Interventions to address mental health issues in healthcare workers during infectious disease outbreaks: A systematic review

The mental health impact on HCWs, during epidemics/pandemics and after, is complex and should be addressed in a sustained way by all governments and healthcare systems, 

which should design and implement intervention strategies to mitigate its impact in a collaborative and interdisciplinary manner.


Journal of Psychiatric Research
D. Zaçe,a,∗,1 I. Hoxhaj,a,1 A. Orfino,b A.M. Viteritti,b L. Janiri,c and M.L. Di Pietroa
Volume 136, April 2021, Pages 319–333
verywellhealth

Abstract

Considering the importance of evidence on interventions to tackle mental health problems in healthcare workers (HCWs) during pandemics, we conducted a systematic review, aiming to identify and summarize the implemented interventions to deal with mental health issues of HCWs during infectious disease outbreaks and report their effectiveness. 

Web of Science, PubMed, Cochrane, Scopus, CINAHL and PsycInfo electronic databases were searched until October 2nd, 2020. Primary-data articles, describing any implemented interventions and their effectiveness were considered pertinent. Studies were screened according to the inclusion/exclusion criteria and subsequently data extraction was performed. Twenty-four articles, referring to SARS, Ebola, Influenza AH1N1 and COVID-19 were included. 

Interventions addressing mental health issues in HCWs during pandemics/epidemics were grouped into four categories: 

  1. informational support (training, guidelines, prevention programs),
  2. instrumental support (personal protective equipment, protection protocols);
  3. organizational support (manpower allocation, working hours, re-organization of facilities/structures, provision of rest areas); 
  4. emotional and psychological support (psychoeducation and training, mental health support team, peer-support and counselling, therapy, digital platforms and tele-support). 

These results might be helpful for researchers, stakeholders, and policymakers to develop evidence-based sustainable interventions and guidelines, aiming to prevent or reduce the immediate and long-term effect of pandemics on mental health status of HCWs.




ORIGINAL PUBLICATION


Interventions to address mental health issues in healthcare workers during infectious disease outbreaks: A systematic review

D. Zaçe,a,∗,1 I. Hoxhaj,a,1 A. Orfino,b A.. Viteritti,b L. Janiri,c and M.L. Di Pietroa


Find below, excerpts from the original publication.


1.Introduction

COVID-19, known as an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), is manifesting several indirect effects, many of which are not known yet, in particular those concerning healthcare workers (HCWs) at the forefront of patient care (Maxwell et al., 2020).


World Health Organization (WHO) declared COVID-19 a global pandemic on March 11, 2020 (Cucinotta and Vanelli, 2020) and up to February 3, 2021, there have been 103, 201, 340 confirmed cases and 2,237,636 deaths (“WHO Coronavirus Disease (COVID-19) Dashboard | WHO Coronavirus Disease (COVID-19) Dashboard,” n. d.). Upon the arrival of the pandemic, health systems were overwhelmed by the impossibility to effectively respond to the needs of the multitude of infected patients, mainly due to the high virulence and contagiousness of SARS-CoV2 and the sudden onset of severe symptoms (Christopher et al., 2020).


HCWs, working under pressure, with prolonged work shifts encountered several ethical dilemmas and saw many of their colleagues lose the battle to SARS-CoV2 (Robert et al., 2020). 

An international survey on COVID-19 management strategies showed that in many countries, HCWs did not have sufficient access to adequate supplies at the beginning of the pandemic and that their healthcare organizations had been slow to apply measures of infection prevention and control (Tartaglia et al., 2020).


Along with the poor supply of personal protective equipment (PPE), they had to deal with the lack of trained personnel, the fear of being infected and becoming a possible infecting vehicle for their families and patients, and frustration over loss of life (Wu et al., 2009).


HCWs could not see their families and friends, so they could not count on their emotional support to get through these difficult times

All these factors undermined the physical and mental well-being of frontline HCWs (Zaka et al., 2020).


