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Mental Health Support of Frontline Medical Personnel in the Javits New York Medical Station Federal COVID-19 Treatment Center
New York City (NYC) was the early epicenter of the COVID-19 pandemic in the United States. By late March 2020, NYC hospitals were overwhelmed, leading to the development of a 452-bed field hospital that became the Javits New York Medical Station (JNYMS).1,2 More than 600 uniformed and other federal personnel, including medical personnel from US Army, Navy, and Public Health Service Commissioned Corps, mobilized to provide medical support to the JNYMS in late March 2020, leading to the treatment of more than 1000 patients with COVID-19 within a 30-day period.1
Literature from the SARS, Ebola, and HIV epidemics indicate that adverse mental health consequences, including burnout, depression, and posttraumatic stress disorder symptoms are common in frontline medical workers.3,4 Emerging data shows a similar trend occurring during the COVID-19 pandemic.5 A recent publication detailed the role of a federal force health protection program created to enhance resiliency of deployed officers during the COVID-19 pandemic, but this focused primarily on providing remote services to frontline workers.6 Another report addressed mental health interventions for health care workers in an academic health care system in NYC during COVID-19.7 However, there has been little published on real-time mental health support for deployed personnel during the pandemic.
Prior publications have described the patient flow, infection control measures, and development of a Consultation-Liaison Psychiatry Service in the JNYMS.2,8,9 Here, we detail the establishment of preventative and responsive mental health services for frontline workers at the JNYMS and explore lessons learned through the outpatient and general support experiences.
Development of Outpatient Mental Health Support Services
At the end of March 2020, the Jacob K. Javits Convention Center was repurposed into the 452-bed JNYMS field hospital, where exposition rooms were transformed into a medical unit and intensive care unit.2 While the majority of personnel providing direct clinical care were specialists, the station also was staffed with uniformed and other federal mental health clinicians, including 5 licensed clinical social workers (LCSWs), 3 psychiatrists, 1 dual-trained internal medicine–psychiatry physician, 1 psychiatric nurse, and 2 behavioral health technicians. To standardize processes early in the deployment, standard operating procedures for behavioral health support of personnel were developed and disseminated within the first few days of the deployment.
The initial mission of the behavioral health team was to establish comprehensive mental health services, as the rapidly shifting mission and unfamiliar environment increased the risk of new-onset stress responses and exacerbating pre-existing stressors in personnel. Behavioral health leadership established operations in conference rooms within the convention center, focusing on identifying, prioritizing, and staffing high-traffic areas. A resiliency center was also established adjacent to the changing room, where all staff would enter and leave the units, and to the dining facility, further increasing traffic. This center was staffed 24 hours a day by at least 1 LCSW and a behavioral health technician with 2 shifts: one from 0630 to 1830 and another from 1830 to 0630. Psychiatrists were available during the day for psychiatry intervention and evaluations, and an on-call schedule was developed for off-hours to provide time-sensitive responses.
The resiliency center was developed to provide a welcoming atmosphere to meet basic needs, including nourishment, healthy social interaction, and a calm environment. Water and food were made available free to personnel, bolstering morale for staff working 12-hour shifts in a pandemic treatment floor where personal protective equipment prevented intake of food or water. Mental health staff were also available to counsel and provide social support to personnel. If personnel wished to discuss stressors or appeared to be in distress, a mental health clinician would provide a real-time intervention or schedule an appointment with the behavioral health team. Resources were made available, including brochures and other reading materials on resilience, stress management, and other mental health topics. Uniformed services and state and federal JNYMS leadership were encouraged to visit the resiliency center to normalize interactions and encourage participation in a behavioral health environment. Signage was placed throughout JNYMS to direct personnel to behavioral health services.
The behavioral health interventions and influence spread from the resiliency center nexus. Initially, therapeutic interventions occurred where and when necessary. One psychiatrist provided crisis intervention to a bereaved soldier in the stairwell within 2 hours of arrival to the JNYMS. Leadership and the behavioral health team recognized that the need for privacy was essential for timely therapeutic interventions, leading to the development of a private individual counseling room. As the area became generally accepted as the central hub of behavioral health activity, space was provided to establish a quiet space and a meditation room. The quiet area provided a cool dark space for personnel to sit quietly in solitude; many were grateful for this reprieve after an overstimulating medical shift. The meditation room supplied sterilized yoga mats for personal mindfulness interventions. The behavioral health team also liaised with military chaplains, who established a spiritual service room near the resiliency center. The chaplains held regular religious services and were available 24 hours a day for timely spiritual interventions.
Rapid notification and movement of uniformed personnel to JNYMS resulted in limited ability for personnel to schedule medical appointments and refill medications. Psychiatrists also had limited access to relevant electronic health record systems. This led to a delay in nonurgent care to evaluate personnel records and confirm prescriptions, especially controlled medications. Local pharmacies filled prescriptions, psychiatrists placed electronic health profiles, and command teams were notified in accordance with US Army and federal regulations.
