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“What do you mean there’s no way to get me my medication?”
A young college student looked at me across the Zoom video psychiatry appointment, visibly angry, and a little saddened.
“There’s a shortage of ADHD drugs, and I’m not even sure when it will end.” I let out an audible sigh, “It’s frustrating, I know.”
“So, then, what do we do?” The patient looks right at me, hoping that I can somehow help him navigate around the barrier. But I can’t.
“There are a few, all pretty not-great, options,” I told him. “You can call a bunch of pharmacies and then tell me which place has it in stock and in what doses. I can then send in prescriptions for what you need. You can also wait until wherever you usually pick it up gets medications back in stock, but I know you need it to function, especially in school, so waiting might be out of the question. Or, we can also talk about switching medications temporarily.”
Switching is far from a simple change or even a helpful one. This patient, like many of those I see, had to try several medications before finding an affordable one that works for him without too many side effects (like insomnia, lack of appetite, and additional anxiety). Even if he decides to give switching a try, there’s no guarantee that the new drug will even be in stock. The shortage has begun to trickle into other medications, moving from Adderall to Ritalin and Concerta, and his new one could be next.
Listening to my series of unhelpful options, my patient looks defeated. I feel responsible for it. “I’m so sorry,” I say, for the fourth or fifth time today alone.
I didn’t have a word for what I was experiencing until the pandemic brought it out into my lexicon: moral injury. Before I went into this field, no one told me that the helplessness that comes with working in mental health is actually constant moral injury.
The term itself originated in the context of the military and war in order to capture an experience of veterans that is distinct from PTSD. At its most basic definition, moral injury occurs when people are exposed to stressful circumstances and either perpetuate, fail to prevent, or witness events that contradict their own values and moral beliefs. The injury part is the distress we feel afterward in any or all areas of our life—psychologically, behaviorally, socially, and spiritually.
In the military, triggering events include times when officers have to make decisions that affect the survival of others, or others where someone failed to perform a duty during a traumatic event. During the early pandemic, we discussed moral injury in health care in reference to resource allocation challenges like masks or ventilators, or seeing far more than the (already difficult) expected amount of suffering and death. Most recently, we have discussed it as a likely outcome of the Dobbs ruling for OB-GYNs. Though few researchers have looked at the prevalence of moral injury in health care, in a study comparing military veterans deployed to combat after 9/11 and health care workers during the pandemic, the overall prevalence rates of potential moral injury were similar.
There was one difference, however: The health care workers reported higher rates of moral injury from others rather than themselves. This means that they were more likely to agree with statements like “I am troubled by having witnessed others’ immoral acts” than “I am troubled by having acted in ways that violated my own morals and values.” An example might be knowing patients should have family members present when they are dying in the hospital, but not being able to because of COVID-related hospital restrictions. This policy may run counter to their individual beliefs of how someone should die, but they feel powerless to change it. The difference between others and self may be related to the idea that health care workers work in a broken system, and may feel more betrayed by others because of it: society, government, or hospital leaders, for example.
As an outpatient psychiatrist, I’m always apologizing for something outside of my control. If it isn’t an ADHD medication shortage, it’s insurance denying other necessary prescriptions. Or a patient being unable to find a therapist. They may change jobs (or, worse, get fired), and the insurance changes or new costs mean they can’t see me anymore. As a result, they now have to find a new psychiatrist in the middle of a pandemic and amid a compounded shortage of mental health providers. Chronically sick to my stomach and injured, I wish them luck.
It isn’t just outpatient, though. When I was in residency we were warned that our first two years, made up of primarily inpatient psychiatry, would be even worse, and they were right. We had patients who kept coming back to the hospital because we didn’t have social support to get them to appointments or to help them afford their medications. There were also the patients waiting days, even weeks, in the emergency room, just to get into the inpatient unit, because we didn’t have enough beds to help all of the people who needed it. I remember being told by my attendings that I just needed to get to my third year of training, where I’d be mostly outpatient, to see that people do get better. That part is true: It’s one of the bright spots of my job and the reason I chose it. But they forgot to tell us that even if individuals improve, the system doesn’t.
It may help to think about moral injury in medicine as the difference between telling someone “We did all we could” and “We did all we could in a broken system without all the necessary resources.” We are all unwilling representatives of the system. I get yelled at or cried to regularly, and as an empath, I absorb it all. I know at the core, my patients’ reactions in my visits aren’t about me, but that doesn’t make it hurt any less. Sometimes apologizing is all I can do, to feel like I’m doing something. Or maybe it’s my way of reminding them that I’m still a good person, trying to be a good doctor.
My reaction, though, is a typical one. Moral injury often leads us to blame ourselves and feel guilty, to feel angry or disgusted, and even ashamed. These negative thoughts about ourselves and others do not immediately mean we have mental health outcomes, but we might start to notice stress reactions like changes in our sleep, overworking, turning to alcohol to cope, and social isolation. While moral injury itself is not a mental health diagnosis, it is a risk factor for developing depression, PTSD, suicidal thoughts, and burnout. As physicians, our rates of depression and burnout are already higher than in other similar groups, and this is just another cause compounding it. In fact, in one study of health care workers over COVID, higher moral injury scores were related to worsened severity of symptoms, including suicidal thoughts.
Beyond the risk to the mental health of the individual health care worker, there is a potential for moral injury to cause people to leave the field entirely. Losing employees will only strain a system with limited access to begin with, particularly for mental health professionals. In fact, according to the Health Resources and Services Administration, by 2030 the demand for psychiatrists will increase by 6 percent, outpacing the supply and leading to a shortage of nearly 18,000 psychiatrists. This number doesn’t even take into account the unmet need due to barriers to receiving mental health care, or the rise in mental health concerns over COVID-19 that have compounded the strain and demand on mental health professionals. Access is already a problem, but when the existing workforce leaves due to moral injury, patients left without care are ultimately the ones who will suffer.
Naming what I’ve been experiencing as moral injury is helpful and is actually a first step in coping. In these moments, many of us—including the bulk of my health care–worker patients and me—are quick to talk down to ourselves and self-blame. It is important instead that we pause, acknowledge our feelings and suffering, and practice self-compassion. To do this, we need to learn to replace our negative thoughts with the ways we talk to someone else we care about—a friend, family member, or even the younger version of ourselves. Our jobs are hard enough without us adding to them by tearing ourselves down.
At the same time, one of the few solutions available to us as individuals is sharing our experiences with moral injury. Medicine is not a field of vulnerability, and as a result, we often feel alone in our experiences and feelings. True self-care for moral injury includes making choices with the help or advice of others, when possible, and looking for support in the conversations that cause distress (or afterwards). Together, in either structured ways or informally after troubling events occur, we can process our experiences and hear different ways to think about or make meaning from what we witnessed. We don’t need to suffer in silence.
Even writing all of this out has helped me.
State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.