committed suicide
by hanging himself from a tree. "He had gone to hospital for checkup
regarding heart ailment. The doctors told him to use a mask and he
misunderstood he was infected with coronavirus," the man's son said.
He also said that his father watched many videos about the
coronavirus outbreak and assumed his symptoms were that of the deadly
infection. "He (his father) wouldn't let any of us come near him. I told
him you don't have infection but he wouldn't listen. May be, if he got
proper counselling, he would have listened," the son added.
* * *
Although there have been no cases of the novel coronavirus in Andhra
Pradesh, the outbreak has caused panic after WHO declared it a global
health emergency. In India, three people tested positive for coronavirus
in Kerala and they are students who had returned from China's Wuhan,
the epicentre of the outbreak.
News broke just recently regarding a male official from South Korea’s Ministry of Justice committing suicide.
He had committed suicide from a bridge across the Han River.
According to Naver News,
the man was an employee at the Office of Emergency Safety Planning
which spearheads the national emergency and disaster management in South
Korea.
South Korean In Charge of COVID-19 Commits Suicide; Unknown If It’s Due to Work
Lest you’re unaware, the Office of Emergency Safety Planning is involved and in charge of containing the COVID-19 outbreak in South Korea.
According to Naver News, the man could be seen in CCTV footage driving his car before crashing into the railing of the Donjak Bridge.
Shortly after, he is seen jumping from the bridge into the Han River. Unfortunately, he died at around 5am South Korean time or around 4am Singapore time.
Body Found Hours Later
The search for his body took a few hours, and it was found at around 8am Singapore time by the Banpo rescue team.
Amidst all the speculations, we can’t be sure whether his reason for
committing suicide was due to his work as there are no clear links at
this time.
South Korea’s Ministry of Justice and the relevant authorities are
currently looking into and investigating why the man committed suicide.
They will also be looking into whether his death was due to his work.
Thomas Schaefer served as finance minister for the German state of Hesse for a decade before his death: EPAThe finance minister of the German region of Hesse has died in an apparent suicide which the state governor suggested was linked to worries over the coronavirus pandemic.
Thomas
Schaefer, a member of Chancellor Angela Merkel’s Christian Democratic
Union, was found on railway tracks at Hochheim, near Frankfurt, on
Saturday.
Police and prosecutors said that the evidence, including
witness statements and examination of the scene, led them to conclude
the 54-year-old killed himself.
State governor Volker Bouffier said Schaefer had worked “literally day and night” to deal with the Covid-19 crisis.
“We
have to assume that he was very worried,” said Mr Bouffier. “Above all,
there are great concerns about whether it will be possible to meet the
huge expectations of the population – especially financial aid.
“I
have to assume that these concerns overwhelmed him. He obviously
couldn’t find a way out. He was desperate and left us. His death is also
a great loss for this country.”
Schaefer had been Hesse’s state
finance minister for a decade and was seen as a potential candidate for
the region’s next governor.
The Hesse CDU party said in a
statement that it was in mourning, adding: “We heard with dismay the
news of his sudden and unexpected death. Our thoughts are with his
family and relatives.” Germany has reported 455 deaths and more than 58,000 confirmed cases of Covid-19 since the start of the outbreak.
Seven days ago the German chancellor went into quarantine after a doctor who gave her a vaccine tested positive for the virus.
The
country has banned public meetings of more than two people and imposed
tight border restrictions in an attempt to slow the spread of the
outbreak. Additional reporting by agencies
A 38-year-old Wilson Borough
man who had become increasingly despondent over the COVID-19 pandemic
and who had recently lost his job shot his longtime girlfriend then
himself on Monday afternoon, police report.
Roderick Bliss, of the unit block of North 17th Street, died at the scene and his death was ruled a suicide,
Northampton County Coroner Zachary Lysek said. The 43-year-old woman
suffered a gunshot wound to the back and is being treated in the
intensive care unit at St. Luke’s University Hospital in Fountain Hill,
police Chief Chris Meehan said. She is expected to survive, Meehan
added.
Police
were called at 1:19 p.m. to 54 N. 17th St. for a report of shots fired
with injuries, Meehan said. After locating Bliss’ body they recovered a
semiautomatic pistol nearby, Meehan said. The woman was conscious and
alert and was able to tell officers that Bliss shot her, Meehan said.