Evidence from the previous pandemics or epidemics suggests that during a disease outbreak HCWs experience several mental health issues, which besides affecting their health and professional performance at the moment, may also have long-term negative effects (Maunder et al., 2003; Serrano-Ripoll et al., 2020; Wu et al., 2009).


HCWs represent a high-risk group for experiencing mental health issues (Maben and Bridges, 2020). 

Mental health disorders of HCWs encountered during previous epidemics included anxiety, depression, exhaustion, post-traumatic stress disorder (O’Sullivan et al., 2007), insomnia, relationship difficulties, behavioral changes (such as anger or substance use) (Waterman et al., 2018), burnout and anticonservative ideas (Maben and Bridges, 2020). 

During the COVID-19 pandemic, the prevalence of anxiety among HCWs varied from 7% (5%–9%) in Singapore to 57% (52%–63%) in Italy, 
while the prevalence of depression ranged between 9% (7%–12%) in Singapore and 51% (48%–53%) in China
(Luo et al., 2020).


HCWs’ well-being is important not only for them and their families, but it also has an enormous impact on the quality of assistance to the patients, having a crucial role in the whole healthcare system (Maben and Bridges, 2020).


But if coping with the pandemic has been challenging for healthcare systems, dealing with the mental health of HCWs seems to be even harder. 

Little attention and time are given to mental health issues of HCWs. 

Published literature focuses mainly on the impact of pandemics on the mental state of HCWs and less on implemented interventions and their effectiveness to overcome these conditions (Luo et al., 2020; Serrano-Ripoll et al., 2020).


Considering the importance of evidence regarding interventions to tackle mental health problems in HCWs during pandemics, we conducted a systematic review, aiming to identify and summarize the implemented interventions to deal with mental health issues of HCWs during infectious disease outbreaks, and report their effectiveness.


Refer to the original publication for the long version of the paper.


3.4. Interventions to address mental health issues of HCWs during infectious disease outbreaks

Considering their content (Table 2), interventions implemented to address mental health issues in HCWs during pandemics/epidemics were grouped into four categories: 

  • informational support, 
  • instrumental support; 
  • organizational support; 
  • emotional and psychological support.

Information support on the pandemic/epidemic was defined as any intervention designed to provide appropriate dissemination of information to HCWs regarding the disease, diagnosis, treatment, and prevention. 

Instrumental support mechanisms were defined as interventions aimed to protect workers from physical exposure to infectious disease and provide training on PPE’s use and disinfection. 

Organizational support was defined as any intervention aimed to change resources, the working environment, work tasks and/or working hours/methods.

Finally, emotional and psychological interventions were those targeting specifically and directly the emotions and psychological status of HCWs.


3.4.1. Informational support

Knowledge regarding the infection causing the pandemic and its prevention was deemed important for the mental health of HCWs during SARS, in Taiwan (Chen et al., 2006) and Canada, (Aiello et al., 2011; Maunder et al., 2003, Maunder et al., 2010), so in-service trainings were reported as a way to reduce their worries. 

These trainings included: intensive SARS protection training basic knowledge (Chen et al., 2006; Maunder et al., 2003); masks’ removal and disinfection process (Chen et al., 2006); SARS survival guide for medical personnel (Chen et al., 2006); procedures for entering rooms with SARS patients; promotion of SARS protection and isolation; procedures for wearing protective equipment (Chen et al., 2006; Maunder et al., 2010); and hospital SARS infection control (Chen et al., 2006). 

The Mount Saint Hospital in Canada sent a daily joint email message to all staff, updating SARS information, outlining procedural changes, and providing information about the numbers of patients with SARS, number of staff in quarantine and staff admitted to hospital for treatment (Maunder et al., 2003). 

Implementing training for the staff and providing information on diagnosis and treatment guidelines, as well as hospital infection guidelines, were considered important in helping mental health of HCWs, also during COVID-19 pandemics, in China and Canada (Cheung et al., 2020; Hong et al., 2020; Sockalingam et al., 2020; Zhou et al., 2020). 

In Spain, a digital tool called “Be + against COVID” provided an online platform for HCWs to identify and refute unfounded rumours and incorrect information as a way to help mental health of HCWs (Mira et al., 2020).


