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The coronavirus pandemic hit New York City emergency physician Lorna Breen, MD, with extraordinary ferocity. She became infected and ill herself, then returned to find her hospital overwhelmed with the sick and dying. Within days, she suffered a mental crisis that she feared would endanger her medical license and her career.

On Monday, the six-month anniversary of Breen's death by suicide, her sister urged emergency physicians to take heed of a new survey that suggests many in their field are struggling -- and dreading the loss of their jobs if they seek help.

"My sister rose to meet the challenges of COVID-19. And we believe that this ultimately cost her her life," said Virginia attorney Jennifer Breen Feist in a presentation at the virtual annual meeting of the American College of Emergency Physicians. "She was so concerned about the stigma of seeking help, so concerned about how she would be perceived by her peers. We believe ultimately it was her downfall."

More than half of 862 emergency physicians surveyed said they're very concerned (24%) or somewhat concerned (33%) about losing their jobs if they seek mental-health treatment, according to a . Forty-five percent said they aren't comfortable seeking mental-health treatment if needed: 30% reported being "not too comfortable," and 15% said they're "not comfortable at all."

The survey was conducted online Oct. 7-20 among a representative sample of emergency physicians. ACEP didn't disclose how the participants were chosen. Results for the entire group of subjects have a margin of error of plus or minus 3 percentage points.

" that the United States alone, about 6,000 emergency physicians contemplated suicide in 2018 alone, and nearly 400 attempted to take their own life. Working in the front lines over the past 6 months dealing with COVID really increased the crisis," said Mark Rosenberg, DO, MBA, president-elect of ACEP and an emergency physician with St. Joseph's Health in New Jersey. "This was not business as usual. Despite the growing toll that serving on the frontlines is having on emergency physicians, many emergency physicians feel they can't seek the mental-health treatment that they need."

Eighty-seven percent of emergency physicians surveyed said they've experienced more stress during the pandemic (just 2% said less or much less) and 72% reported more burnout (5% said less or much less.)

When asked about factors contributing to their stress/burnout, 83% -- the highest percentage – reported fear about family and friends becoming infected. Eighty percent reported fears about their own personal health and safety in regard to the virus, and 65% said they worried about their job/financial security.

Men and rural physicians were the most uncomfortable about seeking mental health care. And overall, survey participants said that if they sought treatment, they'd expect the most stigma at work (73% said there would be "a lot" or "some") and among their colleagues (71% expected "a lot" or "some"). Just 5% in both groups said they expected no stigma. In contrast, only 24% said they'd expect a lot or some stigma at home, and 35% expected those levels of stigma from family.

Several groups were more likely to say they'd avoided seeking mental-health treatment due to fear of professional repercussions: women (33% vs 23% of men), physicians under 45 (31% vs 22% of those 45 and older), and rural (30% vs 26% in suburban areas and 28% in urban areas).

"I do not want to get diagnosed with a mental health condition. Then have to report it on job applications or medical licensing applications/renewals. I am afraid I would potentially lose my job, future job opportunities, license, and eligibility for disability insurance," one respondent said. Another, also citing the reporting requirement, said: "I don't want to be perceived as unfit for duty."

Breen feared her treatment would spell the end of her career, said Jennifer Feist's husband Corey Feist, also an attorney. "Lorna was convinced that her license would be acted on in New York by us finding an inpatient psych stay for her at the University of Virginia. She was not correct about that. New York actually has very favorable state licensing laws. I can't speak to the privileging or credentialing issues. But specific to the licensing law, it is a favorable state. So that leads me to believe that there's a large education opportunity here that we need to make sure that the healthcare workforce knows their local state laws, what the current [status] is." (A compares state medical board initial licensing policies regarding mental health treatment. The report listed New York as one of 9 states with no questions regarding mental health.)

Breen's suicide made national news, with the the role of "an insidious stigma about mental health [that] persisted within the medical community."

"Lorna kept saying, 'I think everybody knows I'm struggling,'" Jennifer Feist told the newspaper. "She was so embarrassed."

As the Times reported, Breen, 49, expressed suicidal thoughts after returning to work as the medical director of the emergency department at Manhattan's NewYork-Presbyterian Allen Hospital in early April. She spent about 11 days in an inpatient psychiatric ward in Virginia, where her sister lives. After her release, the Times said, she kept repeating herself to a friend: "I couldn't help anyone. I couldn't do anything. I just wanted to help people, and I couldn't do anything." On April 26, Breen died.

The Feists have created the Dr. Lorna Breen Heroes Foundation in her memory. The foundation works to build awareness about the stigma of mental-health treatment in the health care world and fund research/programs to reduce burnout and improve well-being.

"We simply need to give [emergency physicians] the reassurance as well as the support that they need to take care of themselves, first and foremost, before they take care of patients," said Corey Feist in the presentation at the ACEP meeting.

ACEP, the American Medical Association, the American Psychiatric Association, and other medical societies are supporting the , which has bipartisan support in Congress. The legislation establishes grants and other support to prevent suicide and burnout among students, residents, and professionals in the healthcare industry.

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