Medical Unit Support Services
Although a robust outpatient behavioral health service was laid out in the JNYMS, the behavioral health team recognized the need to provide mental health interventions within the main patient care areas as well. The intention was to maximize availability and support while minimizing interference to patient care. As previously described, a psychiatric consultation-liaison (CL) team was organized and operated 24 hours a day by early April 2020.9 Indeed, CL psychiatrists have played a valuable role in supporting the unique patient and staff needs in other COVID-19 treatment environments.10 The CL team at JNYMS observed that medical staff were exposed to multiple stressors, including fear of acquiring COVID-19, treating patients with significant medical comorbidities, practicing outside of clinical specialty, working with unfamiliar and limited equipment, and adjusting to frequently shifting changes in personnel and work schedules. Moreover, psychological stress was compounded by long shifts, jetlag, and continuous wear of extensive personal protective equipment, as has been documented in other COVID-19 treatment centers.11
The team of psychiatrists conducted informal rounds to nursing stations to evaluate the morale and develop relationships with the medical team, including nurses, physicians, medics, and other personnel. Areas of high stress and increased interpersonal conflict were identified for more frequent check-ins by mental health clinicians. The psychiatrists and LCSWs were available for informal walk-in therapy when requested by personnel. When the acuity increased, personnel could be accompanied to the individual counseling room for rapid therapeutic interventions. The CL psychiatrists developed professional relationships with the command and medical leadership teams. Through these relationships and sensitive awareness of morale in the medical work environment, psychiatrists were able to advocate for alterations in the nursing work schedule. Leadership was receptive and resultant changes decreased the hours per shift and number of shifts for most nurses. Morale quickly improved, likely resulting in improved quality of patient care and prevention of burnout.
Mental Health Care Beyond JNYMS
Uniformed services and other federal personnel further supplemented health care operations beyond JYNMS. In April 2020, Urban Augmentation Medical Task Forces were organized and distributed throughout regions where COVID-19–related hospitalizations had significantly overwhelmed the local health care force. Urban Augmentation Medical Task Forces often included a psychiatrist, psychologist, and behavioral health technician with the mission to provide mental health support and interventions to patients and medical staff. Combat Operational Stress Control units from US Army medical brigades operated in NYC and the greater northeast region, providing mental health support and resiliency training to military personnel working in civilian hospitals, medical centers, and other health care or support environments. In addition, a LCSW and behavioral health technician worked with New York Army Reserve personnel assigned to mortuary affairs, providing point-of-care interventions at or near the worksite.
A collaborative federal, uniformed services, and state operation led to the development of the HERO-NY: Healing, Education, Resilience, and Opportunity for New York’s Frontline Workforce “Train the Trainer” Series.12 The series was intended to use uniformed services expertise to address mental health challenges related to the COVID-19 epidemic. Psychiatrists and mental health clinicians from JNYMS modeled small group trainings for future medical trainers. In lieu of traditional unidirectional lecturing, which yields limited retention and learning, the panelists demonstrated how to lead interactive small group training with resiliency topics, including goal setting, communication, anger management, and sleep hygiene.
Transition
After the last patient was discharged from JNYMS in May 2020, personnel were quickly redeployed to their duty stations. At the time of mission completion, the JNYMS behavioral health team had been supplemented with psychiatrists, social workers, behavioral health technicians, psychiatric nurse practitioners, psychiatric nurses, and psychologists representing US Public Health Service Commissioned Corps, Army, Air Force, and Navy, and provided comprehensive support to the nearly 1100 patients with COVID-19 and 600 deployed federal and state medical and support personnel.
Lessons Learned and Future Considerations
Behavioral health care provided at JNYMS offers insight into support of frontline workers in pandemic settings, as literature is limited in this area.13 TheJNYMS behavioral health team used strategies similar to military medical interventions in limited and unpredictable environments, such as rapid formalization of team structure and establishment of standard operating procedures to facilitate uniformity across interventions. Physical space was necessary to create an environment conducive to productive mental health interventions, including therapy rooms and quiet and spiritual spaces. Placing behavioral resources in high-traffic areas normalized mental health and maximized accessibility to interventions. Mental health personnel also addressed issues in the work environment, such as providing informal support and crisis interventions to frontline workers. Finally, Urban Augmentation Medical Task Forces mental health personnel and Combat Operational Stress Control units provided therapeutic interventions and resiliency training for military and civilian personnel throughout burdened medical systems beyond JNYMS.
Future operations should consider what equipment and logistic access are necessary to provide psychiatric and psychological care to mobilized federal and uniformed personnel, such as access to frontline worker electronic health records. Given that prior work has found that provision of resources alone is inadequate, frontline medical workers must be aware of where resources are available (eg, signage) and have easy access to material (eg, brochures) focusing on resiliency and psychological health.14 The spaces can be used for formal psychiatric and psychological interventions, such as assessment, therapy, and medication management. Equally important, these spaces serve as a safe place for healthy social interaction and fulfillment of basic needs (eg, nourishment) and a peaceful environment free of stimulation.
Since mental health personnel provide varied services ranging from basic human interaction to complex crisis interventions, mental health personnel should supplement pandemic medical operations. Evidence supports the notion that effective communication and cohesion throughout the entire leadership and health care team structure can improve resilience and implementation of mental health interventions.15 Incorporating mental health personnel into leadership planning meetings would allow for timely recommendations to improve medical logistics and planning of deployment of behavioral health resources. As a general rule, providing behavioral health experts with a seat at the table enhances advocacy and command awareness of the morale and mental health of frontline personnel.
Conclusions
We present the experience of developing mental health support services for deployed personnel during the COVID-19 pandemic and address the real-time mental health treatment and support of deployed uniformed services and federal personnel in the COVID-19 response environment. Timely and effective interventions included securing safe therapeutic space in high-traffic areas, developing relationships with leadership and frontline workers in their own work environments, and disseminating such services throughout the civilian medical system.
Mental health supplementation during the medical response mission strengthened morale in frontline workers in a disaster scenario. We hope that this report and others like it will provide information to improve mental health responses, reinforce mental health support, and encourage research in evidence-based interventions in challenging pandemic and disaster settings.
