When a patient is dying from COVID-19, nurse Molly Nixon will hold their hand. She will tell them they are loved. And, often, she will be the last person they see as they take their final breaths.
“I’m there with them as their last human contact; I’m the last person they see on this earth — and that is so unfair,” said Nixon, a registered nurse at Mercy Health in Muskegon.
Since March 21, the day the COVID-19 unit opened at her hospital, Nixon has been on the frontlines of a pandemic that has killed more than 220,000 Americans and more than 7,000 Michiganders — and could result in the deaths of as many as 400,000 people in the nation by the end of the year. For Nixon and other health care professionals working in Michigan’s hospitals, these past months have been a whirlwind of fear and anxiety, an onslaught of death and sickness and loneliness.*
Now, after seeing multiple members of the same family die in a single day, caring for patients whom she said would “be fine in the morning and dead by the afternoon,” sleeping outside to avoid infecting her husband and 10-year-old daughter, losing longtime friends after they insisted COVID-19 is “fake,” and battling her employer for sufficient protective equipment, like N-95 masks (something Mercy Health denied), Nixon is facing a deeply rooted sadness.
As these months of the pandemic stretch on, and with a likely second wave of COVID-19 on the horizon, she sees in herself the mental health challenges being reported by health care workers, and the general population, nationwide.
“I’m working on a pretty good case of [post-traumatic stress disorder],” Nixon said. “We had to open a second COVID unit [at Mercy Health last] week, and it was a mixture of an adrenaline rush, being super on edge, and just wanting to go home and cover my head with the covers and cry because we know what’s coming. I know I’m going to be the last person somebody sees, and that’s not a good death.”
The Muskegon nurse is certainly not alone in this. Across the country, health care workers, and the public at large, are dealing with the emotional fallout from COVID-19. Symptoms of depression and anxiety, suicidal thoughts, and substance use have increased among Americans during the pandemic, according to a survey the U.S. Centers for Disease Control and Prevention (CDC) conducted in June.
In that study, which surveyed 5,412 adults, 25.5% reported symptoms of anxiety, an increase from 8.1% at the same time in 2019. Of the respondents, 24.3% said they experienced symptoms of depression in June, compared to 6.5% in 2019.
In total, nearly one-third, 30.9%, of the survey participants reported symptoms of depression and anxiety, 26.3% said they experienced symptoms of trauma or stressor-related disorders, and 13.3% noted they had started or increased substance use to cope with the stress or emotions related to COVID-19.
Overall, 40.9% of the 5,470 respondents who completed CDC mental health surveys reported “an adverse mental or behavioral health condition,” the agency wrote. Young adults, Black and Hispanic individuals, and essential workers were hit especially hard.
About 75% of respondents between the ages of 18 and 24 reported at least one adverse mental or behavioral health symptom, such as thoughts of suicide. Fifty-four percent of essential workers, which include nurses and doctors, reported the same. About 18.6% of Hispanic respondents said they had recently seriously considered suicide, as did 15.1% of Black respondents, 30.7% of unpaid caregivers for adults, and 21.7% of essential workers.
In Michigan, state health officials said they don’t yet have publishable numbers related to the impact COVID-19 has had on mental health, but Dr. Debra Pinals, the medical director of behavioral health and forensic programs at the Michigan Department of Health and Human Services (DHHS) said she expects they mirror the national figures.
“We have national data from the CDC that shows Americans are struggling more with anxiety and depression and are turning to substance use,” Pinals said. “We assume the people of Michigan are experiencing similar types of emotional reactions.”
Earlier this year, the Grand Rapids-based Pine Rest Christian Mental Health Services issued a report on the behavioral health impact COVID-19 is having on the state and predicted a 23% increase in suicide deaths in Michigan over the coming year.
“The research literature indicates that the impact of economic downturn, isolation/quarantine, increased substance use, insomnia, and lack of community gatekeepers, among other factors, could all lead to increased deaths by suicide — unless we act,” Pine Rest wrote. “Certain groups of Michiganders are especially at risk for a behavioral health crisis due to COVID-19’s impact, including health care providers, children and adolescents, older adults, the LGBTQ community, and those with autism spectrum disorder.”
A second pandemic
As the public continues to live through COVID-19, which health care officials emphasized is going to be here for a while — a vaccine could be ready in the United States by mid-November, but it will likely be well into 2021 before most people can get it — there is a “second pandemic” building, said Dr. Caelan Soma.
“The second pandemic is this trauma tsunami that’s coming down,” said Soma, the chief clinical officer at Starr Commonwealth, a nonprofit that provides behavioral health services to children and families across Michigan, including at Children’s Hospital of Michigan in Detroit. At the Detroit facility, Starr Commonwealth also provides mental health support to resident physicians.
