Jared A. Greenberg, MD

In this cross-sectional study, Azoulay and colleagues surveyed 950 HCPs in 21 ICUs in France at the beginning of the omicron wave of the COVID-19 pandemic. Their primary outcome was a measure of resilience. Lower levels of resilience were associated with higher levels of anxiety, depression and PTSD. The large sample size allowed the authors to determine multiple predictors of resilience and emotional well-being.

This is an important study that sheds new light on the challenges faced by frontline health care workers during the COVID-19 pandemic. It is disappointing to learn that the prevalences of symptoms of anxiety and depression increased since an earlier study by the authors. In addition, only a minority of respondents felt supported by their supervisors and institution. Collectively, these results suggest a missed opportunity for health care institutions to address the mental health needs of their staff over the course of the pandemic.

Given the cross-sectional nature of the study, one cannot determine the temporal relationship between lower levels of resilience and higher levels of emotional distress. One could argue that the vast majority of participants demonstrated resilience because they had already worked during the early phase of the COVID-19 pandemic and were continuing in their stressful roles. It is possible that the presence of burnout or feeling undervalued by their institution led some participants to be less able to recognize their inherent resilience. Thus, it remains unclear whether instituting resilience building programs would improve wellbeing among experienced HCPs. However, a message of the study is clearly that health care institutions need to spend more time understanding the needs of their staff and providing resources that address these needs.

Timothy Amass, MD, ScM

In this cross-sectional, survey-based study, Azoulay and colleagues sought to explore the relationship between resilience and mental-health symptoms in HCPs in France. As is to be expected from the FAMIREA research group, they present a wonderfully executed evaluation of rates of psychological stress disorders in HCPs (nurses, residents, physicians and “other” HCPs) and model the impact of resilience in these providers on these symptoms.

They report that, of the nearly 1,000 HCPs who responded, symptoms of anxiety were present in 61%, depression in 39% and PTSD in 36%. They note that rates of these symptoms, particularly those of anxiety and PTSD, are much higher during this study period than other comparable studies. Interestingly, but not surprisingly, exhaustion, fear, lack of motivation, increased perceived distress from the “infodemic” of COVID-19 and having a family member with severe COVID-19 were all associated with increased rates of these stress symptoms. Increased resilience, however, as measured and defined by a validated questionnaire, was independently associated with lower stress symptoms scores.

As a practicing ICU physician during the pandemic, these results are not surprising, and neither was the finding that only 8% of respondents felt supported by their institutions. The combination of uncertainty, lack of support and lack of control seemed to create the “perfect storm” of developing stress-related disorders in the HCPs. The inverse correlation of resilience to these symptoms is a logical finding, although I really appreciated the introduction of the concept of “post-traumatic growth” (PTG) as a likely modifiable phenomenon in individuals. Resilience may, in some ways, be a trait of the individual providers where some will be heading into the stressful time with less baseline resilience, regardless of the event, such that maximizing resilience in these individuals may not cross the “resilience threshold” that would be protective against stress-related disorders. If, however, a focus on PTG were employed, all those experiencing traumatic events may be able to develop growth skills regardless of their starting resilience.

This study provides excellent hypothesis generating data offering the opportunity to further explore interventions focused at employing several interventions, including those focused on PTG and resilience. However, as the authors discuss, hospital administrators must be able to provide resources to support HCPs in engaging in these strategies. The challenges of health care finances and HCP shortages provide significant obstacles to meaningfully engaging in mechanisms to help reduce stress-related disorders in HCPs.