On
Tuesday, the woman, who police did not name, was able to speak to
police in more detail. Officers interviewed others as well, Meehan said.
“In
the days prior to the shooting, Bliss had become increasingly upset
over the COVID-19 pandemic," Meehan wrote about the disease caused by
the coronavirus. "Minutes before the shooting Bliss was extremely upset
about the pandemic and the fact that he had recently lost his job.
“He
went into the basement and came outside onto the rear porch with the
victim. While holding the handgun, Bliss told the victim, ‘I already
talked to God and I have to do this.’ The victim ran off the porch and
he shot at her four times striking her once. Bliss then shot himself.”
It
wasn’t immediately clear if Bliss lost his job due to the economic
downturn as communities sheltered in place as the pandemic took hold,
Meehan said.
Borough police were assisted by the coroner’s office, the borough fire department and Suburban EMS, Meehan said.
New York
Gov. Andrew Cuomo recently announced that New York State plans to set
up a free mental health service in which people can speak to mental
health professionals about the emotional toll of the COVID-19 crisis.
Cuomo called on mental health professionals to consider donating their
time to conduct free sessions over the phone or via video for patients
in need of mental health counseling.
Mental health problems such as anxiety and depression are likely to
spike among Americans in the coming weeks because of the uncertainty
created by the pandemic.
COVID-19 has evoked fear in our lives in a way that hasn't been felt
since the 9/11 terrorist attack. The sight of empty grocery store
shelves, streets void of pedestrians, overflowing emergency rooms and
thousands sequestered at home paints a picture of our new reality. Empty
store shelves alone can be deeply distressing for many who fear that
food supplies will run out, triggering all sorts of negative emotions.
Stress, anxiety and depression are normal and expected in the context of
this pandemic. Experts, however, are particularly worried about people
who are predisposed to depression and anxiety. The unique and
unprecedented threat of COVID-19 has exacerbated anxiety, depression and
potential for hysteria in our most vulnerable -- the mentally ill.
Psychologists describe fear as an expected response to a known threat,
such as the seasonal flu, while anxiety is a response to a vague threat.
Dr. Alexander Sanchez, a psychiatrist working in New York City, told ABC
News, “This is a new challenge and the most worrying aspect is the
uncertainty."
At this time, nearly 7 million people in the U.S. are affected by
generalized anxiety disorder and about 6 million with panic disorder.
These numbers are expected to go up in the next few months.
“I expect an increase in anxiety and depressive symptoms to come when
the experience of social distancing and isolation becomes more routine,
Sanchez said. “We are trying to adjust to a new way of maintaining
social connections virtually. There will be some psychic pain while we
adjust."
When asked to pinpoint the primary root of anxiety, Dr. Armando
Gonzalez, also known as Dr. Mondo, who a licensed marriage and family
therapist practicing in Sacramento, California, told ABC News: “There's
no doubt uncertainty is always the lynchpin to anxiety and panic."
He added, "In addition to panic around catching the virus or passing it
on, the financial impact has become a cause for panic too."
Small businesses are struggling to stay afloat and many workers are not
able to perform their jobs under current shelter-in-place orders. The
mounting unknowns, mixed with the financial crisis that is sure to
ensue, is at the root of a rise in anxiety, Mondo said.
Moreover, experts say obsessive compulsive disorder (OCD) will also be on the rise.
Cleaning and washing compulsions are two features of OCD, which can
easily be exacerbated by the threat of infection. Mental health
professions in psychiatry, primary care and even dermatology should be
alerted to potential issues in patients with OCD.
In addition, the current outbreak may exacerbate psychosis-like symptoms
as well as lead to non-specific mental issues (e.g., mood and sleep
disturbances, phobias and panic-like symptoms).
The Centers for Disease Control and Prevention says anxiety and depression may worsen for people who are most susceptible to COVID-19, such as older individuals and those with chronic diseases.
“The elderly are more anxious because of their risk factors in regards to catching the virus," according to Mondo.
For other age groups, there's a level of heightened stress and
uncertainty around when this might end and the financial impact it will
have, Mondo noted.
As more people are asked to stay at home and self-quarantine, feelings
of loneliness and isolation will be common. But experts say there are
several strategies that may help people cope.