Acknowledgments
We would like to acknowledge and thank those serving on the frontlines of the COVID-19 pandemic.
1. CDC COVID-19 Response Team. Geographic differences in COVID-19 cases, deaths, and incidence - United States, February 12-April 7, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):465-471. Published 2020 Apr 17. doi:10.15585/mmwr.mm6915e4
2. Brady K, Milzman D, Walton E, Sommer D, Neustadtl A, Napoli A. Uniformed services and the field hospital experience during Coronovirus Disease 2019 (SARS-CoV-2) pandemic: open to closure in 30 days with 1,100 patients: the Javits New York Medical Station [published online ahead of print, 2021 Feb 13]. Mil Med. 2021;usab003. doi:10.1093/milmed/usab003
3. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of Ebola, Zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9(4):151-156. doi:10.4103/jgid.jgid_66_17
4. Wu P, Fang Y, Guan Z, et al. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry. 2009;54(5):302-311. doi:10.1177/070674370905400504
5. Panchal N, Kamal R, Cox C, Garfield R. The implications of COVID-19 for mental health and substance use. Published February 10, 2021. Accessed April 7, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
6. Myles IA, Johnson DR, Pham H, et al. USPHS Corps Care: force health protection for public health officers during the Ebola and COVID-19 responses. Public Health Rep. 2021;136(2):148-153. doi:10.1177/0033354920984775
7. Ripp J, Peccoralo L, Charney D. Attending to the emotional well-being of the health care workforce in a New York City health system during the COVID-19 pandemic. Acad Med. 2020;95(8):1136-1139. doi:10.1097/ACM.0000000000003414
8. Clifton GT, Pati R, Krammer F, et al. SARS-CoV-2 infection risk among active duty military members deployed to a field hospital - New York City, April 2020. MMWR Morb Mortal Wkly Rep. 2021;70(9):308-311. Published 2021 Mar 5. doi:10.15585/mmwr.mm7009a3
9. Kaplan A, Smith CM, Toukolehto O, van Schalkwyk G. Psychiatric care in a novel federal COVID-19 treatment center: development of a consultation-liaison psychiatry service at the Javits New York Medical Station. Mil Med. 2021;186(5-6):129-131. doi:10.1093/milmed/usaa557
10. Shalev D, Shapiro PA. Epidemic psychiatry: The opportunities and challenges of COVID-19. Gen Hosp Psychiatry. 2020;64:68-71. doi:10.1016/j.genhosppsych.2020.03.009
11. Horn M, Granon B, Vaiva G, Fovet T, Amad A. Role and importance of consultation-liaison psychiatry during the Covid-19 epidemic [published online ahead of print, 2020 Aug 5]. J Psychosom Res. 2020;137:110214. doi:10.1016/j.jpsychores.2020.110214
12. Wei EK, Segall J, Linn-Walton R, et al. Combat stress management and resilience: adapting department of defense combat lessons learned to civilian healthcare during the COVID-19 pandemic [published online ahead of print, 2020 Jul 17]. Health Secur. 2020;10.1089/hs.2020.0091. doi:10.1089/hs.2020.0091
13. Pollock A, Campbell P, Cheyne J, et al. Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Cochrane Database Syst Rev. 2020;11(11):CD013779. Published 2020 Nov 5. doi:10.1002/14651858.CD013779
14. Schreiber M, Cates DS, Formanski S, King M. Maximizing the Resilience of Healthcare Workers in Multi-hazard Events: Lessons from the 2014-2015 Ebola Response in Africa. Mil Med. 2019;184(suppl 1):114-120. doi:10.1093/milmed/usy400
15. Klomp RW, Jones L, Watanabe E, Thompson WW. CDC’s multiple approaches to safeguard the health, safety, and resilience of Ebola responders. Prehosp Disaster Med. 2020;35(1):69-75. doi:10.1017/S1049023X19005144
New York City (NYC) was the early epicenter of the COVID-19 pandemic in the United States. By late March 2020, NYC hospitals were overwhelmed, leading to the development of a 452-bed field hospital that became the Javits New York Medical Station (JNYMS).1,2 More than 600 uniformed and other federal personnel, including medical personnel from US Army, Navy, and Public Health Service Commissioned Corps, mobilized to provide medical support to the JNYMS in late March 2020, leading to the treatment of more than 1000 patients with COVID-19 within a 30-day period.1
Literature from the SARS, Ebola, and HIV epidemics indicate that adverse mental health consequences, including burnout, depression, and posttraumatic stress disorder symptoms are common in frontline medical workers.3,4 Emerging data shows a similar trend occurring during the COVID-19 pandemic.5 A recent publication detailed the role of a federal force health protection program created to enhance resiliency of deployed officers during the COVID-19 pandemic, but this focused primarily on providing remote services to frontline workers.6 Another report addressed mental health interventions for health care workers in an academic health care system in NYC during COVID-19.7 However, there has been little published on real-time mental health support for deployed personnel during the pandemic.
Prior publications have described the patient flow, infection control measures, and development of a Consultation-Liaison Psychiatry Service in the JNYMS.2,8,9 Here, we detail the establishment of preventative and responsive mental health services for frontline workers at the JNYMS and explore lessons learned through the outpatient and general support experiences.
Development of Outpatient Mental Health Support Services
At the end of March 2020, the Jacob K. Javits Convention Center was repurposed into the 452-bed JNYMS field hospital, where exposition rooms were transformed into a medical unit and intensive care unit.2 While the majority of personnel providing direct clinical care were specialists, the station also was staffed with uniformed and other federal mental health clinicians, including 5 licensed clinical social workers (LCSWs), 3 psychiatrists, 1 dual-trained internal medicine–psychiatry physician, 1 psychiatric nurse, and 2 behavioral health technicians. To standardize processes early in the deployment, standard operating procedures for behavioral health support of personnel were developed and disseminated within the first few days of the deployment.