3.4.2. Equipment and supplies

Several articles reported that the provision of PPEs influences the mental health of HCWs. 

In Taiwan, gathering sufficient protective equipment and providing training for wearing and removing them, were part of the SARS prevention plan, which had an impact on HCWs’ self-reported levels of anxiety and depression and on sleep quality (Chen et al., 2006). 

During COVID-19, two Chinese studies have reported how their hospitals have paid special attention to sufficient protection conditions for their staff (Cai et al., 2020; Hong et al., 2020). 

In a COVID-19 designated clinic in China, HCWs received before rotation training, protective devices, supervision of protection procedures, standardized protection process, which aimed to decrease the worry about their own health and that of their families (Hong et al., 2020). 

The “Be + against COVID” resources platform in Spain involved professionals in audio-visual messages to broadcast information on guidelines, such as safe removal of PPEs (Mira et al., 2020).


3.4.3. Organizational support

Planning during a pandemic was considered crucial for the mental health of HCWs by several articles. 

During SARS, a hospital in Canada, implemented a command centre, paying attention to good leadership and teamwork (Maunder et al., 2003). 

The establishment of a Psychosocial Pandemic Committee (PPC) was also a component of Influenza AH1N1 pandemic planning (Aiello et al., 2011). 

Pandemic planning needs to promote informative leadership, transparency, realism, and positive messages, as well as deal with the volume of delayed health care activities to support HCWs’ mental health (Mira et al., 2020).

A special attention was paid to manpower allocation during SARS, in Taiwan (Chen et al., 2006) and to adjustments of the working hours in a designated COVID-19 hospital in China (Hong et al., 2020). 

The latter provided also training, inspection and supervision for its staff (Hong et al., 2020).


Several hospitals had gone through the reorganization of healthcare facilities in order to ensure safer and healthier environments for HCWs. 

During SARS, hospitals in China provided general isolation rooms to handle procedures for SARS cases (Chen et al., 2006). 

During COVID-19, several hospitals reorganized their spaces to provide HCWs with rest areas (Donnelly et al., 2020; Gonzalez et al., 2020; Mira et al., 2020).

In the USA, a 10-bed pediatric unit was converted to an employee rest area providing a place to rest, shower, receive emotional support, and reenergize with snacks and beverages and aromatherapy, soothing music and TV (Gonzalez et al., 2020). 

In UK, another hospital created a safe and supportive environment for staff to rest, have tea and eat, as well as a “Take a Minute” room with recliner chair, mental health resources, well-being information and pamphlets and links to psychology support (Donnelly et al., 2020). 

Furthermore, hospitals in Italy (Giordano et al., 2020) and China (Hong et al., 2020) supported HCWs by offering accommodation, to prevent the risk of contagion in their families

In a COVID-19 designated hospital in China, after 2–3 weeks of continuously working, HCWs were quarantined and convalesced in a vocational resort (Hong et al., 2020).


Mount Sinai Hospital in Canada organized a drop-in support centre with soothing music, snacks and psychiatric staff to help HCWs cope with the mental burden of SARS (Maunder et al., 2003).


3.4.4. Emotional and psychological interventions

3.4.4.1. Psychoeducation and training

Education and training about mental health symptoms were considered of utmost importance to maximize the HCWs’ resilience through effective preparation during pandemics.


Occupational therapists at a Canadian hospital developed a pamphlet with the signs of anxiety and stress, and with information about support resources, that was distributed to every nursing unit that received patients with SARS (Maunder et al., 2003). 

At the same hospital, based on the experience learned from SARS, 156 HCWs received, during Influenza A H1N1, a computer-assisted resilience training, through mixed teaching modalities. 

Normal stress response, psychological first aid, coping approaches, active listening and personal resilience were addressed in several audio and video mini-lectures, printed fact sheets and onscreen notes. 

Relaxation skills were taught with audio modules and the gained knowledge was reinforced by quizzes and games (Maunder et al., 2010). 