The National Alliance of Mental Illness (NAMI) recommends maintaining a
sense of normality and routine that mirrors life’s daily patterns and
practices. Structure and routine are helpful for people with mental
health vulnerabilities, especially during times of uncertainty.
NAMI says to maintain a regular routine and keep up with morning
rituals. Dressing in regular work attire and taking regular breaks are
important. If working from home, NAMI encourages creating a structured,
dedicated work environment and building in self-care as well as daily
benchmarks of achievement.
“We are social creatures, we need each other. The creativity we have
used to connect virtually is cause for hope, but at the end of the day,
virtual meetings are still synthetic connection," said Mondo.
With the inevitable rise in mental health problems in the coming weeks,
states are relying on tele-health to meet the mental health needs of the
population.
“The health care world is working to expand tele-health at a breakneck
pace to meet the needs of the community," said Sanchez. “It helps reduce
the unnecessary use of personal protective equipment by health care
workers and prevent the transmission of disease to patients in office
waiting rooms or public transit."
The New York State Psychiatric Association is working with Gov. Cuomo to encourage participation in free tele-health services.
“We need to remember that this is temporary -- we have been challenged
before and have met and exceeded those challenges as a society," said
Sanchez.
Complete a survey at health.ny.gov/assistance for mental health services.
For mental health crisis, Call the NAMI HelpLine at 800-950-NAMI (6264)
Monday through Friday, between 10:00 am and 6:00 pm EST for mental
health resources.
Visit NAMI.org for additional information on how to seek mental health help.
If you are a loved one is experiencing suicidal thoughts in response to
the outbreak, call The National Suicide Prevention Lifeline at
1-800-273-8255 for free and confidential emotional support 24 hours a
day, 7 days a week.
Yalda Safai MD, MPH, is a psychiatry resident in New York City and contributor to ABC News Medical Unit.
Key Points español 中文 (chinese) Question
What factors are associated with mental health outcomes among
health care workers in China who are treating patients with coronavirus
disease 2019 (COVID-19)? Findings
In this cross-sectional study of 1257 health care workers in
34 hospitals equipped with fever clinics or wards for patients with
COVID-19 in multiple regions of China, a considerable proportion of
health care workers reported experiencing symptoms of depression,
anxiety, insomnia, and distress, especially women, nurses, those in
Wuhan, and front-line health care workers directly engaged in
diagnosing, treating, or providing nursing care to patients with
suspected or confirmed COVID-19. Meaning
These findings suggest that, among Chinese health care workers
exposed to COVID-19, women, nurses, those in Wuhan, and front-line
health care workers have a high risk of developing unfavorable mental
health outcomes and may need psychological support or interventions.
Abstract
Importance
Health care workers exposed to coronavirus disease 2019 (COVID-19) could be psychologically stressed. Objective
To assess the magnitude of mental health outcomes and
associated factors among health care workers treating patients exposed
to COVID-19 in China. Design, Settings, and Participants
This cross-sectional, survey-based, region-stratified study
collected demographic data and mental health measurements from 1257
health care workers in 34 hospitals from January 29, 2020, to February
3, 2020, in China. Health care workers in hospitals equipped with fever
clinics or wards for patients with COVID-19 were eligible. Main Outcomes and Measures
The degree of symptoms of depression, anxiety, insomnia, and
distress was assessed by the Chinese versions of the 9-item Patient
Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the
7-item Insomnia Severity Index, and the 22-item Impact of Event
Scale–Revised, respectively. Multivariable logistic regression analysis
was performed to identify factors associated with mental health
outcomes. Results
A total of 1257 of 1830 contacted individuals completed the
survey, with a participation rate of 68.7%. A total of 813 (64.7%) were
aged 26 to 40 years, and 964 (76.7%) were women. Of all participants,
764 (60.8%) were nurses, and 493 (39.2%) were physicians; 760 (60.5%)
worked in hospitals in Wuhan, and 522 (41.5%) were frontline health care
workers. A considerable proportion of participants reported symptoms of
depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427
[34.0%]), and distress (899 [71.5%]). Nurses, women, frontline health
care workers, and those working in Wuhan, China, reported more severe
degrees of all measurements of mental health symptoms than other health
care workers (eg, median [IQR] Patient Health Questionnaire scores among
physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007;
median [interquartile range {IQR}] Generalized Anxiety Disorder scale
scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001;
median [IQR] Insomnia Severity Index scores among frontline vs
second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001;
median [IQR] Impact of Event Scale–Revised scores among those in Wuhan
vs those in Hubei outside Wuhan and those outside Hubei: 21.0 [8.5-34.5]
vs 18.0 [6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside
Hubei; P < .001). Multivariable logistic regression analysis
showed participants from outside Hubei province were associated with
lower risk of experiencing symptoms of distress compared with those in
Wuhan (odds ratio [OR], 0.62; 95% CI, 0.43-0.88; P = .008).