“We’ve been in this heightened state of arousal for seven, eight months now; at what point do we crash?” Soma said.
For many people, Soma explained, their bodies and, consequently, their mental health, are responding to life right now as though “they are being chased down the hall by a tiger” because there can be a seemingly never-ending wave of overwhelming challenges to address.
Children’s Health doctors are, for example, seeing patients who have lost jobs, are sleeping in their cars, and have nowhere near enough food to eat. One family that Starr Commonwealth recently worked with reported eating toothpaste because they had no money to buy food, Soma said.
People have lost their jobs and health insurance, (of the 1.06 million payroll jobs Michigan lost between February and April, 58% had returned by September), domestic violence calls have increased during the pandemic, and child abuse and neglect has worsened during the pandemic. The resident physicians, meanwhile, are facing increasing amounts of stress and anxiety while dealing with cases rooted not just in health problems but in social and economic crises, Soma said.
“A lot of [patients] are experiencing trauma and stress because of the pandemic: there’s exposure to domestic violence, child abuse, housing, food insecurity,” Soma said. “For staff, they’re not just potentially being exposed to the virus but to really, really hard cases.”
This in turn translates to significant behavioral and mental health challenges for patients and doctors alike.
“All of us are meant to be able to deal with stress and acute stress; we can keep our guard up for about four to six weeks before we get exhausted and worn out and have symptoms, whether that’s in behavior or mood problems or headaches and stomachaches,” Soma said. “After that, our bodies just aren’t meant to deal with stress for that long. And here we are, eight months into a pandemic, and there’s so much uncertainty in every single area of all of our lives. People are doing what they can to survive. That could look like a parent who says, ‘I can’t do it anymore; I can’t do these two jobs.’ Or they’re finding a way to cope and are using drugs or alcohol.”
To address this, Soma and her colleagues are continuing the work they’ve been doing at Children’s Health for the past 18 months, including helping doctors be better able to identify and respond to trauma among patients and connect them with needed support systems.
The nonprofit also is providing trauma assessment and intervention to children and families in addition to the professional training and coaching to the clinic staff and resident physicians at the Detroit hospital. For the resident physicians and other staff, there are group sessions that provide the professionals a space to process trauma and practice self-care.
Soma, who has helped to address trauma following the Sandy Hook shooting and Hurricanes Katrina and Rita, explained it’s crucial, particularly following a disaster like this pandemic, that everyone from physicians to parents understand what chronic stress looks like and how it affects us. A patient who seems like they have attention deficit hyperactivity disorder (ADHD) or substance abuse issues, for example, may actually be facing chronic stress and should be treated for that, Soma explained. To educate everyone from teachers to parents on this, the nonprofit has recently provided about 130,000 free e-learning courses about trauma and resilience.
More than anything, Soma said, there’s no need “for some fancy intervention strategy” when it comes to treating the trauma happening during the pandemic.
In large part, she said it’s about normalizing our emotions — recognizing that it’s OK to feel as though you’re collapsing in the face of these monumental challenges, and to seek help when that happens — connecting those who are struggling with the support systems that exist around them, and attempting to find even small moments of joy in deeply trying times.
“What we find following a disaster or school shootings or suicide, what matters most to survivors is community, a connection to other people,” as well as “sensory experiences” that make us feel better, such as music, dancing, and play for children, Soma said.
“We can be logical about the pandemic and say, ‘We’ll have a vaccine; this won’t go on forever; we’re doing the best we can,’ but those aren’t the things that make us feel better,” she said. “What makes us feel better is face timing a friend or going for a socially distanced walk with a friend.”
That, of course, isn’t to say that going for a walk is going to address all the underlying mental health issues this pandemic is causing, but Soma said it’s that intentional connection with people we care about that will, in large part, get us through this.
“I think that’s what’s going to come following this: we’re going to learn we really relished in this time we had with our family and can’t wait to hug everyone we know,” she said.
Depression drops among doctors, but future is unclear
During the pandemic, physicians nationwide have reported experiencing less depression than normal, potentially because their administrative work has been cut and because of the public’s vocal support for medical professionals, said Dr. Srijan Sen, associate vice president for health sciences research and the Frances and Kenneth Eisenberg Professor of Depression and Neurosciences at the University of Michigan.
Sen, who has been studying how stress and other mental health issues impact physicians for the past 13 years, said it’s a result that he wasn’t expecting. But he noted that despite the decline, doctors continue to face depression at far greater rates than the general public. And with the drop during the pandemic, Sen noted doctors are still experiencing rates of depression above that of the general population.