In-attendance training on normal stress responses, stress symptoms and signs, anticipated stressors, effective coping strategies and the value of personal and organizational resilience (Aiello et al., 2011) was provided also during Influenza A H1N1 to 1250 Canadian healthcare workers. 

A resilience plan was used during Ebola to understand and manage psychological impact in HCWs. The training offered in the pre-incident period explains the nature and impact of stressors and provides images of a hospital disaster response, enabling participants to create individualized resilience plans (Schreiber et al., 2019).

Posters with wellness tips and strategies for mental health protection for all the staff were used also during COVID-19 in Italy (Buselli et al., 2020) and USA (Gonzalez et al., 2020). 

Daily mood broadcast, with positive self-affirmation training was created based on the level of self-reporting emotions, and was sent every evening to the medical team online chat group to reinforce their self-affirmation during COVID-19 in China (Cheng et al., 2020).


3.4.4.2. Mental health support team, peer support and counselling

Mental health teams, consisting of psychiatrists, social workers, psychological counselors, or psychiatric nurses, have been established to psychologically support HCWs and to provide counselling according to their needs. 

A mental health team offered advices and support to the staff in Taiwan (Chen et al., 2006) and Canada (Maunder et al., 2003) during SARS, and group session therapy in Singapore (Khee et al., 2004). 

During COVID-19 pandemic, as well, several hospitals built up teams to support frontline HCWs. 

At hospital units in USA, an occupational, physical therapist offered de-stress exercises (Gonzalez et al., 2020), whereas in another hospital a mental health consultant attended unit meetings to understand HCWs activities and concerns and provided additional individual support (Albott et al., 2020). 

In the latter, peer-group psychological support, in the form of a daily 1-h themed chat group, enabled HCWs to share their emotions and experiences (Albott et al., 2020).

 A Critical Care Peer-Support Network launched weekly Friday Zoom sessions for “coffee and a chat” in UK and laminated wall poster with positive messages (Donnelly et al., 2020).


In China, a weekly Balint group activity, leaded by a psychiatrist, enabled HCWs to discuss about their emotions and share solutions; and an after-work support team offered assistance to HCWs and organized different after-work social activities (Cheng et al., 2020). 

Nurses received online counselling, along with on-site psychological support and mindfulness decompression (Zhou et al., 2020).


3.4.4.3. Therapy and rehabilitation

Cognitive Behavioral therapy (CBT) enables the participant to understand and change the destructive and disturbing emotions that have negative impacts on behavior. 

This therapy was offered during Ebola in Sierra Leone to HCWs experiencing anxiety and depression (Waterman et al., 2018), and to the entire staff during COVID-19 in France (Geoffroy et al., 2020) and Italy (Buselli et al., 2020). 

In Malaysia, during COVID-19, CBT therapy was part of a psychological intervention, including also acceptance and commitment therapy, dialectical behavioral therapy, motivational interviewing, and early intervention program (Ping et al., 2020). 

CBT was part of a three-phase intervention in UK, that aimed at facilitating the HCWs’ recognition of coping strategies and resilience factors (Cole et al., 2020). 

Another type of therapy, implemented in Italy was music therapy, that contained three playlists: 1) “breathing playlist” to favor relaxation and reduce anxiety and stress; 2) “energy playlist” to recover energy and support concentration; and 3) “serenity playlist” to release tension and instill calm and peace of mind (Giordano et al., 2020).


3.4.4.4. Digital platform and tele-support

Several digital platforms and support lines have been created during pandemics aiming to provide psychological support and resources that might protect the psychological well-being and prevent injuries of frontline HCWs.


To prevent and address the stress reactions of HCWs, a digital platform, named “Be + against COVID, was developed and was freely accessible. 

This platform was composed of a website and a mobile app, in three languages: English, Spanish and Portuguese. 

The website contents included resources, presented as documents, infographics, and videos, useful for HCWs to overcome stress reactions.

A mental health hotline was offered providing support by specialized personnel and referral to individual additional counselling. 