Frontline health care workers engaged in direct diagnosis, treatment,
and care of patients with COVID-19 were associated with a higher risk of
symptoms of depression (OR, 1.52; 95% CI, 1.11-2.09; P = .01), anxiety (OR, 1.57; 95% CI, 1.22-2.02; P < .001), insomnia (OR, 2.97; 95% CI, 1.92-4.60; P < .001), and distress (OR, 1.60; 95% CI, 1.25-2.04; P < .001). Conclusions and Relevance
In this survey of heath care workers in hospitals equipped
with fever clinics or wards for patients with COVID-19 in Wuhan and
other regions in China, participants reported experiencing psychological
burden, especially nurses, women, those in Wuhan, and frontline health
care workers directly engaged in the diagnosis, treatment, and care for
patients with COVID-19.
Introduction
Since the end of December 2019, the Chinese city of
Wuhan has reported a novel pneumonia caused by coronavirus disease 2019
(COVID-19), which is spreading domestically and internationally.1 The virus has been named severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2). In this report, we will refer to the disease, COVID-19.
According to data released by the National Health Commission of China,
the number of confirmed cases in mainland China has increased to 80 151
as of March 2, 2020,2
and confirmed cases have been reported in more than a dozen other
countries. Moreover, person-to-person transmission has been recorded
outside mainland China.3
On January 30, 2020, the World Health Organization held an emergency
meeting and declared the global COVID-19 outbreak a public health
emergency of international concern.4
Facing this critical situation, health care workers on
the front line who are directly involved in the diagnosis, treatment,
and care of patients with COVID-19 are at risk of developing
psychological distress and other mental health symptoms. The
ever-increasing number of confirmed and suspected cases, overwhelming
workload, depletion of personal protection equipment, widespread media
coverage, lack of specific drugs, and feelings of being inadequately
supported may all contribute to the mental burden of these health care
workers. Previous studies have reported adverse psychological reactions
to the 2003 SARS outbreak among health care workers.5-8 Studies showed that those health care workers feared contagion and infection of their family, friends, and colleagues,5 felt uncertainty and stigmatization,5,6 reported reluctance to work or contemplating resignation,6 and reported experiencing high levels of stress, anxiety, and depression symptoms,7 which could have long-term psychological implications.7
Similar concerns about the mental health, psychological adjustment, and
recovery of health care workers treating and caring for patients with
COVID-19 are now arising.
Psychological assistance services, including telephone-,
internet-, and application-based counseling or intervention, have been
widely deployed by local and national mental health institutions in
response to the COVID-19 outbreak. On February 2, 2020, the State
Council of China announced that it was setting up nationwide
psychological assistance hotlines to help during the epidemic situation.9
However, evidence-based evaluations and mental health interventions
targeting front-line health care workers are relatively scarce.
To address this gap, the aim of current study was to
evaluate mental health outcomes among health care workers treating
patients with COVID-19 by quantifying the magnitude of symptoms of
depression, anxiety, insomnia, and distress and by analyzing potential
risk factors associated with these symptoms. Participants from Wuhan
city (the capital of Hubei province) and other areas inside and outside
Hubei province in China were enrolled in this survey to compare
interregional differences. This study aimed to provide an assessment of
the mental health burden of Chinese health care workers, which can serve
as important evidence to direct the promotion of mental well-being
among health care workers.
Methods
Study Design
This study followed the American Association for Public Opinion Research (AAPOR)
reporting guideline. Approval from the clinical research ethics
committee of Renmin Hospital of Wuhan University was received before the
initiation of this study. Verbal informed consent was provided by all
survey participants prior to their enrollment. Participants were allowed
to terminate the survey at any time they desired. The survey was
anonymous, and confidentiality of information was assured.
