Mental Health Challenges of Health Professionals in Times of COVID-19
The coronavirus disease 2019 (COVID-19) pandemic evolved to be one of the central health crises of current generations. It affected people of all nations, continents, races, and socioeconomic groups. Rapid responses, such as quarantining of whole communities, closing of schools, social and physical isolation, or shelter-in-place orders, have abruptly changed the daily life of many individuals. 
Health professionals of all disciplines are taking care of patients with COVID-19. The rapid spread of this disease and the severity of symptoms pushed many countries to the limits of their health care systems. They had to deal with a shortage of ventilators and intensive care unit (ICU) beds to care for the surge of critically ill patients, and a lack of personal protective equipment (PPE). Whilst facing a high volume of critically ill patients within a short time, health care professionals were forced to perform to their full potential over an extended time interval. They needed to cope with the societal shifts and emotional stressors faced by all people, when simultaneously facing a greater risk of exposure, extreme workloads, moral dilemmas an a quickly evolving practice environment that differs greatly from what they are familiar with.
Sources of Anxiety
To effectively support health professionals in times of COVID-19, it is necessary to understand the specific sources of anxiety and fear.
8 sources of anxiety could be identified (not all affected everyone in the same ways): 
- Access to the appropriate personal protective equipment
- The risk of being exposed to COVID-19 at the hospital or clinic and then taking the infection home to their family
- Rapid access to testing is unavailable if they develop COVID-19 symptoms combined with the fear of spreading the infection at work
- If they develop the infection they are unsure if their company or organization will have the resources or the ability to support/take care of their personal and family needs
- Difficulty in accessing childcare due to school closures and an increase in work hours
- Personal and family needs will increase with poor support as work hours and demands like food, hydration, accommodation, and transportation increase
- The ability to provide appropriate medical care if deployed to a new hospital or unit, for example, a non-ICU nurse needing to function as an ICU nurse
- Poor access to up-to-date information and communication. 
Identifying these sources of anxiety will allow health care leaders and organizations to appropriately support their health care workforce. The 8 concerns can be categorized into 5 requests from health professionals: hear me, protect me, prepare me, support me, and care for me. This is further explained in this table.
Leaders need to understand these sources of concern and assure health care professionals that their concerns will be recognized. They should develop approaches that will mitigate these concerns to the extent that they are able. Health professionals’ voices and expertise need to be considered for developing emergency preparedness plans as a response to the pandemic. Even if not everything they asked for could be provided, the fact of being asked, listened to and acknowledged will demonstrate an organisation’s respect towards their workforce. This could be translated into the overarching request: honor me.
This kind of gratitude is powerful. It could serve to reinforce the compassion and sacrifices of health workers when risking their own lives to help patients infected with COVID-19. This may help them to overcome empathetic distress and fear to provide care under extraordinarily difficult clinical circumstances on a daily basis. Gratitude should not be outsourced entirely to the public but is the business of leaders in charge as well.
Ethical dilemmas: Personal Risk and Societal Obligation Amidst COVID-19
In the pandemic, vulnerable patients with a risk of complications from COVID-19 have been told to stay home . Healthcare workers are as vulnerable as others but often are facing impossible choices. Whilst fearing for themselves and their loved ones they may feel tremendous guilt. Socialized with a medical ethos that emphasizes selflessness as a key principle, they may struggle with their commitments to patients and colleagues . Medicine is their choice, experienced as a privilege, and honor despite these risks. Is there an obligation to patients to use their training to serve, despite fear and desire for distance to protect themselves? How much risk in caring for others should be acceptable? Does a certain amount of public good outweigh individual health professionals risks? 
There is every reason for health professionals to be concerned about their own well-being. From the beginning of this pandemic, all over the world doctors, nurses and therapists had to deal with a lack of PPEs, some of them were dying whilst fighting the disease. The worldwide death toll among health professionals working with COVID-19 patients is expected to be significant.
What do health professionals owe their societies? Patients depend on doctors and nurses to provide professional care, due to their specialist training, and the monopoly on the provision of health care services. Governments have left hospitals woefully unprepared, not only in terms of ICU beds and ventilators but also in terms of PPE. If the lack of available PPE for frontline health professionals would have occurred naturally, one could argue that health professionals should accept a certain higher degree of risk. But in the current situation, a lack of protective equipment often is caused by the human, cost-cutting design of the health care systems.
Nevertheless, many health professionals are willing to care for patients infected with COVID-19, despite the absence of PPE. There is no reason to take that for granted. Due to these circumstances, some health professionals seek to leave the profession at a time when society could least afford to lose them. Whilst governments (mostly democratically elected by the public) starved health care systems of the necessary resources to do their job safely, it seems to be a bit presumptuously that health workers should be seen to be professionally obliged to risk their well-being.
In an open letter, G20 leaders were prompted by all Presidents of the World Health Professions Alliance to ensure that PPE will reach those who are literally putting their lives on the line to save people from coronavirus. They warned of making mistakes as destructive competition between countries or inactivity, that would cost further lives.
These moral issues need to be openly discussed. None should be judged for his or her decisions. If someone can’t justify accepting these personal risks according to their individual reasoning this decision should deserve the same respect as that we pay to those heroes, who are working despite the risks.