A self-reporting 10-questions test was included to assess acute stress and based on the results recommendations and guidelines were proposed. 

The app was structured in three modules: 1) “advices and recommendations”; 2) “self-assessment on the ability to cope the COVID-19 crisis,” and 3) visit the website (Mira et al., 2020). 

Another mobile-web-based application called “PsySTART-Responder Self Triage System” prompted HCWs to complete a daily self-assessment during Ebola, provided confidential feedback and encouraged the use of a personal resilience plan (Schreiber et al., 2019).


A digital learning package was developed in UK focusing on psychological impacts of COVID-19, psychologically supportive teams, communication, social support, self-care, and emotions management, providing coping approaches and information regarding the resources (Blake et al., 2020).


Psychological telephone hotline was available during COVID-19 in France providing assistance by identifying the symptoms, offering adequate responses and referring to additional psychological support if needed, like CBT or specialized psychiatric consultation (Geoffroy et al., 2020).


In USA, COVID-19 mental health counselling was offered to HCWs by a “24 h/7 Mental Health COVID-19 Hotline” (Feinstein et al., 2020) and to both, HCWs and their families by a “Centralized Support Helpline” (Gonzalez et al., 2020). 

A confidential telephone support line was also offered to all hospital staff during SARS in Canada, particularly for those in quarantine, creating an informal network of phone support (Maunder et al., 2003).


Tele-education programs focusing on mindfulness exercise, COVID-19 information resources, case-based discussion on stress management skills, and reflection exercises were also provided weekly in Canada (Sockalingam et al., 2020).


safety and health magazine

3.5. Efficacy of interventions

Even though all the articles included in the systematic review reported implemented interventions, only seven articles (29%) provided data on their effectiveness. 

Two weeks, one month and three months after the implementation of a SARS prevention program in Mount Sinai Hospital, anxiety, depression, and sleep quality among HCWs were significantly better (Chen et al., 2006). 

A Computer-assisted resilience training implemented in this hospital during influenza A H1N1 was successful in improving confidence in support and training (Before and after intervention Mean difference = 1.1 p < 0.001); pandemic self-efficacy (Before and after intervention Mean difference = 5.1 p < 0.001); and ways of coping and interpersonal problems (Before and after intervention Mean difference = −3.7 p < 0.001) (Maunder et al., 2010). 

At the same hospital, a higher proportion of participants (76% vs 35%) felt more confident to cope with the influenza A H1N1 pandemic after a resilience training on influenza information, normal stress responses, anticipated stressors, reinforces principles of coping and the value of organizational and personal resilience (Aiello et al., 2011).

A group-based intervention based on psycho-education and simple CBT principles, delivered by peers in Six Ebola Treatment Centres in Sierra Leon resulted efficient in improving stress (F (3, 51) = 7.89; p < 0.01), depression (F (3, 84) = 11.68; p < 0.01), anxiety (F (3, 78) = 3.40; p < 0.05), behavior (F (3, 84) = 6.08; p < 0.01) and relationships (F (3, 69) = 3.72; p < 0.05) among HCWs, while there were no significant differences in sleep (Waterman et al., 2018).

The online psychological information, offered by Renmin Hospital of Wuhan University during COVID-19, improved insomnia [Yes vs No OR = 1.507 (1.162–1.955)], Post-traumatic stress disorder (PTSD) [Yes vs No OR = 1.556 (1.155–2.097)] and anxiety [Yes vs No OR = 1.325 (1.020–1.721)], while the sufficient protection conditions had a positive impact on PTSD (Cai et al., 2020).


Personalized training including COVID-19 diagnosis and treatment guidelines, hospital infection guidelines, diagnosis and treatment plan, operation of common medical protective equipment, online and on-site psychological counselling and mindfulness decompression among nurses working in emergency isolation wards of COVID-19 in China was found efficient in improving the rescue ability of nurses and avoiding the occurrence of cross infection. The Self-Rating Anxiety Scale score decreased after training (p = 0.019), while there was no statistical difference in Self-Rating Depression Scale (p = 0.306) (Zhou et al., 2020).