The study is a cross-sectional, hospital-based survey
conducted via a region-stratified, 2-stage cluster sampling from January
29, 2020, to February 3, 2020. During this period, the total confirmed
cases of COVID-19 exceeded 10 000 in China. To compare the interregional
differences of mental health outcomes among health care workers in
China, samples were stratified by their geographic location (ie, Wuhan,
other regions inside Hubei province, and regions outside Hubei
province). Because Wuhan was most severely affected, more hospitals in
Wuhan were sampled. Hospitals equipped with fever clinics or wards for
COVID-19 were eligible to participate in this survey. A total of 20
hospitals in Wuhan (10 designated by the local government to treat
COVID-19 and 10 nondesignated), 7 hospitals in other regions of Hubei
province, and 7 hospitals from 7 other provinces with a high incidence
of COVID-19 (1 hospital from each province) were included. In total, 34
hospitals were involved. Milestone events during the outbreak of
COVID-19 and the duration of this study are presented in the eFigure in
the Supplement.
Participants
One clinical department was randomly sampled from each
selected hospital, and all health care workers in this department were
asked to participate in this study. The target sample size of
participants was determined using the formula N = Zα2P(1 − P) / d2, in which α = 0.05 and Zα = 1.96, and the estimated acceptable margin of error for proportion d
was 0.1. The proportion of health care workers with psychological
comorbidities was estimated at 35%, based on a previous study of the
SARS outbreak.7
To allow for subgroup analyses, we amplified the sample size by 50%
with a goal of at least 1070 completed questionnaires from participants.
Outcomes and Covariates
We focused on symptoms of depression, anxiety, insomnia,
and distress for all participants, using Chinese versions of validated
measurement tools.10-13 Accordingly, the 9-item Patient Health Questionnaire (PHQ-9; range, 0-27),10 the 7-item Generalized Anxiety Disorder (GAD-7) scale (range, 0-21),11 the 7-item Insomnia Severity Index (ISI; range, 0-28),12 and the 22-item Impact of Event Scale–Revised (IES-R; range, 0-88)13
were used to assess the severity of symptoms of depression, anxiety,
insomnia, and distress, respectively. The total scores of these
measurement tools were interpreted as follows: PHQ-9, normal (0-4), mild
(5-9), moderate (10-14), and severe (15-21) depression; GAD-7, normal
(0-4), mild (5-9), moderate (10-14), and severe (15-21) anxiety; ISI,
normal (0-7), subthreshold (8-14), moderate (15-21), and severe (22-28)
insomnia; and IES-R, normal (0-8), mild (9-25), moderate (26-43), and
severe (44-88) distress. These categories were based on values
established in the literature.10-13
The cutoff score for detecting symptoms of major depression, anxiety, insomnia, and distress were 10, 7,14
15, and 26, respectively. Participants who had scores greater than the
cutoff threshold were characterized as having severe symptoms.
Demographic data were self-reported by the participants,
including occupation (physician or nurse), sex (male or female), age
(18-25, 26-30, 31-40, or >40 years), marital status, educational
level (≤undergraduate or ≥postgraduate), technical title (junior,
intermediate, or senior), geographic location (Wuhan, Hubei province
outside Wuhan, or outside Hubei province), place of residence (urban or
rural), and type of hospital (secondary or tertiary). The different
technical titles of respondents refer to the professional titles
certificated by the hospital. Participants were asked whether they were
directly engaged in clinical activities of diagnosing, treating, or
providing nursing care to patients with elevated temperature or patients
with confirmed COVID-19. Those who responded yes were defined as
frontline workers, and those who answered no were defined as second-line
workers.
Statistical Analysis
Data analysis was performed using SPSS statistical
software version 20.0 (IBM Corp). The significance level was set at
α = .05, and all tests were 2-tailed. The original scores of the 4
measurement tools were not normally distributed and so are presented as
medians with interquartile ranges (IQRs). The ranked data, which were
derived from the counts of each level for symptoms of depression,
anxiety, insomnia, and distress, are presented as numbers and
percentages. The nonparametric Mann-Whitney U test and
Kruskal-Wallis test were applied to compare the severity of each symptom
between 2 or more groups. To determine potential risk factors for
symptoms of depression, anxiety, insomnia, and distress in participants,
multivariable logistic regression analysis was performed, and the
associations between risk factors and outcomes are presented as odds
ratios (ORs) and 95% CIs, after adjustment for confounders, including
sex, age, marital status, educational level, technical title, place of
residence, working position (first-line or second-line), and type of
hospital.
