Are we planning ahead for coronavirus frontliners’ PTSD?

Mr Tanveer (not real name) is a doctor. He is currently serving in a reputed government hospital at Dhaka as a frontline responder in this coronavirus situation. 

His family has never experienced such elevated expressions of anger, sadness, and fear in his behaviour compared to what they have been experiencing lately. He becomes paranoid and moves away very fast from anyone who passes by him even in his living room. 

This behaviour is working like a reflex, which does not seem to bother him. Instead, whenever people around him freeze in response to his reflexes, it bothers him.

A constable working in the special branch of Police's Protection Unit allegedly committed suicide a few days back even after testing negative for coronavirus. He is a victim of social stigma as his line of work was supposedly open to the risk of infection. 

"His family members and neighbours suspected that he was Covid-19 positive patient and started avoiding him. He broke down mentally and did not even eat properly for the last few days," said the Khilgaon police station officer-in-charge Moshiur Rahman.

Recently one of Mr Soumik's (not real name) younger friend from university days snapped in an unusually rude way at his comments on social media about Bangladesh government's way of compensating public servants over coronavirus infection.

Later he discovered, nearly all of this younger friend's family members are public servants and most of them are serving in the field. The known risk agitates all family members, all the time, but they are helpless.

The emerging threat

The three cases above may seem like disparate events to anyone, but for social scientists, they are an early warning for what is coming ahead in the future days. This unimaginably massive threat involves the mental health of the frontline responders (healthcare workers and volunteers, police, field administration, etc). 

We are talking about Post-traumatic Stress Disorder (PTSD) which is an anxiety disorder defined by the co-occurrence in survivors of extreme adversity, re-experiencing avoidance and hyper-arousal symptoms. 

Unlike most other mental disorders, the diagnosis of PTSD relies on associating concurrent symptoms with a previous "traumatic" event. The association is both chronological (symptoms starting after the event) and content related: PTSD re-experiencing and avoidance symptoms involve recollections and reminders of the traumatic event. 

Symptoms include trouble regulating one's emotions, difficulty trusting others, and bouts of aggression, anxiety, and depression.
Individuals who suffer from PTSD-

•    Continuously and uncontrollably relive the very distressing elements of the traumatic event in the form of intrusive recollection and a sense of permanent threat,

•    Avoid places, situations, and mental states that can evoke such recollections.

Sources of the threat

The wellbeing and emotional resilience of the frontline responders are key components of maintaining essential services during this COVID-19 outbreak. So, it is crucial to anticipate the stresses accompanying their work and put supports in place for them. 

Monitoring and assessment of their mental health and wellbeing of frontline personnel are important. As important, it is to ensure their successful reintegration with work colleagues if they become infected. In this case, both institutional and self-care strategies play vital roles.

Frontline workers who are serving in this situation may experience stress related to:

•    Physical strain from protective equipment e.g. dehydration, heat, exhaustion

•    Physical isolation (restrictions on touching others, even after working hours)

•    Constant awareness and vigilance regarding infection control procedures

•    Pressures regarding procedures that must be followed which prohibits spontaneous actions

•    Possible separation from family members and concern about them

•    Fear of infection and subsequent events for self, patients, and family

•    Self- conflict while facing competing needs and demands

Again there are internal and external stigmas, such as:

•    Other people's fear of contact with the ones- 

o    treating infected patients

o    controlling crowd

o    managing field administration by being among people or in infection-prone areas

•    Workers' self-stigma about voicing their needs and fears.

Dealing with the threat

Pain and suffering are two separate feelings. Pain is the reasonable, healthy feeling one experience after a loss. Whereas, suffering involves shame that is generated by self for acknowledging the pain. The shame might result in self-punishment, negative self-talk, feeling of isolation from others, and panic which causes more pain and the cycle goes on. 

Dealing with this threat requires the institution or the employer to acknowledge the pain at first hand. The pain might remain unnoticed if frontline responders face shortness of time, stigma, difficulty in acknowledging or recognizing their own needs, strong service-orientation, and fear of being removed from their duties. 

So, institutions or even government as an employer or caregiver need to be proactive, encouraging and supportive of creating an environment free of coercion, stigma, and fear.

Again, considering self-care is both complex and challenging as the people in these roles are prioritizing the needs of others over their own. Hence, this multi-faceted strategy must be phased in a proper way to support self-control and contribution of these frontliners without making them feel unrealistically responsible for every event related to infection, provocation, death, and managerial errors. 

Emergency responders like the present frontliners are suggested to engage themselves in the following behaviours while at work by the mental health experts worldwide:

•    Self-monitoring and pacing

•    Regular check-ins with colleagues, family, and friends

•    Working in partnerships or teams

•    Brief relaxation/stress management breaks

•    Regular peer consultation and supervision

•    Time-outs for basic bodily care and refreshment

•    Regularly seeking out accurate information and mentoring to assist in making decisions

•    Keeping anxieties conscribed to actual threats

•    Doing their best to maintain helpful self-talk and avoid overgeneralizing fears

•    Focusing their efforts on what is within their power

•    Acceptance of situations they cannot change

•    Fostering a spirit of fortitude, patience, tolerance, and hope

Why plan ahead?

Mental health stressors resulting from other disasters have been studied before. But researchers around the world have confirmed that a combination of all these as the consolidated form in a single crisis like this one is unprecedented. 

A post-coronavirus survey-based study published in the Journal of the American Medical Association examined the mental health outcomes of 1,257 health care workers in 34 hospitals from China. 

The results confirmed the presence of symptoms related to depression (50 percent), anxiety (45 percent), insomnia (34 percent), and psychological distress (71.5 percent) among the responders. Evidently, keeping them behind on crucial information, shortage of essential equipment and drowning community panic takes the biggest blow on them.

Before the aftermath takes place, the frontliners need to be reassured that if they feel any acute increase in anxiety, depression, or other conditions they must consider seeking professional help. 

Institutionally, free telemedicine options are suggested where a government-supported national 24/7 distress helpline should be ready to hear and treat these heroes of modern times.

We need to remember; traumas do not just come and go in the light of day. They gradually buildup and take even more time to heal. So, to sustainably endure through this dreadful time we need to empathise, destigmatise, and recognise the value of these overactive brains.

The author is a writer and researcher.