“The rates [of depression] coming down to what is still a high level—that being an improvement is a problem,” Sen said. “Pre-COVID, doctors felt they became doctors to work with patients and help them get better, but most of our time as physicians is spent documenting stuff on charts and working with administrators. We’re not spending most of our time with patients. That turned around a little in COVID.”
Over the past 13 years, Sen has studied about 23,000 doctors and found that, during their first year out of medical school, their rates of depression skyrocket from about 4% — akin to what the general population is experiencing — to 25% in a year’s time. That drops as doctors move further into their careers, but the lifetime rates of depression among doctors remains at about 10 to 15%, Sen said.
While he’s pleased to see doctors are currently less depressed, Sen is concerned about what is going to happen further down the road as the pandemic continues. He noted that women doctors could be especially hurt by the pandemic.
“We had a paper last year on gender differences, and, under pre-COVID conditions, the way medicine was structured seemed to drive women physicians out of medicine,” Sen said. “Within six, seven years of training, about half of women physicians were not working or were working part-time, mostly because of work-family conflict. My sense is that’s getting much worse during COVID.”
For a state, and country, experiencing doctor shortages, that’s a big problem, Sen said.
“There’s good data that women are better physicians and spend time with patients more,” Sen said. “We don’t have nearly enough physicians. If COVID drives more women out of medicine, that will have long-term effects on physician shortages for decades. We need to address that…and make it possible for women physicians to stay in the field and in their jobs at this time.”
Achieving that is a complicated process, but it essentially boils down to the field of medicine, and our society at large, creating a workplace that is supportive of women doctors being able to have a life outside of work, Sen said.
‘We just want to live to see tomorrow’
Throughout the pandemic, nurses across Michigan and the United States have reported shortages of personal protective equipment (PPE), such as masks and gowns.
As nurses faced crowded COVID-19 units and more patients dying on them than ever before, they did so in bandanas fashioned into masks and other gear that left them feeling deeply afraid and vulnerable in the face of COVID-19.
This lack of PPE not only endangers health care professionals’ physical health, it contributes to mounting mental health issues for workers as they face anxiety and fear over their safety, nurses interviewed by the Michigan Advance said.
While nurses said that the current PPE situation is not the nightmare it once was, they stressed that they still do not have adequate protective gear and often have to fight for the equipment they do have.
“To ask for protective gear and be dismissed like we’re being unreasonable is upsetting,” said Nixon, the nurse at Mercy Health in Muskegon. “We just want to do our job. We just want to live to see tomorrow.”
Fred Wyese, a registered nurse who has worked in the COVID-19 unit at Mercy Health in Muskegon since it opened in March, said workers were “scrambling for gowns” at the beginning of the pandemic.
“When we were first given a [powered air-purifying respirator] mask, we were supposed to keep track of the amount of time it was actually on us because it had a life of 18 hours of use time; I’m still in my original shield,” Wyese said, referring to the masks that health care workers will use to protect themselves while working with COVID patients.
Both Wyese and Nixon said N-95 masks, which are also used to protect health care workers treating COVID-19 patients, have been hard to come by, especially when the pandemic began.
“In the beginning, when the COVID unit first opened, there were no N-95s, no protective gear,” Nixon said.
Things began to improve, especially after the nurses’ union, SEIU Healthcare Michigan, got involved and threatened to go to the media, but there are still significant issues with PPE, the nurses said.
“We’re not able to get them as they’re recommended to be worn,” Nixon said of N-95 masks. “We’re expected to make N-95s last for a week; they’re really not designed for that. They’re designed to be used one a day, and that’s not happening. And our nurses on non-COVID units are not getting PPE, and they’re getting asymptomatic COVID patients.”
Angela Klinske, a spokeswoman for Mercy Health, said in an emailed statement that the hospital system has “always put the safety of our patients and colleagues first, and we have always worked closely with the unions that represent our nursing staff and service colleagues.”
“We will continue to do so,” Klinske wrote. “We continue to have ample supply of appropriate PPE for our health care workers for the patient care they provide.”
As nurses said they dealt with the lack of PPE, they were facing a scene no one had experienced before.
“Before we would intubate someone to put them on a ventilator, we tried to call their family, get anyone on the phone so they could have some last words with them because it was an 80% mortality rate once they went on a vent,” Wyese said. “That’s some pretty harsh stuff you have to do. This was a death sentence we were giving people.”
Still, nurses continue to show up to work and treat people whose bodies are being ravaged by COVID-19 because “that’s what we do,” both Nixon and Wyese said. But as they navigate a strong sense of loyalty to their patients, their profession and their colleagues, the nurses said they have no doubt the pandemic will negatively impact their mental health in the future.