Results
Demographic Characteristics
In the study, among the 1830 health care workers (702
[38.4%] physicians and 1128 [61.6%] nurses) asked to participate, 1257
respondents (68.7%) completed the survey. The occupational and
geographic data of nonrespondents were similar to those of respondents
(eTable 1 in the Supplement).
Of the 1257 responding participants, 493 (39.2%) were physicians, and
764 (60.8%) were nurses. The response rates for physicians and nurses
were 70.2% and 67.7%, respectively. Of the participants, 760 (60.5%)
worked in Wuhan, 261 (20.8%) worked in Hubei province outside Wuhan, and
236 (18.8%) worked outside Hubei province. Most participants were women
(964 [76.7%]), were aged 26 to 40 years (813 [64.7%]), were married,
widowed, or divorced (839 [66.7%]), had an educational level of
undergraduate or less (953 [75.8%]), had a junior technical title (699
[55.6%]), and worked in tertiary hospitals (933 [74.2%]). A total of 522
participants (41.5%) were frontline health care workers directly
engaged in diagnosing, treating, or caring for patients with or
suspected to have COVID-19. Nearly all participants (1220 [97.1%]) lived
in urban areas (Table 1).
Severity of Measurements and Associated Factors
A considerable proportion of participants had symptoms
of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427
[34.0%]), and distress (899 [71.5%]). Nurses, women, frontline workers,
and those in Wuhan reported experiencing more severe symptom levels of
depression, anxiety, insomnia, and distress (eg, severe depression among
physicians vs nurses: 24 [4.9%] vs 54 [7.1%]; P = .01; severe anxiety among men vs women: 10 [3.4%] vs 56 [5.8%]; P = .001; severe insomnia among frontline workers vs second-line workers: 9 [1.7%] vs 3 [0.4%]; P < .001;
severe distress among workers in Wuhan vs Hubei outside Wuhan and
outside Hubei: 96 [12.6%] vs 19 [7.2%] among those in Hubei outside
Wuhan and 17 [7.2%] among those outside Hubei; P < .001) (Table 2).
Compared with those working in tertiary hospitals, participants working
in secondary hospitals were more likely to report severe symptoms of
depression (53 [5.6%] vs 25 [7.7%]; P = .003), anxiety (48 [5.1%] vs 18 [5.5%]; P = .046), and insomnia (10 [1.0%] vs 2 [0.6%]; P = .02) but not distress (Table 2).
Scores of Measurements and Associated Factors
The median (IQR) scores on the PHQ-9 for depression, the
GAD-7 for anxiety, the ISI for insomnia, and the IES-R for distress for
all respondents were 5.0 (2.0-8.0), 4.0 (1.0-7.0), 5.0 (2.0-9.0), and
20.0 (7.0-31.0), respectively. Similar to findings in severity of
symptoms, participants who were nurses, women, frontline health care
workers, and working in Wuhan had higher scores in all 4 scales compared
with those who were physicians, men, second-line health care workers,
and working in Hubei province outside Wuhan or outside Hubei province
(eg, median [IQR] PHQ-9 scores among physicians vs nurses: 4.0 [1.0-7.0]
vs 5.0 [2.0-8.0]; P = .007; median [IQR] GAD-7 scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] ISI scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001;
median [IQR] IES-R scores among those in Wuhan vs those in Hubei
outside Wuhan and those outside Hubei: 21.0 [8.5-34.5] vs 18.0
[6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside Hubei; P < .001) (Table 3).
Compared with health care workers in tertiary hospitals, those in
secondary hospitals reported higher scores on scales measuring symptoms
of depression, anxiety, and insomnia (median [IQR] PHQ-9 score, 4.0
[1.0-7.0] vs 5.0 [2.0-9.0]; P < .001; median [IQR] GAD-7 score, 3.0 [0-7.0] vs 4.0 [1.0-7.0]; P = .005; median [IQR] ISI score, 4.0 [2.0-9.0] vs 6.0 [2.0-10.0]; P = .008).
