a. Identification of specific risks for mental health for healthcare workers in the beginning of the first wave ofthe COVID-19 pandemic
Prior to implementing a consultation service(CovidPsy) for HCW, we attempted to identify potential mental health risks to design our consultation methodology and adapt the terms of care that could be offered. We identified these using data from previous respiratory pandemicsof Severe Acute Respiratory Syndrome (SARS) in 2002-2003 and Middle East Respiratory Syndrome (MERS) in 2012,information from foreign media outlets, such as those in China where the pandemic began, adapting it to our own needshaving only limited experience with the virus in our own university hospital before implementing the CovidPsy consultation. We distinguished two main categories of stress factors: a) work-related stress during COVID-19 outbreak; b) direct stress consequences of COVID-19.
i. Work-related stress during the COVID-19 outbreak
Risk of loss of control
Faced with an uncontrollableviral outbreak and its treatment, HCW might have felt powerless to help their patients. For example, as the influx of patients increased, urgent improvised decisions had to be made to spare care resources, which at the time were almost entirely dedicated to managing COVID-19, and specifically implementing algorithms to prioritize care. As a result, the clinical activity of HCW was brutally and rapidly transformed, shaking the very basis of their professional identity. For many, time stood still from the start of this first wave of the health crisis. Unpredictability contaminated all aspects of the HCW's daily life, and especially when exposed to certain COVID-19 patients who experienced rapid deterioration.
Risk of work intensity
In our university hospital, HCW were "requisitioned", meaning that their vacation was suspended for an indefinite period of time, and were given in rare instances, time to decompress. Faced with difficulties anticipating healthcare resource needs during this unprecedented crisis, as well as absenteeism linked to staff contamination by SARS-CoV-2, HCW had to change medical units accordingly, regularly modifying their schedule, thus creating very unstable and intense working conditions.
Risk of loss of sense
In light of the pandemic, non-COVID clinical activities had to be abruptly suspended, giving the impression of patient abandonment. The question of patient triage arose, on the grounds of efficiency: COVID patients who needed to be given priority in intensive care units were those for whom an improvement in prognosis was considered more likely. Therefore, this management priority for COVID-19, to the detriment of other healthcare activities and their consequences . In some instances, these situationsled to value conflictsand a profound loss of sense in many HCW who risked to no longer feel useful in the exercise of their profession.
Risk of burnout
Finally, during the first wave of the COVID-19 outbreak, concomitant losses of control and sense, as well as workload, increased, which are recognized as important factors of burnout as described by Maslach . HCW are known to be exposed at higher risk of burnout and their complications  and some work factors such as lack of input or control for physicians, excessive workloads, inefficient work processes, clerical burdens have been identified for physicians .For these reasons, we considered it was important to investigate burnout and treat it in the context of this psychiatric consultation for HCW.
ii. Direct stress consequences of COVID-19
An unpredictable virus
In the course of their work, HCW were exposed to potential contamination by SARS-CoV-2 and subsequent increased risk of transmission to loved ones. The contradictory information surrounding the subject contributed to the caregivers’ insecurity, as it was objectively impossible to guarantee protection, due to a lack of knowledge on the transmission modes of the virus.
Specifically, HCW could find themselves faced with unpredictable, sudden, and numerous deaths, quantities they were not accustomed to, including those in intensive care units,even if they had previous experience with critical situations. In their personal lives, like the rest of the general population, many HCW were alsoimpacted due to the illness and deaths of those closest to them.
A risk of social isolation outside of work
The confluence for manyHCW of significant stress, the prioritization of professional duties above all others,and the restriction of social contacts and leisure time outside the hospital,has contributed to increasesin the risk for psychological distress such as anxiety, depression and traumatic experience during this period. Furthermore, holidays for hospital staff were abolished in most countries. In some cases, HCW were beginning to report situations of very painful rejection from their relatives for fear of contamination.
A risk of stress related disorders and psychotraumatic sequelae
Faced with a highly stressful situation, the subject's coping skills may be overwhelmed and give rise to reactive depressive or anxious symptoms. Depending on the level of personal resources available to mobilize coping strategies, and confronted with the same situation, some workers will develop anxious and / or depressive symptoms, whereas others may be able to adapt. Interindividual variability in reactions to a very stressful and unprecedented situation such as the COVID-19 pandemic was expected.
