Watercolor painting telepathy.

Supporting the Mental Health of Those on the COVID-19 Frontlines

By Stephanie Schorow for the Global Mass Vaccination Site Collaborative

The communication to Ariadne Labs from Nobhojit Roy, Chief of Surgery at BARC Hospital in Mumbai, India, was blunt and heartbreaking: 

What would really benefit us is how to cope with burnout and fatigue for my frontline COVID warriors. They have been at it for days on end. Senior critical care physicians who have spent their working lives seeing death are breaking down and crying.”

The time was the spring of 2021. COVID-19 cases were overwhelming India’s hospitals and clinicians were reeling from the pressure of trying to hold the line on a relentless pandemic. Moreover, this was not a problem unique to India. 

The urgent need for mental health support for clinicians is now being addressed by a new initiative, the Strength in Crisis Collaboration, a partnership between Ariadne Labs and mental health professionals in Mumbai to provide support for  frontline health care workers. This effort was spearheaded by Mary Brindle, MD, MPH, Director of Ariadne Labs’ Safe Surgery Safe Systems, and by Jahnavi S. Kedare, MD, MBBS, DNB, DMP, Additional Professor of Psychiatry at BYL Nair Hospital, Mumbai, and T.N. Medical College.

Drs. Brindle and Kedare gave a presentation on the development of the collaboration, its impact, and the implications for similar programs during the Dec. 10, 2021, meeting of the Global Mass Vaccination Site Collaborative, which was launched by Ariadne Labs in spring 2021 to facilitate rapid information exchange to improve impact and safely deliver vaccinations to more people.

One of the issues that led to the collaboration was the recognized value of a more robust mental health support structure for health care workers in India. Early in the pandemic a survey of India’s health care workers found that 47 percent suffered from depression, 50 percent from anxiety, and 45 percent reported a low quality of life. Yet a study by the World Economic Forum found that a majority of Indian citizens surveyed believed people with mental illnesses should not be given any responsibility and that the main causes of mental issues is a lack of self-discipline and will-power. 

“So you can imagine if you are a frontline health worker and you are really struggling with depression and anxiety and you would feel that asking for support might be regarded as basically saying you were not capable of doing your job,’’ Brindle said. “That was a real cause of tension.” 

In May 2020 Brindle was working with the American College of Surgeons to start exploring physician and frontline worker wellness, an issue that had come up during COVID-19. “We had a small grant at the time to pursue this; it was recognized as something critically important,” she said. Then through Lifebox and another Ariadne Labs staffer, Brindle was connected with Kedare in India, and a collaboration was eventually established. 

“India, as the second most populous country in the world, has suffered a lot during COVID and we have had a lot of cases,” Kedare told members of the GMVSC. “Fortunately our vaccination drive (has been conducted with) very, very good speed and 1.4 billion people have received vaccine doses.” However the rapid spread of COVID-19 in the spring and the lockdowns caused stress.

Health workers endured work overloads without breaks. They struggled with fear of infection for themselves and their families and personal loss. Specialists missed working in their field. 

Access to mental health services is limited in India, particularly in rural areas; according to Kedare, only 20 percent of adults with mental illnesses have access to a health facility and only 10 percent of people with mental health disorders receive treatment. 

Organizations, such as the Indian Psychiatric Society, began mental health support efforts with helplines, online services and telemedicine. NGOs and individual mental health professionals also joined these efforts. 

Kedare and the Department of Psychiatry of TN Medical College in Mumbai created a model of intervention for health care workers. This included orientation workshops for residents and telephone support to residents on duty. “We literally called up each and every resident doing COVID duty every 15 days or so to find out how they were dealing with the situation – whether they were sleeping well, eating well, or whether they had any issues to discuss,” Kedare said. 

Telephone support was provided to health care workers who tested positive for COVID-19, ranging from physicians to support staff. Psychiatry residents provided individual in person or online counseling and peer support.

The negative attitudes and the lack of mental health resources available to health care workers are not isolated to India. Solutions to address these deficits frequently exist within those communities most impacted. The Strength in Crisis Collaborative showcases, in particular, the knowledge and dedication of mental health professionals in Mumbai who were determined to develop programs and infrastructure to support their frontline colleagues.

Now, Kedare, Brindle, LifeBox and colleagues are working as a team to see how this model, which was rapidly instituted, can be refined and modified for other institutions.

“What more can we give to the health care workers so that they are empowered to face the pandemic in a better fashion,” Kedare said. 

The Bombay Psychiatric Society will serve as the platform for a newly named “Strength in Crisis Collaboration” with participation from Ariadne Labs, Lifebox, and Mumbai Mental Health. The collaboration has begun to build a strong mental health support infrastructure in Mumbai to support trainees and health care workers in COVID and beyond. It is creating models on managing stress, building resilience and managing loss. 

Three three-hour online workshops were held on Sunday mornings and received positive feedback. A mental health professional network dedicated to support health care workers will be created as will resource packages to support health care workers in Mumbai. 

The collaborative is looking at the next steps to spread the learnings, including developing cross-professional resource packages, writing academic articles, and creating presentations for international groups. Already well over 1,000 health care workers and trainees have been directly impacted by the workshops and materials developed as part of this collaborative although the true reach and spread will be hard to measure. The creation of a foundation of support offers the opportunity for immeasurable long-term benefits to the health system. 

Health care workers “are slogging through and we’re going to see more issues with burnout and mental health,” Brindle told the Collaborative members. “This area is going to get more significant, rather than less.” 

Key Takeaways

  • Where once the pandemic was seen as a crisis, now it must be viewed as an ongoing issue and long-term support systems are needed. 
  • Systems should stay flexible and adaptable. Teams should work across fields of expertise and develop an international network. 
  • Be proactive. Instead of waiting for workers to reach out, for example, call clinicians regularly to ask about stress and other issues. This allows a clinician to open up about issues with a supportive person. 
  • Physicians and nurses aren’t the only groups who need support. Laboratory workers and other staff may be suffering from the crush of the pandemic. 
  • Trainings and workshops can be held at unconventional times. For example, Sunday morning workshops proved to be popular in India and could be popular elsewhere. 
  • Advance training can be done for mental health professionals who, in turn, can create outreach programs.

The Global Mass Vaccination Collaborative was launched in April, 2021 as a way for stakeholders directing vaccination campaigns around the world to come together and learn from each other’s efforts. This blog series was launched as a way to record and share the learning and insights gained from this collaboration. You can read blogs from our previous meetings here.