A scenario-based simulation training implemented in a hospital in China during COVID-19 significantly increased Personal Strength of HCWs including: assertiveness, mental preparedness, self-efficacy, internal locus of control, and internal locus of responsibility [all scored 4.24 in Likert scale 1–5 (p < 0.001)] (Cheung et al., 2020).


Music Therapy, offered to the staff of a designated Coronavirus Unit of the University Hospital of Bari, Italy through three different playlists (Breathing Playlist, Energy Playlist and Serenity Playlist) improved their mental health status. The Breathing Playlist significantly decreased the intensity of perceived sadness (t = 6,432, df = 20, p < 0,05), fear (t = 9,735, df = 20, p < 0,05) tiredness (t = 7,695, df = 20, p < 0,05), and worry between T0 and T1 (t = 5,056, df = 20, p < 0,05). The Energy Playlist significantly decreased tiredness (t = 4,873, df = 20, p < 0,05), sadness (t = 8,545, df = 20, p < 0,05), fear (t = 6,419, df = 20, p < 0,05), and worry (t = 6,190, df = 20, p < 0,05), while the Serenity Playlist had a positive impact on sadness (t = 4,614, df = 11, p = 0,001), fright (t = 7,707, df = 11, p = 0,000), and worry (t = 2,956, df = 11, p = 0,013) (Giordano et al., 2020).


The psychological health support scheme during COVID-19 in China, which included a daily measurement of mood, a daily mood broadcast with positive affirmation, an online peer-group activity, Balint groups and an after-work support team, enabled the staff to have an overall positive outlook. They reported a daily mood index between 7 and 9 out of 10, for six weeks of continuous work. The average number of self-reports of life-related gains (gain-work, gain-life and gain-physiology) increased rapidly from 0.75 to above 1.0 and were significantly associated to the daily mood index, which reflects the effectiveness of the intervention programme (β = 0.452; p < 0.01) (Cheng et al., 2020).


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4. Discussion

This systematic review aimed to identify and summarize the interventions implemented during infectious disease outbreaks to deal with mental health issues of HCWs and report their effectiveness. 

We identified twenty-four articles which described interventions implemented by different healthcare structures/facilities, to prevent or reduce mental health problems of HCWs during SARS, Ebola, Influenza A H1N1 and COVID-19. The identified interventions concerned four main categories: 1) informational support, 2) instrumental support; 3) organizational support; and 4) emotional and psychological interventions. However, only 37.5% of the included articles reported data on the effectiveness of the implemented interventions. Most articles described the experience of high-income countries, with regard to COVID-19, and addressed all healthcare staff.

While the psycho-emotional interventions targeted directly specific mental symptoms such as stress, depression, PTSD, anxiety, behavioral changes or psychotic symptoms, the interventions reported in the other three categories (informational, instrumental, and organizational) targeted perceived mistrust, fear, confidence in support and training, pandemic-related self-efficacy, personal strength, tiredness or worry, which could be intermediate psychological factors for well-being and mental health. 

Creating feelings of safety, providing reliable and timely information, along with organizational support have been previously acknowledged in literature as ways to improve the resilience and well-being of HCWs, with the final aim of protecting their mental health (Huey and Palaganas, 2020).


The organizational-level interventions, promoting leadership and teamwork (Maunder et al., 2003) and paying special attention to manpower allocation (Chen et al., 2006), adjustments of the working hours (Hong et al., 2020), have been reported as interventions that ensure safer and healthier environments, help the staff feel better and calmer and promote mental health wellbeing among HCWs (Gray et al., 2019). 

Organizational interventions to improve HCWs’ mental health were also reported by a Cochrane review, which concludes that changing work schedules can reduce stress, but other organizational interventions have no clear effects (Marine et al., 2006). 

The importance of interventions targeting organizational structures to prevent or reduce negative mental health impacts on healthcare workers during the COVID-19 pandemic was also acknowledged by a rapid systematic review (Muller et al., 2020), published while our systematic review was ongoing. 