This COVID-19 context created situations of potential or actual death of patients,which meet the definition of traumatic events, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) .Subjects who had a history of trauma, either related or not to their professional activity, and/or a psychiatric history of depression, had a greater vulnerability for the risk of acute stress disorder (ASD) or post-traumatic stress disorder(PTSD) .Importantly, PTSD risk factors have been well studied during previous Coronavirus epidemics . On the basis of past experiences and the identification of risk factors directly due to the COVID-19, a risk of PTSD in HCW seemed to be important and warranted further investigation. PTSD is associated with a poor prognosis and an important risk of comorbidities such as substance and alcohol abuse. Prevention strategies are known to reduce the risk of chronic evolution to PTSD, such as an early identification and care for people at risk for PTSD even if the effectiveness of some interventions like cognitive-behavioral therapies (CBT), Eyes Movement Desensitization Reprocessing (EMDR), and pharmacological strategies,requires further study .
An opportunity of resilience and post-traumatic growth
Important emphasis is placed on the potential psychiatric complications of this health crisis. However, in traumatic situations, psychological benefits grouped under the emerging notion of post-traumatic growth, can on the contrary develop in the aftermath of a traumatic event. Authors of a qualitative review on disaster-exposed organizations identified several protective factors after a disaster: training, experience, and perceived (personal) competence; social support; and effective coping strategies. Post-traumatic growth can provide a greater appreciation of life andrelationships, enhancing self-esteem and providing a sense of accomplishment and better understanding of an individual’s work. The exploration of these protective factors appeared as important of the risk factors for PTSD in time of COVID-19.
b. Implementation of the CovidPsy psychiatric consultation
i. Establishment of the permanence CovidPsy
Recommendations for setting up support systems for caregivers were quickly disseminated by World Health Organization at the start of the crisis based on previous epidemics, highlighting the need to organize system for the prevention and the management of the mental suffering of the HCW.Within a few days in our hospital, the CovidPsy psychiatric consultation service was not only established, but a hotline, support psychologist positions in the COVID units, and hypnosis sessions were deployed. Material aids were offered such as parking spaces, accommodation in hotels for people who lived far away, and free meals.
The service of liaison psychiatry, the staff health service and Health Care Directorate, receivedan official mandate the 16h of March, 2020 from the medical director of university Hospital of Geneva and three days later, the 19th of March, a psychiatricconsultation was offered to the hospital workers. The liaison psychiatry team usually works with hospitalized or outpatient patients for somatic pathologies and is not supposed to take care of the mental health of employees. However, in the psychiatry liaison chart, we are very aware of the importance of being attentive to the psychiatric impact of some clinical situations on their mental health and its potential impact on their work, and we have found that this demand made sense for us in the heart of this crisis. After the first step, when we received an official mandate, we made a request to two consultation offices. We implemented a 7 day a week, 9 AM to 6 PM consultation service, to receive any HCWrequesting help,free of charge and without an appointment. Furthermore, HCW were able toreach the hotline for an initialscreening and could then be referred directly to the consultation office. We chose a name and conceived of a framework for the consultation. We werereinforced by medical staff from our other psychiatric services within the department, in addition toprivate psychiatrists,and benefited from our close collaboration with clinical nursing specialists. A common network spacewas set up to exchange informationand share our calendars, as a way of referral for each consultation. Wecontacted the hospital communication service to widely disseminatethe information on the modalities of this service to hospital collaborators,regarding the opening of psychiatric consultation.Once per week, acoordination meeting was helf with the people in charge of the support systems (psychiatric consultation, hotline, psychologists support). Moreover, several training sessions were provided to the team, recalling important theoretical-clinical basis for colleagues who were less familiar with this clinical field and to transmit guidelines for the permanence, from the reception of the healthcare worker to the end of the care. We additionally provided sessions on advice for preventing exhaustion and vicarious trauma for the psychiatric consultation team who were exposed to heavy emotional burden arising fromcaring for their colleagues as well as to the global effect of the pandemic. Daily intervision sessions were organized to analyze and discuss the clinical situations and their care.
The psychiatric consultation team was composed of hospital and private psychiatrists- psychotherapists, and clinical specialist nursesin psychiatry,whose usual clinical activity was reduced, thanks to the solidarity of other psychiatric services and the Health Care Directorate.The final team for the psychiatric consultation was composed of 9 psychiatrists- psychotherapists and 8 clinical specialist nurses in psychiatry to ensure the presence of at least one psychiatrist-psychotherapist and nurse at all times during opening hours.The psychiatric intervention policies (guidelines for the intervention, organization of the permanence, and establishment of the duty schedule) were defined. Our crisis intervention and algorithm modelswere inspired by disaster psychiatry . They consisted of a preventive model based on the identification of traumatic stressors and high-risk subjects of psychological suffering.