The initial mission of the behavioral health team was to establish comprehensive mental health services, as the rapidly shifting mission and unfamiliar environment increased the risk of new-onset stress responses and exacerbating pre-existing stressors in personnel. Behavioral health leadership established operations in conference rooms within the convention center, focusing on identifying, prioritizing, and staffing high-traffic areas. A resiliency center was also established adjacent to the changing room, where all staff would enter and leave the units, and to the dining facility, further increasing traffic. This center was staffed 24 hours a day by at least 1 LCSW and a behavioral health technician with 2 shifts: one from 0630 to 1830 and another from 1830 to 0630. Psychiatrists were available during the day for psychiatry intervention and evaluations, and an on-call schedule was developed for off-hours to provide time-sensitive responses.
The resiliency center was developed to provide a welcoming atmosphere to meet basic needs, including nourishment, healthy social interaction, and a calm environment. Water and food were made available free to personnel, bolstering morale for staff working 12-hour shifts in a pandemic treatment floor where personal protective equipment prevented intake of food or water. Mental health staff were also available to counsel and provide social support to personnel. If personnel wished to discuss stressors or appeared to be in distress, a mental health clinician would provide a real-time intervention or schedule an appointment with the behavioral health team. Resources were made available, including brochures and other reading materials on resilience, stress management, and other mental health topics. Uniformed services and state and federal JNYMS leadership were encouraged to visit the resiliency center to normalize interactions and encourage participation in a behavioral health environment. Signage was placed throughout JNYMS to direct personnel to behavioral health services.
The behavioral health interventions and influence spread from the resiliency center nexus. Initially, therapeutic interventions occurred where and when necessary. One psychiatrist provided crisis intervention to a bereaved soldier in the stairwell within 2 hours of arrival to the JNYMS. Leadership and the behavioral health team recognized that the need for privacy was essential for timely therapeutic interventions, leading to the development of a private individual counseling room. As the area became generally accepted as the central hub of behavioral health activity, space was provided to establish a quiet space and a meditation room. The quiet area provided a cool dark space for personnel to sit quietly in solitude; many were grateful for this reprieve after an overstimulating medical shift. The meditation room supplied sterilized yoga mats for personal mindfulness interventions. The behavioral health team also liaised with military chaplains, who established a spiritual service room near the resiliency center. The chaplains held regular religious services and were available 24 hours a day for timely spiritual interventions.
Rapid notification and movement of uniformed personnel to JNYMS resulted in limited ability for personnel to schedule medical appointments and refill medications. Psychiatrists also had limited access to relevant electronic health record systems. This led to a delay in nonurgent care to evaluate personnel records and confirm prescriptions, especially controlled medications. Local pharmacies filled prescriptions, psychiatrists placed electronic health profiles, and command teams were notified in accordance with US Army and federal regulations.
Medical Unit Support Services
Although a robust outpatient behavioral health service was laid out in the JNYMS, the behavioral health team recognized the need to provide mental health interventions within the main patient care areas as well. The intention was to maximize availability and support while minimizing interference to patient care. As previously described, a psychiatric consultation-liaison (CL) team was organized and operated 24 hours a day by early April 2020.9 Indeed, CL psychiatrists have played a valuable role in supporting the unique patient and staff needs in other COVID-19 treatment environments.10 The CL team at JNYMS observed that medical staff were exposed to multiple stressors, including fear of acquiring COVID-19, treating patients with significant medical comorbidities, practicing outside of clinical specialty, working with unfamiliar and limited equipment, and adjusting to frequently shifting changes in personnel and work schedules. Moreover, psychological stress was compounded by long shifts, jetlag, and continuous wear of extensive personal protective equipment, as has been documented in other COVID-19 treatment centers.11
The team of psychiatrists conducted informal rounds to nursing stations to evaluate the morale and develop relationships with the medical team, including nurses, physicians, medics, and other personnel. Areas of high stress and increased interpersonal conflict were identified for more frequent check-ins by mental health clinicians. The psychiatrists and LCSWs were available for informal walk-in therapy when requested by personnel. When the acuity increased, personnel could be accompanied to the individual counseling room for rapid therapeutic interventions. The CL psychiatrists developed professional relationships with the command and medical leadership teams. Through these relationships and sensitive awareness of morale in the medical work environment, psychiatrists were able to advocate for alterations in the nursing work schedule. Leadership was receptive and resultant changes decreased the hours per shift and number of shifts for most nurses. Morale quickly improved, likely resulting in improved quality of patient care and prevention of burnout.
Mental Health Care Beyond JNYMS
Uniformed services and other federal personnel further supplemented health care operations beyond JYNMS. In April 2020, Urban Augmentation Medical Task Forces were organized and distributed throughout regions where COVID-19–related hospitalizations had significantly overwhelmed the local health care force. Urban Augmentation Medical Task Forces often included a psychiatrist, psychologist, and behavioral health technician with the mission to provide mental health support and interventions to patients and medical staff. Combat Operational Stress Control units from US Army medical brigades operated in NYC and the greater northeast region, providing mental health support and resiliency training to military personnel working in civilian hospitals, medical centers, and other health care or support environments. In addition, a LCSW and behavioral health technician worked with New York Army Reserve personnel assigned to mortuary affairs, providing point-of-care interventions at or near the worksite.