There were no differences in hospital status for scores of distress
(median [IQR] IES-R score: workers in tertiary hospitals, 19.0
[7.0-32.0]; workers in secondary hospitals, 20.0 [6.0-31.0]; P = .46).
However, frontline health care workers from tertiary and secondary
hospitals reported equally high scores on all 4 scales (eg, median [IQR]
PHQ-9 score, 5.0 [2.0-8.0] vs 6.0 [3.0-9.0]; P = .08) (Table 4).
In pairwise comparisons, participants from Hubei province outside Wuhan
and participants outside Hubei province reported similar levels of
symptoms of depression, anxiety, insomnia, and distress but were all
lower than that of health care workers in Wuhan, the origin of the
epidemic (eTable 2 in the Supplement).
Analyses of scores of 3 factors (avoidance, intrusion, and
hyperarousal) derived from the IES-R are presented in eTable 3, eTable
4, and eTable 5 in the Supplement.
Risk Factors of Mental Health Outcomes
Multivariable logistic regression analysis showed that,
after controlling for confounders, being a woman and having an
intermediate professional title were associated with severe symptoms of
depression, anxiety, and distress (eg, severe depression among women:
OR, 1.94; 95% CI, 1.26-2.98; P = .003; severe anxiety among those with intermediate professional titles: OR, 1.82; 95% CI, 1.38-2.39; P < .001).
Compared with working in a tertiary hospital, working in secondary
hospitals was associated with more severe symptoms of depression (OR,
1.65; 95% CI, 1.17-2.34; P = .004) and anxiety (OR, 1.43; 95% CI, 1.08-1.90; P = .01).
Working outside Hubei province was associated with a lower risk of
feeling distressed than working in Wuhan (OR, 0.62; 95% CI, 0.43-0.88; P = .008).
Compared with working in second-line positions, working in the
frontline directly treating patients with COVID-19 appeared to be an
independent risk factor for all psychiatric symptoms after adjustment
(depression, OR 1.52; 95% CI, 1.11-2.09; P = .01; anxiety, OR 1.57; 95% CI, 1.22-2.02; P < .001; insomnia, OR 2.97; 95% CI, 1.92-4.60; P < .001; distress: OR, 1.60; 95% CI, 1.25-2.04; P < .001) (Table 5).
Discussion
This cross-sectional survey enrolled 1257 respondents
and revealed a high prevalence of mental health symptoms among health
care workers treating patients with COVID-19 in China. Overall, 50.4%,
44.6%, 34.0%, and 71.5% of all participants reported symptoms of
depression, anxiety, insomnia, and distress, respectively. Participants
were divided in 3 groups (Wuhan, other regions in Hubei province, and
regions outside Wuhan province) to compare interregional differences.
Most participants were female, were nurses, were aged 26 to 40 years,
were married, and worked in tertiary hospitals with a junior technical
title. Nurses, women, those working in Wuhan, and frontline workers
reported more severe symptoms on all measurements. Our study further
indicated that being a woman and having an intermediate technical title
were associated with experiencing severe depression, anxiety, and
distress. Working in the front line was an independent risk factor for
worse mental health outcomes in all dimensions of interest. Together,
our findings present concerns about the psychological well-being of
physicians and nurses involved in the acute COVID-19 outbreak.
In this study, a significant proportion of participants
experienced anxiety, depression, and insomnia symptoms, and more than
70% reported psychological distress. In a previous study during the
acute SARS outbreak, 89% of health care workers who were in high-risk
situations reported psychological symptoms.8
The psychological response of health care workers to an epidemic of
infectious diseases is complicated. Sources of distress may include
feelings of vulnerability or loss of control and concerns about health
of self, spread of virus, health of family and others, changes in work,
and being isolated.15 The fact that COVID-19 is human-to-human transmissible,1,3 associated with high morbidity, and potentially fatal16
may intensify the perception of personal danger. Additionally,
predictable shortages of supplies and an increasing influx of suspected
and actual cases of COVID-19 contribute to the pressures and concerns of
health care workers.17
Of note, 76.7% of all participants were women, and 60.8%
were nurses (90.8% of whom were female). Our findings further indicate
that women reported more severe symptoms of depression, anxiety, and
distress. Frontline nurses treating patients with COVID-19 are likely
exposed to the highest risk of infection because of their close,
frequent contact with patients and working longer hours than usual.18,19
Moreover, 71.5% of all nurses had junior titles, indicating that most
had fewer years of work experience. During the SARS outbreak, a study
conducted among health care workers in emergency departments also showed
that nurses were more likely to develop distress and use behavioral
disengagement than physicians.15
Frontline nurses treating patients with SARS were physically and
psychologically challenged when committing themselves to providing
high-quality nursing care for patients.19-22
Moreover, at the early stage of the SARS epidemic, nurses may have been
less likely to be warned about exposure or provided with adequate
protections.22 Particular attention is warranted regarding the mental health well-being of women and nurses treating patients with COVID-19.