Staying Resilient in a Time of Crisis
The occurrence of stress and psychological stress under the conditions of the current pandemic represents a largely normal reaction to an extraordinary event. In connection with the current COVID-19 pandemic, health professionals are experiencing the same reactions as other population groups. However, health professionals are exposed to specific additional stressors during the COVID-19 epidemic:
- Experiencing stigmatization by other people when working with patients with COVID-19 (e.g. due to concerns of others that healthcare professionals may be infected themselves)
- Strict safety measures such as wearing protective clothing (if available, otherwise this will be an additional stressor), the permanent need for concentration and vigilance, as well as strictly regulated procedural instructions that limit spontaneity and autonomy, and the reduction of physical touch
- Higher occupational burdens (longer working hours, more patients, high training pressure)
- Reduced social support as a result of long working hours and stigmatization of health professionals in dealing with COVID-19 patients
- Reduced self-care due to lack of time and energy
- Insufficient information about the consequences of long-term exposure to COVID-19 infected patients
- Worrying about infecting their family and caregivers with COVID-19
- Confrontation with frustration and anger against the government or the health system by patients
- Feelings of isolation from being separated from the team they usually work with
- Worrying that colleagues are faced with additional work if they are in quarantine by themselves.
- Being asked to make life-and-death decisions that are potentially inconsistent with their values.
Although the occurrence of stress, psychological stress and negative emotions can generally be regarded as a normal reaction under the current circumstances, the stresses that health professionals are exposed to in the course of their work during the COVID-19 pandemic generally have the potential to promote mental illnesses such as anxiety disorders, depression or trauma disorders. In the context of the last SARS outbreak in China, increased levels of stress, anxiety, depression and general psychological stress among health professionals were identified. 
- It is important to make clear that it does not mean that someone is "falling down" on the job or even “weak”.
- Strong emotions, irritability or mood swings are understandable and not to blame.
- Even under the current extreme conditions, it is important to ensure that basic needs are met, to take sufficient breaks, to eat a healthy diet and to remain physically active.
- Remember strategies that were helpful in managing difficult times previously and apply these now.
- In addition, sharing with colleagues who experience similar burdens (without violating professional duties such as confidentiality) can help to reduce the individual suffering or feelings of isolation.
- Having social contacts privately is an important component for maintaining health. If family members or friends are afraid of getting infected, keep in touch by phone or messenger services.
- In order to gain feelings of control and security, keep up daily routines or establish new ones.
In addition, to consider being part of a team and doing a meaningful task can help to better cope with mental stress. Nevertheless, the aftermath of the pandemic on health workers will not be rosy and not be ameliorated by applause and idol worship in the media.
It is important that managers keep an eye on the psychological stress of their employees in addition to their numerous other tasks and create an atmosphere in which the employees will have the feeling that they can approach their superiors regarding their stresses. Stress and psychological stress should be taken seriously and the protection of employees should be given high priority.
In order to promote orientation, feelings of control and self-efficacy, leaders should also make sure that all relevant information is available to their employees and that there is clear and unambiguous communication. In addition, it should be ensured that employees have the opportunity to take breaks and recreational opportunities and carry out necessary self-care measures, even in phases of high workload. 
To make use of the stress-reducing effect of collegial exchange, managers should give their employees opportunities to share with other team members and to promote collegial support. Employees should have access to psychosocial and psychological help, whereby it is particularly relevant that the potential use of help is not associated with stigmatization. 
When caring for their staff, leaders should also keep an eye on their own self-care because they represent important role models. Furthermore, flexible changes in working hours should be made possible if health workers themselves or close family members are affected by stressful events. They also play an important role in conveying appreciation, as this can play an important protective role with regard to mental health in times of crisis. 
- Healthcare professionals are faced with numerous strains and stressors as part of the COVID-19 pandemic.
- Prevention and reduction of psychological stress of health professionals are of central individual importance but also plays an important role in maintaining the health system's functionality.
- A normalization of stress and strong emotions, social support, the maintenance of basic needs and self-care plays a central role. 
COVID-19 and Suicide Risk
Social distancing interventions have been implemented for reducing the rate of new infections but could be increasing the potential risk for adverse outcomes such as suicide. Nevertheless, this complex issue is mostly occurring for more than just one reason. Economic stress, social isolation, a lack of access to community support or religious activities and barriers to mental health services could be associated with higher suicide rates as a result of the pandemic.
Health Care Professional Suicide Rates
Studies document higher suicide rates among medical professionals. This general at-risk group is currently serving in the front lines to fight against COVID-19. As highlighted above, health professionals struggle with additional stresses compared to the rest of the population. Therefore they deserve (and need) specific support and prevention services. Staying connected and maintaining caring and loving relationships per social media in times of social distancing - which actually means to keep a physical, not a social distance - is more important than ever to prevent such tragic incidents. Also, the services of telemental health need to be enlarged to ensure easy access for those in despair or under tough strains.
Suicides are preventable. Please make sure to know the phone numbers and addresses of relevant mental health services in your country of work. Furthermore, suicide prevention efforts - and of course not just for health professionals - should become a national public health priority, before it’s too late.
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