A collaborative federal, uniformed services, and state operation led to the development of the HERO-NY: Healing, Education, Resilience, and Opportunity for New York’s Frontline Workforce “Train the Trainer” Series.12 The series was intended to use uniformed services expertise to address mental health challenges related to the COVID-19 epidemic. Psychiatrists and mental health clinicians from JNYMS modeled small group trainings for future medical trainers. In lieu of traditional unidirectional lecturing, which yields limited retention and learning, the panelists demonstrated how to lead interactive small group training with resiliency topics, including goal setting, communication, anger management, and sleep hygiene.
Transition
After the last patient was discharged from JNYMS in May 2020, personnel were quickly redeployed to their duty stations. At the time of mission completion, the JNYMS behavioral health team had been supplemented with psychiatrists, social workers, behavioral health technicians, psychiatric nurse practitioners, psychiatric nurses, and psychologists representing US Public Health Service Commissioned Corps, Army, Air Force, and Navy, and provided comprehensive support to the nearly 1100 patients with COVID-19 and 600 deployed federal and state medical and support personnel.
Lessons Learned and Future Considerations
Behavioral health care provided at JNYMS offers insight into support of frontline workers in pandemic settings, as literature is limited in this area.13 TheJNYMS behavioral health team used strategies similar to military medical interventions in limited and unpredictable environments, such as rapid formalization of team structure and establishment of standard operating procedures to facilitate uniformity across interventions. Physical space was necessary to create an environment conducive to productive mental health interventions, including therapy rooms and quiet and spiritual spaces. Placing behavioral resources in high-traffic areas normalized mental health and maximized accessibility to interventions. Mental health personnel also addressed issues in the work environment, such as providing informal support and crisis interventions to frontline workers. Finally, Urban Augmentation Medical Task Forces mental health personnel and Combat Operational Stress Control units provided therapeutic interventions and resiliency training for military and civilian personnel throughout burdened medical systems beyond JNYMS.
Future operations should consider what equipment and logistic access are necessary to provide psychiatric and psychological care to mobilized federal and uniformed personnel, such as access to frontline worker electronic health records. Given that prior work has found that provision of resources alone is inadequate, frontline medical workers must be aware of where resources are available (eg, signage) and have easy access to material (eg, brochures) focusing on resiliency and psychological health.14 The spaces can be used for formal psychiatric and psychological interventions, such as assessment, therapy, and medication management. Equally important, these spaces serve as a safe place for healthy social interaction and fulfillment of basic needs (eg, nourishment) and a peaceful environment free of stimulation.
Since mental health personnel provide varied services ranging from basic human interaction to complex crisis interventions, mental health personnel should supplement pandemic medical operations. Evidence supports the notion that effective communication and cohesion throughout the entire leadership and health care team structure can improve resilience and implementation of mental health interventions.15 Incorporating mental health personnel into leadership planning meetings would allow for timely recommendations to improve medical logistics and planning of deployment of behavioral health resources. As a general rule, providing behavioral health experts with a seat at the table enhances advocacy and command awareness of the morale and mental health of frontline personnel.
Conclusions
We present the experience of developing mental health support services for deployed personnel during the COVID-19 pandemic and address the real-time mental health treatment and support of deployed uniformed services and federal personnel in the COVID-19 response environment. Timely and effective interventions included securing safe therapeutic space in high-traffic areas, developing relationships with leadership and frontline workers in their own work environments, and disseminating such services throughout the civilian medical system.
Mental health supplementation during the medical response mission strengthened morale in frontline workers in a disaster scenario. We hope that this report and others like it will provide information to improve mental health responses, reinforce mental health support, and encourage research in evidence-based interventions in challenging pandemic and disaster settings.
Acknowledgments
We would like to acknowledge and thank those serving on the frontlines of the COVID-19 pandemic.
New York City (NYC) was the early epicenter of the COVID-19 pandemic in the United States. By late March 2020, NYC hospitals were overwhelmed, leading to the development of a 452-bed field hospital that became the Javits New York Medical Station (JNYMS).1,2 More than 600 uniformed and other federal personnel, including medical personnel from US Army, Navy, and Public Health Service Commissioned Corps, mobilized to provide medical support to the JNYMS in late March 2020, leading to the treatment of more than 1000 patients with COVID-19 within a 30-day period.1
Literature from the SARS, Ebola, and HIV epidemics indicate that adverse mental health consequences, including burnout, depression, and posttraumatic stress disorder symptoms are common in frontline medical workers.3,4 Emerging data shows a similar trend occurring during the COVID-19 pandemic.5 A recent publication detailed the role of a federal force health protection program created to enhance resiliency of deployed officers during the COVID-19 pandemic, but this focused primarily on providing remote services to frontline workers.6 Another report addressed mental health interventions for health care workers in an academic health care system in NYC during COVID-19.7 However, there has been little published on real-time mental health support for deployed personnel during the pandemic.
Prior publications have described the patient flow, infection control measures, and development of a Consultation-Liaison Psychiatry Service in the JNYMS.2,8,9 Here, we detail the establishment of preventative and responsive mental health services for frontline workers at the JNYMS and explore lessons learned through the outpatient and general support experiences.
Development of Outpatient Mental Health Support Services
At the end of March 2020, the Jacob K. Javits Convention Center was repurposed into the 452-bed JNYMS field hospital, where exposition rooms were transformed into a medical unit and intensive care unit.2 While the majority of personnel providing direct clinical care were specialists, the station also was staffed with uniformed and other federal mental health clinicians, including 5 licensed clinical social workers (LCSWs), 3 psychiatrists, 1 dual-trained internal medicine–psychiatry physician, 1 psychiatric nurse, and 2 behavioral health technicians. To standardize processes early in the deployment, standard operating procedures for behavioral health support of personnel were developed and disseminated within the first few days of the deployment.