“I don’t know anyone who’s had breakdowns, but I do know there’s a PTSD-like effect it can have on you,” Wyese said. “… There’s a numbing thing that happens; you have to get used to [working with COVID]. It’s like anything: you push it aside, but it will affect us down the road.”
As for now, Nixon and Wyese said the camaraderie among the COVID-19 unit nurses, as well as support from the hospital’s chaplain, helps the health care workers continue to face this pandemic.
“Our hospital chaplain has adopted all of us on the COVID unit,” Nixon said. “On particularly bad days, I have cried to her because it’s rough.”
The nurse went on to say that her mental health would likely be better “if people didn’t tell me what I was experiencing was fake.”
“I’m a pretty strong person, and I can accept death is a part of life, but please don’t tell me it’s fake because it’s not,” she said. “I’m not living in an alternate reality. … Still, it doesn’t matter if someone gets in my face, calls me a liar and then tomorrow they end up in the COVID unit. I will still care for you.”
It is crucial that the public understands their physical health, and their support of hospital staff, is tied to both the physical and mental health of nurses and other health care workers, Nixon said.
“If all you’re asked is to wear a piece of fabric on your face — we might save 100,000 lives because of this collective act of solidarity — please do that,” she said. “Nurses need the public to stand in solidarity with us. We need safe working conditions.”
‘It’s OK to ask for help’
As health care workers navigate the pandemic, state health officials said they’re focusing on providing mental health resources for them and other vulnerable populations, including Black and Hispanic individuals. Black and Hispanic residents in Michigan, and across the country, have been disproportionately infected and killed by COVID-19.
In April, DHHS received a $1.9 million federal grant that helps the state health department to provide free crisis counseling for Michiganders suffering from stress, anxiety, depression, and other mental health issues due to the pandemic. With the grant, the health department increased the number of trained counselors available through the state’s 24-hour COVID-19 hotline (1-888-535-3136).
“It provides crisis counseling that’s a type of support specific to the disaster — counseling around the stressors people are feeling,” said Pinals, the medical director of behavioral health and forensic programs at MDHHS.
As part of the grant, outreach specialists too are working to connect vulnerable populations to mental health resources, including health care providers and first responders, people experiencing racial and ethnic health disparities, unemployed residents, people with substance use disorder, immigrants, educators, and people with intellectual and developmental disabilities, among others.
In addition to the COVID-19 hotline, the state in April launched what’s known as a “warmline” for Michiganders living with mental health conditions. The warmline (888-733-7753) operates from 10 a.m. to 2 a.m. seven days a week and connects individuals with “certified peer support specialists who have lived experiences of behavioral health issues, trauma or personal crises, and are trained to support and empower the callers,” per DHHS.
It is intended to serve individuals living with such mental health issues as anxiety, depression and trauma. Individuals in crisis, including those considering suicide, are urged to contact the Disaster Distress Helpline at 800-985-5990 or the National Suicide Prevention Lifeline at 800-273-8255.
Over the course of two weeks in October, the warmline received 471 calls — two of which were considered to be crisis calls, a DHHS spokesman said.
The state of Michigan also received two other federal grants in August that have helped them address mental health needs due to COVID. The grants, which totaled $2.5 million, were from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Federal Emergency Management Agency (FEMA). The SAMHSA grant provides Michigan’s Behavioral Health and Developmental Disabilities Administration with $2 million to support state residents living with mental health and/or substance use disorders. A portion of the grant also goes to supporting health care professionals.
With this funding, DHHS has partnered with five Community Mental Health Services Programs (CMHSPs) identified as having the greatest needs relative to the pandemic: Au Sable Valley Community Mental Health Authority (which serves Iosco, Ogemaw and Oscoda counties), Detroit Wayne Integrated Health Network, Genesee Health System, HealthWest in Muskegon County, and Saginaw County Community Mental Health Authority. These programs are able to use the funding from this grant to train staff, provide mental health screenings, expand telehealth services, and create programs to help patients manage depression, anxiety, trauma, and grief related to COVID-19.
The FEMA grant, which totaled $372,000, allowed the state to further invest in crisis counselors with the COVID-19 hotline, mental health outreach to the Detroit metro area, and emotional support for COVID-19 patients living in state-supplied isolation housing.
Pinals emphasized state officials have focused on providing free mental health resources for anyone who needs them, including information about stress management, meditation and more, through the Stay Well website.
“We’ve been working really hard to get the word out there that there are these resources,” Pinals said of the variety of state programs, from the hotline therapists to the Stay Well website. “We want there to be a more open dialogue about the fact that there’s strain and stress and that it’s OK to ask for help. These are hard times, and you don’t want your mental health to get ahead of you.”
Correction: The story originally had the wrong number of nurses in Michigan.