Psychological effects of COVID-19

I believe that throughout these months much has been written not only about the systemic effects of the new coronavirus, but also about its ocular involvement and the possibility of its transmission through tears. In fact, one of the first doctors to die was an ophthalmologist. And recently thromboembolic phenomena in the retina have been described by a Brazilian group.

But a few days ago, a work by the prestigious LV Prasad Eye Institute appeared in the Indian Journal of Ophthalmology, achieving considerable impact even in the media, and I found it interesting to comment on it. Its title was "Psychological impact of COVID-19 on ophthalmologists in training and ophthalmologists in India".¹ This pandemic has left us with many more sequels than we imagine. Some will come to light over the next few months and we should be prepared for them.

In the above-mentioned work, 2355 ophthalmologists and residents were surveyed (constituting 20% of the sample). A total of 52.8% recognized a serious impact on their activity and 37% also had economic impacts. Psychological distress was measured by means of the Patients Health Questionnaire (PHQ-9), with almost 33% having depression, 21.4% moderate depression and 4.3% severe depression. The multivariate analysis showed that the depressive effects were greater in younger people and even greater in residents. These effects were also seen in medical students. In a study of 530 students conducted in Saudi Arabia, 23.5% were discouraged after confinement, with loss of concentration and a notable decrease in academic performance.²

At present there is little doubt that the pandemic and the measures taken to counteract it have had a clear psychological impact on us: anxiety, depression, insomnia, denial, anguish and fear. The psychological effects are attributed to direct and indirect effects of the disease itself and of confinement. Asymptomatic transmission of the disease causes fear and anxiety. In addition, the lack of personal protection measures and a certain degree of social discrimination towards health care workers increase the levels of stress and anxiety.

Many institutions, including universities, have developed systems and cabinets for psychological support and not only for workers who are in the “front line”.³

Medicine is considered, in itself, a stressful activity. The great physical demand, psychological pressure and inefficient work that we are often required to do leads to the well-known "burnout", which affects to some extent 50% of health professionals in the USA and I suppose in most countries.

Health professionals are cumulatively exposed to traumatic, fear-producing situations. In the face of fear, individuals may be in shock, confused, disorganized, stressed, hyperactive or frozen. These situations have a high emotional impact and the way this impact is managed can be a determining factor in the development of so-called post-traumatic stress.

In some cases, health professionals have put in place not very adequate protection mechanisms, involving dehumanizing pain and suffering, which can lead to the depersonalization and dehumanization of patients. In other words, a detachment from the emotions of pain, which in the end are the outcome of the reality we are living. When this detachment takes place it prevents our normal psychological functioning because the experience is not processed and we cannot learn from it or transforme it. Quite simply, it remains encapsulated, giving rise to other symptoms of post-traumatic stress.

This pandemic is going to increase many of these problems. A lack of clear government response, at least initially, the problems arising from the lack of reliable testing and efficient masks had a traumatic impact on all of us. Add to that years of disinvestment in healthcare, which left hospitals without resources to adapt to an explosive demand for critical care and protective measures.

In a survey of 1257 doctors and nurses in China at the height of the pandemic, 50% reported symptoms of depression, 44% reported anxiety and 34% reported insomnia.

In Spain, the Ministry of Health updated its scientific-technical protocol for handling the COVID-19 coronavirus in May. This new version includes a section that addresses the impact of the pandemic on mental health, both by the virus itself and the emerging social situation, with special emphasis on health professionals, who are one of the most vulnerable groups to suffer psychological disorders along with hospitalized patients, people with previous mental disorders caused by difficult situations derived from isolation and economic crises.

It was clear that, like any health worker, ophthalmologists fear for their own health and that of their families. Accordingly, fear is added to the economic crisis and the uncertainty of a new outbreak in the autumn.

Special mention should be made of residents. The class that has now graduated will be forever marked by the pandemic. The parties, dinners and farewell celebrations, common in any of our hospitals, have been replaced by a simple goodbye, with a mask and observing the safety distance.

But those who are going to join now will not get any better. Their incorporation has been delayed and they have been determined to design a telematic system (ICTs now seem like the balm of the Saracen knight Fierabras, capable of mitigating any disease), which is neither prepared nor tested, producing uncertainty and increasing the already stressful experience.

I'm not a pessimist, I've never been one, but I think we need to keep these things in mind. Now that the terraces are absurdly full and have stopped applauding at 8 pm to cheer the valiant health professionals, we should remember that researchers have not yet been able to start their work (soccer players have) and that over the next few months we will have to help normalise the psychological effects that this pandemic has left us with.