The initial mission of the behavioral health team was to establish comprehensive mental health services, as the rapidly shifting mission and unfamiliar environment increased the risk of new-onset stress responses and exacerbating pre-existing stressors in personnel. Behavioral health leadership established operations in conference rooms within the convention center, focusing on identifying, prioritizing, and staffing high-traffic areas. A resiliency center was also established adjacent to the changing room, where all staff would enter and leave the units, and to the dining facility, further increasing traffic. This center was staffed 24 hours a day by at least 1 LCSW and a behavioral health technician with 2 shifts: one from 0630 to 1830 and another from 1830 to 0630. Psychiatrists were available during the day for psychiatry intervention and evaluations, and an on-call schedule was developed for off-hours to provide time-sensitive responses.
The resiliency center was developed to provide a welcoming atmosphere to meet basic needs, including nourishment, healthy social interaction, and a calm environment. Water and food were made available free to personnel, bolstering morale for staff working 12-hour shifts in a pandemic treatment floor where personal protective equipment prevented intake of food or water. Mental health staff were also available to counsel and provide social support to personnel. If personnel wished to discuss stressors or appeared to be in distress, a mental health clinician would provide a real-time intervention or schedule an appointment with the behavioral health team. Resources were made available, including brochures and other reading materials on resilience, stress management, and other mental health topics. Uniformed services and state and federal JNYMS leadership were encouraged to visit the resiliency center to normalize interactions and encourage participation in a behavioral health environment. Signage was placed throughout JNYMS to direct personnel to behavioral health services.
The behavioral health interventions and influence spread from the resiliency center nexus. Initially, therapeutic interventions occurred where and when necessary. One psychiatrist provided crisis intervention to a bereaved soldier in the stairwell within 2 hours of arrival to the JNYMS. Leadership and the behavioral health team recognized that the need for privacy was essential for timely therapeutic interventions, leading to the development of a private individual counseling room. As the area became generally accepted as the central hub of behavioral health activity, space was provided to establish a quiet space and a meditation room. The quiet area provided a cool dark space for personnel to sit quietly in solitude; many were grateful for this reprieve after an overstimulating medical shift. The meditation room supplied sterilized yoga mats for personal mindfulness interventions. The behavioral health team also liaised with military chaplains, who established a spiritual service room near the resiliency center. The chaplains held regular religious services and were available 24 hours a day for timely spiritual interventions.
Rapid notification and movement of uniformed personnel to JNYMS resulted in limited ability for personnel to schedule medical appointments and refill medications. Psychiatrists also had limited access to relevant electronic health record systems. This led to a delay in nonurgent care to evaluate personnel records and confirm prescriptions, especially controlled medications. Local pharmacies filled prescriptions, psychiatrists placed electronic health profiles, and command teams were notified in accordance with US Army and federal regulations.
Medical Unit Support Services
Although a robust outpatient behavioral health service was laid out in the JNYMS, the behavioral health team recognized the need to provide mental health interventions within the main patient care areas as well. The intention was to maximize availability and support while minimizing interference to patient care. As previously described, a psychiatric consultation-liaison (CL) team was organized and operated 24 hours a day by early April 2020.9 Indeed, CL psychiatrists have played a valuable role in supporting the unique patient and staff needs in other COVID-19 treatment environments.10 The CL team at JNYMS observed that medical staff were exposed to multiple stressors, including fear of acquiring COVID-19, treating patients with significant medical comorbidities, practicing outside of clinical specialty, working with unfamiliar and limited equipment, and adjusting to frequently shifting changes in personnel and work schedules. Moreover, psychological stress was compounded by long shifts, jetlag, and continuous wear of extensive personal protective equipment, as has been documented in other COVID-19 treatment centers.11
The team of psychiatrists conducted informal rounds to nursing stations to evaluate the morale and develop relationships with the medical team, including nurses, physicians, medics, and other personnel. Areas of high stress and increased interpersonal conflict were identified for more frequent check-ins by mental health clinicians. The psychiatrists and LCSWs were available for informal walk-in therapy when requested by personnel. When the acuity increased, personnel could be accompanied to the individual counseling room for rapid therapeutic interventions. The CL psychiatrists developed professional relationships with the command and medical leadership teams. Through these relationships and sensitive awareness of morale in the medical work environment, psychiatrists were able to advocate for alterations in the nursing work schedule. Leadership was receptive and resultant changes decreased the hours per shift and number of shifts for most nurses. Morale quickly improved, likely resulting in improved quality of patient care and prevention of burnout.
Mental Health Care Beyond JNYMS
Uniformed services and other federal personnel further supplemented health care operations beyond JYNMS. In April 2020, Urban Augmentation Medical Task Forces were organized and distributed throughout regions where COVID-19–related hospitalizations had significantly overwhelmed the local health care force. Urban Augmentation Medical Task Forces often included a psychiatrist, psychologist, and behavioral health technician with the mission to provide mental health support and interventions to patients and medical staff. Combat Operational Stress Control units from US Army medical brigades operated in NYC and the greater northeast region, providing mental health support and resiliency training to military personnel working in civilian hospitals, medical centers, and other health care or support environments. In addition, a LCSW and behavioral health technician worked with New York Army Reserve personnel assigned to mortuary affairs, providing point-of-care interventions at or near the worksite.
