key: cord-0967326-nndnf3hj authors: Priede, Amador; López-Álvarez, Inés; Carracedo-Sanchidrián, Diego; González-Blanch, César title: Intervenciones de salud mental para trabajadores sanitarios durante la pandemia de COVID-19 en España date: 2021-02-04 journal: Rev Psiquiatr Salud Ment DOI: 10.1016/j.rpsm.2021.01.005 sha: 46810447210b0173afeeee8d6785575c7d7bbb00 doc_id: 967326 cord_uid: nndnf3hj Objective: In order to reduce distress associated with working with COVID-19 patients, several psychological intervention programs for healthcare workers have been developed in Spain. We aimed to describe the main characteristics and components of these programs for healthcare workers treating COVID-19 patients in Spanish hospitals. Material and methods: An online survey was designed to evaluate the main characteristics of psychological intervention programs for healthcare workers during the peak of COVID-19 pandemic. Results: Valid responses were received from 36 hospitals. Most of these programs offered both in-person and online therapy. The most common aim of these interventions was emotional regulation, which was treated by psychoeducational and cognitive-behavioural techniques in individual interventions. Group interventions mainly used psychoeducation and mindfulness. Only half of the teams that offered in-person interventions received training in the proper use of personal protective equipment. Conclusions: Several hospitals in Spain have developed mental health interventions for healthcare workers during the COVID-19 pandemic, deploying a wide range of therapeutic modalities and techniques. The rapid implementation of these programs during the pandemic suggests that safety may not have received sufficient attention. The planning and development of interventions for healthcare workers during pandemics merits greater attention by national and regional authorities and institutions. Antecedentes: Para reducir el malestar psicológico asociado a tratar pacientes con COVID-19, se han desarrollado numerosos programas de intervención en España. Este estudio pretende describir las principales características y componentes de los programas para trabajadores sanitarios que atienden COVID-19 en hospitales españoles. Método: Se elaboró y distribuyó una encuesta online para evaluar las principales características de los programas de intervención psicológica para trabajadores sanitarios durante la pandemia de COVID-19. Resultados: Se recibieron respuestas válidas de 36 hospitales. La mayoría de los programas ofrecía intervención presencial y online/telefónica. El principal objetivo de estos programas fue mejorar la regulación emocional. Las intervenciones individuales emplearon principalmente psicoeducación y técnicas cognitivo-conductuales, mientras que las grupales emplearon psicoeducación y mindfulness. Sólo la mitad de los equipos que ofrecían intervenciones presenciales habían recibido la formación adecuada para usar equipos de protección individual. Conclusiones: Numerosos hospitales en España han desarrollado intervenciones de salud mental para trabajadores sanitarios durante la pandemia por COVID-19, empleando una gran variedad de modalidades terapéuticas. La rápida implementación de estos programas durante la pandemia sugiere que la necesidad de seguridad ha podido subestimarse. La planificación y desarrollo de intervenciones psicológicas durante las pandemias merece mayor atención por parte de las autoridades competentes. J o u r n a l P r e -p r o o f 3 Resumen Antecedentes: Para reducir el malestar psicológico asociado a tratar pacientes con COVID-19, se han desarrollado numerosos programas de intervención en España. Este estudio pretende describir las principales características y componentes de los programas para trabajadores sanitarios que atienden COVID-19 en hospitales españoles. Método: Se elaboró y distribuyó una encuesta online para evaluar las principales características de los programas de intervención psicológica para trabajadores sanitarios durante la pandemia de COVID-19. Resultados: Se recibieron respuestas válidas de 36 hospitales. La mayoría de los programas ofrecía intervención presencial y online/telefónica. El principal objetivo de estos programas fue mejorar la regulación emocional. Las intervenciones individuales emplearon principalmente psicoeducación y técnicas cognitivo-conductuales, mientras que las grupales emplearon psicoeducación y mindfulness. Sólo la mitad de los equipos que ofrecían intervenciones presenciales habían recibido la formación adecuada para usar equipos de protección individual. Conclusiones: Numerosos hospitales en España han desarrollado intervenciones de salud mental para trabajadores sanitarios durante la pandemia por COVID-19, empleando una gran variedad de modalidades terapéuticas. La rápida implementación de estos programas durante la pandemia sugiere que la necesidad de seguridad ha podido subestimarse. La planificación y desarrollo de intervenciones psicológicas durante las pandemias merece mayor atención por parte de las autoridades competentes. The outbreak and the rapid spread of the coronavirus disease 2019 (COVID-19) has become pandemic and is threatening the health of people around the world 1 . One of the countries facing the most severe crisis is Spain, with more than 377,906 confirmed cases of COVID-19 and 28,813 deaths as of August 21, 2020 2 . The rapid increase in cases of COVID-19 in Spain is threatening the capacity of the well-established Spanish National Health System (Spanish acronym, SNS) 3 . As a result, the workload for healthcare professionals has increased substantially, with prolonged hours of work and higher stress due to the potential risks involved in this work, which is common cause of burnout and mental health disorders during outbreaks of infectious diseases 4 . These same problems were also detected in during the COVID-19 