A Review of Mental Health Responses to Pandemics
We are globally facing a pandemic due to COVID-19. Prior research has shown that the effects of pandemics and epidemics can result in a plethora of psychological effects. This review article will summarize some of the findings and provide insights to possible future directions. Given that number of infections in the U.S. has skyrocketed in comparison to other countries, it is imperative that we understand the existing evidence to guide the administration of effective interventions to patients and healthcare professionals.
The coronavirus disease 2019 (COVID-19) outbreak was declared a public health emergency by the World Health Organization (WHO) on 30 January 2020. All 34 regions of China had cases of infection at the time of declaration. The total case count had risen to greater than severe acute respiratory syndrome (SARS) of 2003. The origin of the pandemic is believed to be derived from a seafood wholesale market in the city of Wuhan of Hubei Province in late December 2019. The number of cases increased exponentially, eventually spreading widely across the world .
Effects on Mental Health
Prior research shows there can be a profound psychological impact that outbreaks can inflict on people. It can precipitate new symptoms in people without mental illness, exacerbate symptoms of those already suffering from mental illness, and cause stress to the caregivers and family members. People may experience anxiety about becoming sick or dying themselves, feelings of helplessness, or blame other people who are ill .
Identified mental health symptoms include depression, anxiety, panic attacks, somatic symptoms, and posttraumatic stress disorder symptoms, sometimes even delirium, psychosis, and suicidality [3-5].
A survey was conducted in China during the initial outbreak of COVID-19:
• 53.8% of respondents rated the psychological impact as moderate or severe
• 16.5% endorsed moderate to severe depressive symptoms
• 28.8% endorsed moderate to severe anxiety symptoms, and
• 8.1% endorsed moderate to severe stress levels (Figure 1)
Closure of community services and the collapse of industries adversely affects economy. Increased unemployment rates coupled with financial losses can conjure up negative emotions . Stigma and blame of affected communities as we have seen evidence of with COVID-19 can affect trade and cause more uncertainty and unrest. Those with depression or anxiety may further ruminate on concerns of contracting the virus .
Effects on healthcare professionals
The newness of COVID-19, lack of testing, effective treatment, protective equipment and medical supplies, extended workloads, and other concerns influence how outbreaks affect healthcare professionals. The combination of these factors can put stress on individuals and the systems that employ them .
Healthcare professionals who respond to outbreaks reported increased feelings of stress; feeling traumatized, and have higher levels of depression and anxiety . The higher the risk of exposure, the more anxiety and fear arises, along with the fear of spreading infection to their families and partners. Healthcare workers can find themselves negotiating the fine balance between their professional duties, anxiety, and altruism, and these things can cause conflict among them.
Healthcare workers who are directly exposed to infected patients, such as those in emergency departments, intensive care units, isolation inpatient rooms are at greater risk of developing adverse mental health outcomes . The work involved is highly demanding, requiring making difficult decisions that are emotionally and ethically taxing. One systematic review looking at the effects of the disaster on the mental health of healthcare workers found risk factors such as poor coping skills, lack of training and lack of social support could contribute to the development of adverse psychological effects . Public health authorities and media tend to focus on the biologic effects during epidemics, and less attention is given to mental health related issues. However, during the recent COVID-19 pandemic, there has been increasing calls for attention to mental health related effects .
We can discuss the mental health effects of COVID-19 on healthcare professionals also by using the concept used in the military known as moral injury. Moral injury is the psychological distress that is the result of actions or inactions that violate a person’s ethical and moral code . Individuals may experience negative thoughts about themselves and others, shame, guilt, which may result in symptoms of depression, posttraumatic stress disorder, even suicidal ideation . Individuals can also experience a period of post-traumatic growth, which can increase self-esteem, resilience, perspectives and values .
The way a person is supported before, during or after a highly challenging situation can influence whether there is psychological growth or injury. Proper preparation of staff on the realistic burden of disease interventions, risks to their wellbeing, challenges can reduce the risk of mental health problems. Team leaders can use the model of Schwartz rounds, where a forum is provided for healthcare workers to reflect on the emotional impact of their work .
Avoidance behaviors often occur with trauma, so staff need to be checked in on, especially the ones who feel they are too busy to attend such meetings. In general, support from colleagues and supervisors positively affects their mental health . It is important to note that one session debriefing can do more harm than good, and so therefore should be avoided . Evidence of moral injury has resonated with medical students with exposure to trauma in pre hospital care and in emergency rooms, so it is quite possible that a similar concept can occur with healthcare workers treating patients with COVID-19 [18- 19].
that can be instrumental to primary prevention. Some groups are more vulnerable to the psychosocial effects of pandemics. These include people who acquire the disease, the elderly, the immune compromised, those living or receiving care in board and care homes or nursing homes, people with preexisting medical, psychiatric, and substance use problems, and healthcare workers .
One of the main takeaways from data from China is that it was reported that older adults are at higher risk from death due to complications from COVID-19 than younger people. Among the older adults, severity of illness was also associated with having serious underlying medical comorbidities. It was reported that about 80% of deaths occurred in adults age 60 or above. Most cases, around 80% were classified as mild, and one death was reported in a person 19 years of age or younger (0.1%) . In the United States, about 49 million people are over 65 years of age.
A study of 125 hospitalized patients with COVID-19 showed 57 had an ischemic stroke, 39 patients had altered mental status, which included encephalitis, and encephalopathy. Ten of the patients carried a psychosis diagnosis, six had a dementia like presentation. The patients were between the age range of 20s to 90s, and although strokes were more common in older patients, half of those with altered mental status were under the age of 60 . It remains unknown what is causing the neuropsychiatric effects, and further research is warranted to understand the neuropsychiatric sequela.
A meta-analysis of 3027 patients diagnosed with COVID-19 showed that being male, over 65, and smoking was associated with disease progression. Hypertension, diabetes, cardiovascular and respiratory disease were statistically significantly higher is critically ill patients. Clinical presentations such as fever, shortness of breath, and certain elevated laboratory values such as wbc, Cr, LDH, hypersensitive cardiac troponin I, PCT, and d-dimer can also be predictive of disease progression .
In one study, the incidence of stroke in COVID-19 patients was about 5% with a median age of 71.6. Patients who acquired stroke had a higher incidence of risk factors like hypertension, diabetes, previous cerebrovascular disease, coronary artery disease, and developing stroke was also associated with more severe disease. It is possible that elevated c-reactive protein and d-dimer, which indicate abnormalities in the coagulation pathway and an inflammatory state, may predispose one to develop stroke .
In the UK, in the aftermath of a crisis, the National Institute for Health and Care Excellence put forth guidelines recommending active monitoring of staff so that those who have mental health symptoms can be triaged to receive evidence-based treatment . A similar model should be instituted in the United States to assure healthcare workers have access to mental health resources. There are some emerging networks that aim to provide emotional and social support to healthcare workers on the frontlines. One example is Physician Support Line, a hotline run by volunteer psychiatrists that physicians can call for emotional support.
High Risk Populations
It is important for psychiatrists to understand which population groups may be at higher risk for the development and mortality associated with COVID-19. We play a role in dissemination of knowledge of public health to our patients and providing information
As part of psycho educational efforts, the knowledge of the above information may be used to educate younger patients that although they may not necessarily contract severe illness, their elderly loved ones may. This may help bolster efforts to motivate patients to follow public health recommendations such as physical distancing, hand washing, wearing masks, etc.