This rapid review addressed a variety of outcomes, including six studies that reported the implementation of interventions to prevent or reduce mental health problems during COVID-19 pandemic. 

The authors argue that a focus on individual risk and resilience factors alone, without considering system-level factors, could hinder the discovery of underlying organizational faults, which could be important target for impactful interventions (Muller et al., 2020). 

We add to this work the results of studies conducted during other infectious disease outbreaks, which could provide valuable insights and lessons to address this issue during the current pandemic.


Providing sufficient PPEs to HCWs reduced the levels of anxiety and depression and improved sleep quality (Chen et al., 2006) and decreased the worry about their own health and that of their families (Hong et al., 2020). 

In line with this, many staff members of the Second Xiangya Hospital of Central South University stated that they did not need a psychologist but needed more rest without interruption and enough protective supplies. 

Clear communication of directives/precautionary measures were seen by HCWs themselves as fundamental factors to help reduce mental health problems (Chan and Chan, 2004), reporting that the more they learned about the disease the safer they felt among each other and to be near their families (Feinstein et al., 2020).


Psycho-emotional interventions, including psychological education and training (Aiello et al., 2011; Buselli et al., 2020; Maunder et al., 2003, 2010; Schreiber et al., 2019), therapy (Buselli et al., 2020; Cole et al., 2020; Geoffroy et al., 2020; Ping et al., 2020; Waterman et al., 2018), counselling, team and peer support (Albott et al., 2020; Chen et al., 2006; Gonzalez et al., 2020; Khee et al., 2004; Maunder et al., 2003; Zhou et al., 2020), offered in attendance or through online platforms, deemed important to foster the HCWs resilience during pandemics/epidemics. 

Our findings are in line with the literature, that identified resilience workshops, group problem solving, cognitive behavioral training, mindfulness training and their combination, as the main psycho-emotional education interventions to develop resilience among HCWs (Huey and Palaganas, 2020; Rogers, 2016). 

Another systematic review and meta-analysis showed that mindfulness-based interventions have the potential to reduce stress among HCWs (Burton et al., 2017). 

However, there is no evidence on therapeutical interventions based on dynamic interpersonal techniques. 

Colleague sessions have been reported to create a sense of personal wellbeing and mutual learning, through sharing with others, which helps HCWs become aware of their emotions and accept them (Feinstein et al., 2020).

Nevertheless, the implementation of psychological intervention services may face barriers, as medical staff may be unwilling to participate. 

This has been reported during COVID-19 pandemic in China where front-line nurses refused any psychological help and stated that they did not have any problems, even though they showed excitability, irritability, unwillingness to rest, and signs of psychological distress (Chen et al., 2020).


The large burden of mental illness, often exacerbated by stigma and discrimination, may delay help-seeking also among HCWs (Clement et al., 2015). 

Furthermore, the prevalence of new psychiatric symptoms manifesting in hospital workers during infectious disease outbreaks, could be underestimated because of the absence of standardized evaluation (Sockalingam et al., 2020). 

Considering that, designing and implementing interventions that expect HCWs to ask for help may not be much effective. 

In this regard, the support systems initiated by higher levels could play a crucial role in recognising the individual struggles and providing a timely response.


Interventions at the facility or higher levels could be an important resource for HCWs’ mental health, who in fact identify multiple support systems, including their hospitals, colleagues, families, friends, and society

With logistical support from their hospital and peer support and encouragement among colleagues, HCWs report a sense of safety and feel they are not alone (Liu et al., 2020). 

These interventions should include all departments, not only frontline HCWs, considering the numerous non-frontline workers that were affected by the COVID-19 pandemic (Sockalingam et al., 2020). 

Moreover, these interventions should be able to identify and support at-risk HCWs who may be predisposed to stress reactions because of lower initial resilience, inadequate or inappropriate coping, or exposure to atypically high levels of risk (Zhou et al., 2020). 

When choosing the adequate intervention, barriers and facilitators should be considered. 