outbreak 5, 6 Furthermore, a recent meta-analysis found that, during the COVID-19 pandemic, healthcare workers shows significant levels of depression, anxiety and insomnia symptoms 7 . However, it is noteworthy that these prevalence studies are based on self-report screening questionnaires rather than diagnostic interviews, which may result in an overestimation of the real prevalence. Previous research conducted in health care workers involved in treating patients with an infectious disease during an outbreak has shown an increase in short and long-term mental health problems in these populations. Several studies have shown that, during the outbreak of the Severe Acute Respiratory Syndrome (SARS) in 2003, health care workers were at increased risk of developing psychological distress 8, 9 , which persisted over time 10 To manage the psychological problems in China during the COVID-19 outbreak, several psychological intervention programs were developed in Chinese hospitals to support frontline health care workers [12] [13] [14] . However, the efficacy of these interventions was partially reduced due to certain impediments. For example, medical doctors and nurses were frequently reluctant to participate in psychological interventions, as their focus was on ensuring better working conditions, including adequate rest periods and better protective equipment and safety 13 . Other authors have pointed to difficulties in developing these interventions, mainly: 1) problems with planning and implementation of the interventions, 2) problems in cooperation and decoupled interventions from mental health services and community health services, and 3) an excessive number of volunteers (e.g., counsellors, nurses or teachers) in the intervention teams, with a scarce number of mental health professionals 15 . Sadly, over 54,000 health professionals have been infected with the coronavirus in Spain 2 , among the highest infection rates among healthcare professionals worldwide 16 . Given that the risk of contagion is one of the main stressors during a pandemic, frontline healthcare workers in Spain are particularly vulnerable to developing mental health issues [17] [18] [19] . To reduce the distress associated with working with COVID-19 patients, many hospitals in the SNS have developed mental health interventions to assist these professionals. However, no comprehensive study has been performed to date to determine the characteristics of these psychological interventions, including their active components, their duration and availability, or the conditions in which they were implemented. Furthermore, although common guidelines have been proposed for the In this context, the aim of the present study was to assess and describe the main characteristics and components of psychological intervention programs offered to healthcare workers treating COVID-19 patients in Spanish hospitals during the peak of the outbreak. An ad hoc online survey was designed in Google Forms (Google LLC). The survey assessed the most relevant variables in mental health interventions for healthcare workers, including data related to the following: site, training of team members, main objectives, characteristics of the interventions, setting, working hours, implementation of the program, and personal protective equipment (PPE), among others (see Appendix A). The survey was distributed to mental health professional societies and key SNS hospitals using mailing lists provided by those organisations, and also distributed on social media. The survey was available online from March 23, 2020 through April 5, 2020. Participation was voluntary and no compensation was given. The present study has been authorized by the Valdecilla Biomedical Research Institute (IDIVAL) Internal Scientific Committee (Santander, Spain). No ethics committee approval was needed because the study did not involve any personal data from human subjects. J o u r n a l P r e -p r o o f 8 Only data from public or semi-public (public-private) hospitals were considered as these institutions were responsible for treating most COVID-19 patients. Responses from other healthcare services or private hospitals were not considered. Only responses from members of mental health services at public or semi-public hospitals were included. In some cases, more than one individual from the same hospital responded to the survey. In these cases, any discrepancy was resolved by contacting the intervention team directly. Descriptive statistics are presented. Non-parametric tests (phi and Kruskal-Wallis H test) were performed to compare variables. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS, v.19.0). We received a total of 50 responses. We discarded duplicate responses (same hospital, n=10 responses) and those from other mental health services that did not fulfil the eligibility criteria (n=4, one response each from the following: primary care centre; health consortium; a program not associated with the SNS; and one response without any information). Finally, mental health intervention programs from 36 hospitals were considered valid for further analysis. Respondents were mainly members of the intervention teams (n=29; 80.6%) or coordinators of those teams (n=6; 16.7%). for their own staff, while the other two programs were created by regional health systems to serve multiple hospitals. All the intervention programs were created ad hoc to manage mental health issues in healthcare workers during the COVID-19 pandemic. The most common objectives of the programs were as follows: 1) "to improve emotion regulation" (n=35; 97.2%), 2) "to reduce physiological arousal" (n=31; 86.1%), 3) "to improve the professionals' communication skills with their patients" (n=19; 52.8%), and 4) "to improve communication among the members of medical teams" (n=16; 44.4%). The median (IQR) time required to prepare