A collaborative federal, uniformed services, and state operation led to the development of the HERO-NY: Healing, Education, Resilience, and Opportunity for New York’s Frontline Workforce “Train the Trainer” Series.12 The series was intended to use uniformed services expertise to address mental health challenges related to the COVID-19 epidemic. Psychiatrists and mental health clinicians from JNYMS modeled small group trainings for future medical trainers. In lieu of traditional unidirectional lecturing, which yields limited retention and learning, the panelists demonstrated how to lead interactive small group training with resiliency topics, including goal setting, communication, anger management, and sleep hygiene.
Transition
After the last patient was discharged from JNYMS in May 2020, personnel were quickly redeployed to their duty stations. At the time of mission completion, the JNYMS behavioral health team had been supplemented with psychiatrists, social workers, behavioral health technicians, psychiatric nurse practitioners, psychiatric nurses, and psychologists representing US Public Health Service Commissioned Corps, Army, Air Force, and Navy, and provided comprehensive support to the nearly 1100 patients with COVID-19 and 600 deployed federal and state medical and support personnel.
Lessons Learned and Future Considerations
Behavioral health care provided at JNYMS offers insight into support of frontline workers in pandemic settings, as literature is limited in this area.13 TheJNYMS behavioral health team used strategies similar to military medical interventions in limited and unpredictable environments, such as rapid formalization of team structure and establishment of standard operating procedures to facilitate uniformity across interventions. Physical space was necessary to create an environment conducive to productive mental health interventions, including therapy rooms and quiet and spiritual spaces. Placing behavioral resources in high-traffic areas normalized mental health and maximized accessibility to interventions. Mental health personnel also addressed issues in the work environment, such as providing informal support and crisis interventions to frontline workers. Finally, Urban Augmentation Medical Task Forces mental health personnel and Combat Operational Stress Control units provided therapeutic interventions and resiliency training for military and civilian personnel throughout burdened medical systems beyond JNYMS.
Future operations should consider what equipment and logistic access are necessary to provide psychiatric and psychological care to mobilized federal and uniformed personnel, such as access to frontline worker electronic health records. Given that prior work has found that provision of resources alone is inadequate, frontline medical workers must be aware of where resources are available (eg, signage) and have easy access to material (eg, brochures) focusing on resiliency and psychological health.14 The spaces can be used for formal psychiatric and psychological interventions, such as assessment, therapy, and medication management. Equally important, these spaces serve as a safe place for healthy social interaction and fulfillment of basic needs (eg, nourishment) and a peaceful environment free of stimulation.
Since mental health personnel provide varied services ranging from basic human interaction to complex crisis interventions, mental health personnel should supplement pandemic medical operations. Evidence supports the notion that effective communication and cohesion throughout the entire leadership and health care team structure can improve resilience and implementation of mental health interventions.15 Incorporating mental health personnel into leadership planning meetings would allow for timely recommendations to improve medical logistics and planning of deployment of behavioral health resources. As a general rule, providing behavioral health experts with a seat at the table enhances advocacy and command awareness of the morale and mental health of frontline personnel.
Conclusions
We present the experience of developing mental health support services for deployed personnel during the COVID-19 pandemic and address the real-time mental health treatment and support of deployed uniformed services and federal personnel in the COVID-19 response environment. Timely and effective interventions included securing safe therapeutic space in high-traffic areas, developing relationships with leadership and frontline workers in their own work environments, and disseminating such services throughout the civilian medical system.
Mental health supplementation during the medical response mission strengthened morale in frontline workers in a disaster scenario. We hope that this report and others like it will provide information to improve mental health responses, reinforce mental health support, and encourage research in evidence-based interventions in challenging pandemic and disaster settings.
Acknowledgments
We would like to acknowledge and thank those serving on the frontlines of the COVID-19 pandemic.
1. CDC COVID-19 Response Team. Geographic differences in COVID-19 cases, deaths, and incidence - United States, February 12-April 7, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):465-471. Published 2020 Apr 17. doi:10.15585/mmwr.mm6915e4
2. Brady K, Milzman D, Walton E, Sommer D, Neustadtl A, Napoli A. Uniformed services and the field hospital experience during Coronovirus Disease 2019 (SARS-CoV-2) pandemic: open to closure in 30 days with 1,100 patients: the Javits New York Medical Station [published online ahead of print, 2021 Feb 13]. Mil Med. 2021;usab003. doi:10.1093/milmed/usab003
3. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of Ebola, Zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9(4):151-156. doi:10.4103/jgid.jgid_66_17
4. Wu P, Fang Y, Guan Z, et al. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry. 2009;54(5):302-311. doi:10.1177/070674370905400504
