Sara Well, RN, has been a critical care nurse for 12 years. It’s one of the most stressful parts of the hospital, with patients hanging in the balance between life and death, their anxious family members fixtures in the waiting room. Well has seen patients live, sometimes miraculously so. She’s also seen them die. Her job has also always contained some element of risk to herself, as patients with infectious diseases sometimes come in for treatment. But even with over a decade of experience, she says working during COVID-19 is a completely different type of stress.

“We have always experienced patient loss, but not due to a mass casualty event,” Well says. To date, the Centers for Disease Control and Prevention (CDC) reports that 1.5 million people in the U.S. have contracted the coronavirus, and over 93,000 people have died from it—almost equal to the number of Americans who died in the Korean and Vietnam Wars combined. Being confronted with those massive losses day in and day out takes a toll, says Well. “We deal with [death] all day, then we go home to care for our own families, do the dishes, or everything else that’s needed,” she says.

Many of us are experiencing elevated levels of stress, anxiety, or sadness due to the pandemic—an estimated 70 percent of Americans felt moderate to severe mental distress in April, according to a preprint study from San Diego State University and Florida State University. But caregivers on the front lines are particularly at risk for having their mental health hit hard. A study published in JAMA Network Open of health-care workers who worked with coronavirus patients in China found that during the worst of the pandemic, 50 percent of workers had symptoms of depression, 44.6 percent reported symptoms of anxiety, and a whopping 71.5 percent reported distress. “Working in the front line was an independent risk factor for worse mental health outcomes in all dimensions of interest,” the study authors concluded.

The pandemic isn’t even over yet (far from it), and it’s already contributing to headlines about the country entering a mental health crisis and, most tragically, some reports of COVID-19 front-line workers dying by suicide. These are the people who are working around the clock to take care of us. But who is taking care of them?

Why burnout in health care is a bigger risk during COVID-19

Boulder, Colorado-based ER doctor and Fragile author Shannon Sovndal, MD, is used to working in a stressful environment. “In the ER, we’re used to dealing with patients with infectious diseases such as hepatitis, HIV, and tuberculosis. We’re also used to patients being intoxicated and combative, at times. It can be a dangerous place to be,” he says. “That is the baseline. Then you add in a pandemic.”

That’s why neuroscientist, psychiatrist, and mindfulness teacher Judson Brewer, MD, PhD, worries that the unique strains of the pandemic on health-care workers will further increase their risk of burnout, a medical condition characterized by three distinct dimensions: feelings of energy depletion or exhaustion, feelings of negativism or cynicism related to one’s job, and reduced professional efficacy. “[Health-care workers’] brains are constantly on high alert because they are working longer hours and are experiencing even more stressful circumstances,” he says. “That is not a sustainable state to live in for a prolonged amount of time,” he says.

“Nursing already has a high burnout rate, and part of that is because the loss of a patient is really emotional,” Well adds. “We are the ones by the bedside, interacting with both the patient and their family.” When a patient dies—whether because of COVID-19 or another reason—nurses have a checklist to follow, a list of tasks to complete and quickly get the room ready for the next patient. “We have 30 minutes sometimes to get the patient out and a new patient in. This doesn’t leave much time to grieve or process what’s happening.” Magnify that loss by tens of thousands and that leaves many nurses and other health-care professionals little time or space to process what they’re experiencing.

Dr. Sovndal has also struggled to handle the volume of very sick patients who need his care. “The COVID-19 patients, they can’t have their families by their bedsides and I feel badly for them. But I also can’t stay by their bedside to comfort them because there are other COVID-19 patients on my mind that I know I have to get to,” he says. “It takes a toll because you can’t be as compassionate as you perhaps want to be.”

Additionally, since COVID-19 is an infectious disease with no cure, front-line workers have to grapple with the constant fear of exposure. “When I signed up for emergency medicine, I knew I was going to deal with infectious diseases… But I’ve never actually been fearful of a patient until now,” Candice Meck, DO, previously told Well+Good. “This is a highly contagious virus and I’m afraid.”

“A big stress of mine is not only being worried about myself, but for the 400 paramedics and first responders, especially in terms of keeping them safe from being infected,” Dr. Sovndal says. Part of the problem is the persistent shortage of personal protective equipment (PPE), which is putting many health-care workers and other front-lines professionals at even greater risk of contracting the virus themselves.