the programs, defined as the time elapsed between the start of clinical interventions and the first preparation meeting, was 5 days (5). Note that two programs began clinical interventions before the first team meeting and four began on the same day of the first team meeting. These programs were created after a proposal made by mental health professionals (n=23; 63.9%), the director of mental health services (n=9; 25.0%), hospital management (n=3; 8.3%), and others (n=1; 2.8%). Psychological intervention teams had a median (IQR) of 10 (14) members. The teams were composed of clinical psychologists (50.1%), clinical psychology interns (18.1%), psychiatrists (15.6%), psychiatry interns (7.2%), and other staff (9.0 %). Table 1 shows the professional profile categorized by hospital size. The presence of newly-hired personnel (one site) or volunteers (five sites) was infrequent. More than half of the teams included professionals with specific training in emergencies and disaster situations (n=21; 58.3%). Most of the team leaders were clinical psychologists (n=19; 52.8%). --- Table 1 This is the first study to describe mental health interventions for healthcare workers in Spanish hospitals during the COVID-19 pandemic. Our results show that, prior to the national lockdown, several hospitals in Spain had developed some type of intervention to improve emotion regulation and/or to reduce anxiety/stress among hospital staff. In terms of the content of the interventions evaluated in our study, we found that psychoeducation and mindfulness were highly prevalent, both for group and individual interventions. By contrast, the main approach for individual interventions was cognitive-behavioural therapy. Another aim of some of the interventions in Spanish hospitals was to improve communication within the medical team. Some organizations strongly recommend these type of intervention as they can reduced the anxiety associated with uncertainty and dysfunction in communication flows 25, 26 . The interventions in the present study were delivered mainly by mental health specialists, primarily clinical psychologists. This is important and a positive feature of these programs, especially given that one of the main issues detected in China was the high number of volunteers delivering these interventions 15 . Mental health professionals are preferable over volunteers as they guarantee higher professional skills, are better integrated within the health care system and ensure the continuity of care over the time. However, a wide range of different interventions was offered at these hospitals, and there was a notable lack of coordination among the institutions and no national guidelines were available. Better coordination among hospitals would likely improve the quality of the interventions, in part by ensuring that "best practices" are used. During the COVID-19 outbreak in China, it has been found that depression and anxiety levels among healthcare workers were higher in women, nurses, professional working in a secondary hospital, and frontline workers (direct contact with patients) 7 Although there was a clear necessity during the pandemic to quickly develop and implement mental health programs for healthcare workers, this has raised several issues. As our results show, some hospitals implemented these interventions with scant preparation, even commencing the interventions before conducting preparatory meetings. This implies that safety issues might have been overlooked (e.g., appropriate training in the use of PPE). The present study has several limitations. First, the study is based on a convenience sample. We did not systematically collect data from all Spanish hospitals (about 492 public and semi-public hospitals). Thus, it is probable that some types of interventions were not considered. Moreover, the proportion of hospitals offering such psychological interventions for healthcare workers remains unknown. Furthermore, other programs developed by different institutions (i.e. professional associations, non-governmental organizations) outside the SNS were not included. However, the main objective of the present study was to describe the characteristics of the interventions for healthcare workers, in order to inform decision making during the pandemic, it is likely that a more complex design would need more time and, consequently, cause an unwanted delay in access to information. Second, the study period is limited to the peak of the pandemic in Spain, and some interventions may have been developed and implemented later to treat distress associated with a different phase of the pandemic. By contrast, the study has several important strengths. For example, all of the data was directly provided by members of the teams involved in the interventions, thus increasing the validity of these data. Also, the rapid assessment of these programs allows us to precisely describe the psychological interventions deployed during the peak of the pandemic. Future research should seek to more comprehensively evaluate the intervention programs, including their acceptability, safety, efficacy, and effectiveness. According with a systematic review 28 A long-term, longitudinal approach is needed to assess the evolution of mental health of healthcare workers and the effects on mental health of potential risk factors for burnout 31 . In addition, the development of electronic health technologies for psychological treatment and evidence-based self-help interventions during pandemics is warranted 32, 33 The response of mental health teams to the COVID-19 pandemic in Spanish hospitals included diverse psychological interventions for healthcare workers. These interventions may have enhanced emotion regulation skills among health care workers and helped to prevent the incidence of mental disorders. 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