Based on data and the knowledge from previous epidemics of mental health is impacted in hospital workers, we identified the following risks: 1) Burnout; 2) Trauma disorders (acute stress disorder trauma, vicarious trauma, post-trauma stress disorder); 4) Anxiety and depression symptoms. We proposed a systematic screening of these risks at the beginning of the consultation using the French version of The Pocket Guide to the DSM-5 TMDiagnostic Exam whose licence has been obtained for each survey  and completed the evaluation with some questions on psychiatric history, their family and social circles, and working conditions. Depending on this evaluation, this was followed by a personalized therapeutic interventionusing specific guidelines.Consultations were carried out by a psychiatrist-psychotherapists and a clinical specialist nurse in psychiatry to encourage complementary interventions and to partition emotional burden in a face-to-face. If acute stress symptoms were identified, recommended interventions after a traumatic event such as defusing intervention, psychoeducation intervention on PTSD and/orEyes Movement Desensitization Reprocessing (EMDR) for recent trauma were provided. If burnout symptoms were identified, we gave feedback about these symptoms to the hospital workers directly and suggested asick leave. In front of anxiety symptoms and/or acute stress symptoms, we used stress management tools like safe place, cardiac coherence and basic mindfulness. For all the clinical situations, analyses of stress factors were conducted with the person who consulted and a search of strategies to cope with them was undertaken. Personal resources were sought and reinforced as much as possible. Medications could be also be prescribed depending on the psychiatric evaluation. We proposed short interventions which should not exceed three consultations with a few exceptions. We organized a referral for another follow-up if required because the HCW was not clinically sufficiently improved (private psychiatrist-psychotherapistor psychologist-psychotherapistor consultation center depending on the hospital).
c. Systematic data collection
We collected personal data (data birth, phone number, marital status, phone number, mail), information on working conditions (position held, department, work in COVID yard, change of service due to COVID-19 outbreak, ...), medical and psychiatric history and previous trauma, risk factors for severe forms of COVID-19, contamination by SARS-CoV-2.
We chose to use a systematic screening with scales to look for these risks before each consultation to adapt the intervention to the needs of the worker. HCWcompleted different validated tools in their French versions to look for main psychiatric situations that were expected, before the intervention (methods previously described): 1) Maslach Burnout Inventory-Human Services Survey (MBI-HSS) consisted in three dimensions: Emotional Exhaustion (EE), Depersonalization (DP) and Personal Achievement (PA). The cutoff points of the MBI-HSS were ≤ 21 and ≤ 32 for the EE subscale, ≤ 23 and ≤ 30 for the reduced (PA) subscale, ≤ 6 and ≤ 12 for the (DP) subscale, and ≤ 15 and ≤ 17 (i.e., low, moderate, and high level) . The level of burnout was considered high if EE was ≥ 27, PA was ≤ 21, and DP was ≥ 13; moderate if EE was 17-26, PA was 38-22, and DP was 7-12; and low if EE was ≤ 16, PA was ≥ 39, and DP was ≤ 6; 2) Hospital Anxiety and Depression Scale (HADS) which assesses transdiagnostic symptoms of anxiety and depression in patients with a somatic disorder, using a cutoff total score of 11 for anxiety and for depression. 3) Peritraumatic distress inventory (PDI)which screens for distress symptoms during and immediately following a traumatic event,using a cutoff at 15 to identify a high risk of future PTSD ; 4)Peritraumatic Dissociative Experiences Questionnaire (PDEQ) which screens for dissociative symptoms such as depersonalization and derealization during and immediately following a traumatic event,using a cutoff at 15 to identify a high risk of future PTSD ; 5) Posttraumatic Stress disorder Checklist for DSM-5 (PCL-5) which assesses current symptoms of PTSD, using a cutoff score of 33 to identify a PTSD diagnosis which was giveninstead of PDI and PDEQ only in the case of PTSD diagnosis made in the presence of PTSD criteria present more than one month, , to assessPTSD severity .
All HCW (clinical and non-clinical HCW) of our university hospital were able to ask for a consultation at the permanence without an appointment, and not only employees who were in charge of COVID-19 patients.
i. Quantitative analysis
Descriptive statistical analyses were made using Excel® and an R®software package provided by the R Foundation for Statistical Computing. Qualitative variables were expressed as frequencies and percentages. Quantitative variables were expressed as means with minimum and maximum values. Missing data were taken into account for these descriptive analyses and indicated in the corresponding tables (see “n”).
i. Qualitative analysis
We also performed a qualitative analysis of the47 written interview notes of HCW that consented to participate in the study: we systematically analyzed the interviews and looked for frequent themes of difficulties expressed by workers. Using content analysis methodology, a coder reviewed all interviews scripts for recurrent themeswhich they then categorized and sub-categorized, while comparing emerging categories to each other to determine their substance and significance . A recurrent theme was defined as a theme occurring more than two times in the interviews of two different HCWs.