5. Panchal N, Kamal R, Cox C, Garfield R. The implications of COVID-19 for mental health and substance use. Published February 10, 2021. Accessed April 7, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
6. Myles IA, Johnson DR, Pham H, et al. USPHS Corps Care: force health protection for public health officers during the Ebola and COVID-19 responses. Public Health Rep. 2021;136(2):148-153. doi:10.1177/0033354920984775
7. Ripp J, Peccoralo L, Charney D. Attending to the emotional well-being of the health care workforce in a New York City health system during the COVID-19 pandemic. Acad Med. 2020;95(8):1136-1139. doi:10.1097/ACM.0000000000003414
8. Clifton GT, Pati R, Krammer F, et al. SARS-CoV-2 infection risk among active duty military members deployed to a field hospital - New York City, April 2020. MMWR Morb Mortal Wkly Rep. 2021;70(9):308-311. Published 2021 Mar 5. doi:10.15585/mmwr.mm7009a3
9. Kaplan A, Smith CM, Toukolehto O, van Schalkwyk G. Psychiatric care in a novel federal COVID-19 treatment center: development of a consultation-liaison psychiatry service at the Javits New York Medical Station. Mil Med. 2021;186(5-6):129-131. doi:10.1093/milmed/usaa557
10. Shalev D, Shapiro PA. Epidemic psychiatry: The opportunities and challenges of COVID-19. Gen Hosp Psychiatry. 2020;64:68-71. doi:10.1016/j.genhosppsych.2020.03.009
11. Horn M, Granon B, Vaiva G, Fovet T, Amad A. Role and importance of consultation-liaison psychiatry during the Covid-19 epidemic [published online ahead of print, 2020 Aug 5]. J Psychosom Res. 2020;137:110214. doi:10.1016/j.jpsychores.2020.110214
12. Wei EK, Segall J, Linn-Walton R, et al. Combat stress management and resilience: adapting department of defense combat lessons learned to civilian healthcare during the COVID-19 pandemic [published online ahead of print, 2020 Jul 17]. Health Secur. 2020;10.1089/hs.2020.0091. doi:10.1089/hs.2020.0091
13. Pollock A, Campbell P, Cheyne J, et al. Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Cochrane Database Syst Rev. 2020;11(11):CD013779. Published 2020 Nov 5. doi:10.1002/14651858.CD013779
14. Schreiber M, Cates DS, Formanski S, King M. Maximizing the Resilience of Healthcare Workers in Multi-hazard Events: Lessons from the 2014-2015 Ebola Response in Africa. Mil Med. 2019;184(suppl 1):114-120. doi:10.1093/milmed/usy400
15. Klomp RW, Jones L, Watanabe E, Thompson WW. CDC’s multiple approaches to safeguard the health, safety, and resilience of Ebola responders. Prehosp Disaster Med. 2020;35(1):69-75. doi:10.1017/S1049023X19005144
1. CDC COVID-19 Response Team. Geographic differences in COVID-19 cases, deaths, and incidence - United States, February 12-April 7, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(15):465-471. Published 2020 Apr 17. doi:10.15585/mmwr.mm6915e4
2. Brady K, Milzman D, Walton E, Sommer D, Neustadtl A, Napoli A. Uniformed services and the field hospital experience during Coronovirus Disease 2019 (SARS-CoV-2) pandemic: open to closure in 30 days with 1,100 patients: the Javits New York Medical Station [published online ahead of print, 2021 Feb 13]. Mil Med. 2021;usab003. doi:10.1093/milmed/usab003
3. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of Ebola, Zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9(4):151-156. doi:10.4103/jgid.jgid_66_17
4. Wu P, Fang Y, Guan Z, et al. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry. 2009;54(5):302-311. doi:10.1177/070674370905400504
5. Panchal N, Kamal R, Cox C, Garfield R. The implications of COVID-19 for mental health and substance use. Published February 10, 2021. Accessed April 7, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
6. Myles IA, Johnson DR, Pham H, et al. USPHS Corps Care: force health protection for public health officers during the Ebola and COVID-19 responses. Public Health Rep. 2021;136(2):148-153. doi:10.1177/0033354920984775
7. Ripp J, Peccoralo L, Charney D. Attending to the emotional well-being of the health care workforce in a New York City health system during the COVID-19 pandemic. Acad Med. 2020;95(8):1136-1139. doi:10.1097/ACM.0000000000003414
8. Clifton GT, Pati R, Krammer F, et al. SARS-CoV-2 infection risk among active duty military members deployed to a field hospital - New York City, April 2020. MMWR Morb Mortal Wkly Rep. 2021;70(9):308-311. Published 2021 Mar 5. doi:10.15585/mmwr.mm7009a3
9. Kaplan A, Smith CM, Toukolehto O, van Schalkwyk G. Psychiatric care in a novel federal COVID-19 treatment center: development of a consultation-liaison psychiatry service at the Javits New York Medical Station. Mil Med. 2021;186(5-6):129-131. doi:10.1093/milmed/usaa557
10. Shalev D, Shapiro PA. Epidemic psychiatry: The opportunities and challenges of COVID-19. Gen Hosp Psychiatry. 2020;64:68-71. doi:10.1016/j.genhosppsych.2020.03.009
11. Horn M, Granon B, Vaiva G, Fovet T, Amad A. Role and importance of consultation-liaison psychiatry during the Covid-19 epidemic [published online ahead of print, 2020 Aug 5]. J Psychosom Res. 2020;137:110214. doi:10.1016/j.jpsychores.2020.110214
12. Wei EK, Segall J, Linn-Walton R, et al. Combat stress management and resilience: adapting department of defense combat lessons learned to civilian healthcare during the COVID-19 pandemic [published online ahead of print, 2020 Jul 17]. Health Secur. 2020;10.1089/hs.2020.0091. doi:10.1089/hs.2020.0091
13. Pollock A, Campbell P, Cheyne J, et al. Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Cochrane Database Syst Rev. 2020;11(11):CD013779. Published 2020 Nov 5. doi:10.1002/14651858.CD013779
14. Schreiber M, Cates DS, Formanski S, King M. Maximizing the Resilience of Healthcare Workers in Multi-hazard Events: Lessons from the 2014-2015 Ebola Response in Africa. Mil Med. 2019;184(suppl 1):114-120. doi:10.1093/milmed/usy400
15. Klomp RW, Jones L, Watanabe E, Thompson WW. CDC’s multiple approaches to safeguard the health, safety, and resilience of Ebola responders. Prehosp Disaster Med. 2020;35(1):69-75. doi:10.1017/S1049023X19005144