Another finding in our study was that, compared with
those in Hubei province outside Wuhan and those outside Hubei province,
health care workers in Wuhan reported more severe symptoms of
depression, anxiety, insomnia, and distress. Multivariable logistic
regression analysis showed that working outside Hubei province was
associated with lower risk of experiencing distress. These findings
indicated more stress among health care workers in Wuhan, the origin and
epicenter of the epidemic in China. In addition, working as a frontline
health care worker with direct engagement of patients with COVID-19 was
an independent risk factor for all symptoms. As frontline health care
workers in Wuhan were at especially high risk for symptoms of
depression, anxiety, insomnia, and distress, their mental health may
require special attention.
Limitations
This study has several limitations. First, it was
limited in scope. Most participants (81.2%) were from Hubei province,
limiting the generalization of our findings to less affected regions.
Second, the study was carried out during 6 days and lacks longitudinal
follow-up. Because of the increasingly arduous situation, the mental
health symptoms of health care workers could become more severe. Thus,
long-term psychological implications of this population are worth
further investigation. Third, this study was unable to distinguish the
association of symptoms with being a clinician in this region vs simply
living in this region (because there was no comparator group) and was
also unable to distinguish preexisting mental health symptoms vs new
symptoms. Fourth, although the response rate of this study was 68.7%,
response bias may still exist if the nonrespondents were either too
stressed to respond or not at all stressed and therefore not interested
in this survey.
Conclusions
In this survey study of physicians and nurses in
hospitals with fever clinics or wards for patients with COVID-19 in
China, health care workers responding to the spread of COVID-19 reported
high rates of symptoms of depression, anxiety, insomnia, and distress.
Protecting health care workers is an important component of public
health measures for addressing the COVID-19 epidemic. Special
interventions to promote mental well-being in health care workers
exposed to COVID-19 need to be immediately implemented, with women,
nurses, and frontline workers requiring particular attention.
Corresponding Authors: Zhongchun Liu, MD, Department of Psychiatry, Renmin Hospital of Wuhan University, 238 Jiefang Rd, Wuhan 430060, China (zcliu6@whu.edu.cn);
Shaohua Hu, MD, Department of Psychiatry, First Affiliated Hospital,
Zhejiang University School of Medicine, 79 Qingchun Rd, Hangzhou 310003,
China (dorhushaohua@zju.edu.cn).
Author Contributions:
Drs Liu and S. Hu had full access to all of the data in the study and
take responsibility for the integrity of the data and the accuracy of
the data analysis. Drs Lai, Ma, and Y. Wang contributed equally and
share first authorship. Drs Liu and S. Hu contributed equally as senior
authors.
Concept and design: Liu, S. Hu.
Acquisition, analysis, or interpretation of data: Lai, Ma, Y. Wang, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang.
Drafting of the manuscript: Lai, Ma, Y. Wang, Liu, S. Hu.
Critical revision of the manuscript for important intellectual content: Lai, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang, Liu, S. Hu.
Statistical analysis: Ma, Y. Wang, Liu, S. Hu.
Obtained funding: Liu, S. Hu.
Administrative, technical, or material support: Lai, Cai, J. Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, H. Wang, G. Wang.
Supervision: G. Wang, Liu, S. Hu.
Conflict of Interest Disclosures: None reported.
Funding/Support:
This study was supported by grants 2018YFC1314600 and 2016YFC1307100
from the National Key Research and Development Program of China.
Role of the Funder/Sponsor:
The funder had no role in the design and conduct of the study;
collection, management, analysis, and interpretation of the data;
preparation, review, or approval of the manuscript; and decision to
submit the manuscript for publication.
Additional Contributions: We thank all the participants who contributed to our work.
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