Their persistent exposure to COVID-19 also means that many front-line health-care workers can’t rely on the same kind of in-person support from loved ones they normally would. Dr. Sovndal says he hasn’t kissed his wife or kids since the pandemic started. Other health-care workers have taken steps to remove themselves completely from their house, sleeping in the garage or elsewhere, in order to keep their loved ones as safe as possible from the virus. But this also puts them at risk of feeling isolated and cut off from their normal support networks.

As if all of this wasn’t already stressful enough, 1.4 million health-care workers lost their jobs in April. Hospital visits across the country are down 30 percent below average as people continue to avoid medical care unless absolutely necessary, which impacts these facilities’ income. The layoffs are a double-edged sword for health-care workers—those who lost their jobs now have to worry about how to pay their bills and find a new job in a shuttering economy; those spared by layoffs have to take on the burden of extra work that their former colleagues used to do.

The mental toll of being a COVID-19 caregiver extends beyond the hospital doors, too. Amy Cirbus, PhD, LMHC, LPC, the director of clinical content at Talkspace, says many therapists are feeling caregiver burnout, too. “One reason for this is that the client volume has increased,” she says. (Aimee Daramus, PsyD, a psychologist in Chicago, IL, recently told Well+Good that her workload has increased 25 percent during the pandemic thanks to a big increase in clients.) “But also, what makes being a therapist during COVID-19 different is that there is a disproportionate amount of clients who are in crisis, which demands more of you and takes more out of you,” she says.

Combatting burnout in a world gripped by the pandemic

It’s not an understatement to say that the pandemic has put a huge strain on the mental health of many health-care workers. However, Well says a silver lining is that COVID-19 has magnified the burnout problem that has long existed for medical and mental health professionals. “People are more aware of it now and it’s finally getting some attention,” she says. The pandemic inspired her to launch an online platform called Nurses Back to Health, where nurses can receive free counseling. “This is a grassroots effort other nurses and I are building ourselves because we see the need,” she says. “We know we need better coping strategies because we need to be our best selves for our patients.”

Dr. Brewer has also been working on an app to help health-care workers address their burnout in a way that fits in with their extremely demanding schedules. According to a small study he conducted, just 10 minutes of mindfulness-based techniques helped lower stress in physicians by 50 percent after one month of regularly putting them into practice. Inspired by the results, he developed a free app, Breathe by Dr. Jud, last year and updated in April based on the findings from his study. The app helps users practice short exercises that the study found most effective, such as breathing and meditation exercises.

Dr. Cirbus and Talkspace, meanwhile, are working on ways to support therapists while the pandemic wears on. The platform has established internal support groups, creating a safe (virtual) space where the therapists can share their own fears and anxieties. “A lot of what we talk about in these groups is how to draw the line between helping others and helping ourselves,” Dr. Cirbus says. For those who don’t have time or may not want to commit to a virtual group, she says closed Facebook communities specifically for therapists can be helpful because you can dip in and out of them, enlisting support on an as-needed basis.

There are other newly developed resources for health-care workers that can help. Project Parachute, which started as a local movement in North Carolina, now has more than 500 volunteer therapists in 37 states, all offering pro bono therapy sessions to front-line health workers. Meditation app Headspace also launched a free COVID-19 resource, Weathering the Storm, with meditations, sleep support, and movement exercises. There is also a crisis texting service, For the Frontlines, developed by Aetna and CVS Health, which offers free help for COVID-19 caregivers if they text FRONTLINE to 741741. Those who do so will immediately be connected with a trained crisis volunteer.

“It’s important that we have measures like these in place now because there is going to continue to be a mental health demand,” Dr. Cirbus says, particularly among health-care workers. According to Reuters, psychiatrists at Mount Sinai Hospital in New York City predict between 25 percent and 40 percent of front-line workers may suffer from post-traumatic stress disorder (PTSD) as a result of their involvement in the outbreak. Dr. Cirbus says that she unfortunately expects many front-line workers to hit their breaking point soon as the crisis continues to grind on, making the therapists taking care of them busier than ever. “In order for us to anticipate these needs, it’s important we have a groundwork in place for therapists to feel supported and taken care of so they themselves don’t get burned out,” she says.

Well adds that it’s crucial all health-care workers get the help they need as soon as possible, especially due to predictions that there could be a second wave of the pandemic later this year. “Experts are saying it could be even worse this winter,” she says. “Mentally, we need to be ready.”