Based on a recently published Cochrane review factors that could hinder the implementation of these interventions include 

  • frontline workers, or the organizations in which they worked, not being fully aware of what they needed to support their mental well-being; 
  • and a lack of equipment, staff time or skills needed for an intervention. 

On the other hand, factors that could facilitate their implementation include: 

  • interventions that could be adapted for local needs; 
  • having effective communication, both formally and socially; 
  • and having positive, safe and supportive learning environments for frontline workers (Pollock et al., 2020).

Among the included articles, only 37.5% reported the efficacy of the implemented interventions on HCWs’ mental health. 

Given the limited number of articles on the effectiveness of all the interventions it was not possible to quantitatively analyse it. 

Furthermore, most articles described bundle interventions, so it was not possible to identify the single intervention that was successful in preventing or reducing mental health problems among HCWs during infectious disease outbreaks. 

Considering that there is a lack of high-quality, well-designed studies, this systematic review highlights the need for further research that evaluate the effectiveness of different interventions implemented to prevent or reduce mental health problems in HCWs during infectious disease outbreaks. 

Given that the majority of studies were conducted in high-income countries, future articles should also address the interventions in low-and-middle-income countries, which might be influenced by economic and socio-cultural factors. 

Another gap in the research evidence, identified by our systematic review, is the lack of randomized controlled trials, which if conducted properly could provide important results on the effectiveness of the interventions.

Moreover, facilitators and barriers to the implementation of these interventions should be identified and considered in the pandemic planning process. There is the need to evaluate the interventions provided in usual care, in order to understand whether these interventions could be applicable also during epidemics/pandemics outbreak.


The results of this systematic review should be considered in the light of some limitations. 

First, it may not be generalizable, considering the fact that these interventions may be context-specific and may vary on the country’s economic, social and cultural background as well as healthcare system (Tartaglia et al., 2020). 

Furthermore, included articles enrolled convenience samples or voluntary response samples which could be a font of bias. A publication bias may be present, since we only included peer-reviewed articles published in English. 

Furthermore, considering the load of articles published on the current pandemic it is possible that we might have missed a certain number of articles. Among the included articles, 33.35% did not have a specific study design so their methodological quality could not be assessed. Of those, 87.5% addressed COVID-19 pandemic which is supported by the fact that during this pandemic many studies have been rapidly published, sometimes pushed through peer-review, hence having low methodological quality.


Despite the limitations, this systematic review adds important information to the evidence published so far on the mental health of HCWs during infectious disease outbreaks and provides data that could be timely used, in a moment when HCWs’ mental health management appears to be challenging

Our search strategy, aimed to be as comprehensive as possible, encompassing six different databases, including PsycInfo, for psychological articles, and Cinhal for nurses-related articles, and further extended to reference hand search. Another strength of our review was the broad inclusion criteria for healthcare workers and different infectious disease outbreaks.


The mental health impact on HCWs, during epidemics/pandemics and after, is complex and should be addressed in a sustained way by all governments and healthcare systems, which should design and implement intervention strategies to mitigate its impact in a collaborative and interdisciplinary manner

These interventions should be multi-factorial, considering the four categories reported in our work. 

Providing information in a timely and correct way, providing sufficient equipment, adjustments of the working hours, manpower allocation and reorganization of healthcare facilities to ensure safer and healthier environments seem to be imperative for the mental health of HCWs. 


Mental health response of HCWs and the healthcare system capability to appropriately address their needs should be recognized, and an intervention plan should be integrated within the pandemic surveillance program. 

Data hereby reported might be helpful for the researchers, stakeholders and policymakers for the development of evidence-based sustainable interventions and guidelines, aiming to prevent or reduce the immediate and long-term effect of infectious disease outbreaks on mental health status of all HCWs. 

Furthermore, the gaps in knowledge identified by this systematic review may lead to targeted and more quickly initiated future research, focusing on RCTs that evaluate the effectiveness of different interventions, considering facilitators and barriers that affect their implementation, in different economic, social and cultural contexts, to address mental health problems of HCWs during infectious disease outbreaks.


Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Originally published at https://www.sciencedirect.com.

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