During the outbreak of infectious disease, the population’s psychological reactions play a critical role in shaping both the spread of the disease and the occurrence of emotional distress and social disorder during and after the outbreak. Despite this fact, sufficient resources are typically not provided to manage or attenuate pandemics’ effects on mental health and wellbeing. While this might be understandable in the acute phase of an outbreak, when health systems prioritize testing, reducing transmission, and critical patient care, psychological and psychiatric needs should not be overlooked during any phase of pandemic management.
There are many reasons for this. It is known that psychological factors play an important role in adherence to public health measures (such as vaccination) and in how people cope with the threat of infection and consequent losses. These are clearly crucial issues to consider in the management of any infectious disease, including COVID-19. Psychological reactions to pandemics include maladaptive behaviors, emotional distress, and defensive responses. People who are prone to psychological problems are especially vulnerable.
All of these features are in clear evidence during the current COVID-19 pandemic.
One study of 1210 respondents from 194 cities in China in January and February 2020 found that 54% of respondents rated the psychological impact of the COVID-19 outbreak as moderate or severe; 29% reported moderate to severe anxiety symptoms, and 17% reported moderate to severe depressive symptoms. Notwithstanding possible response bias, these are very high proportions—and it is likely that some people are at even greater risk. During the 2009 H1N1 influenza outbreak (‘swine flu’), a study of mental health patients found that children and patients with neurotic and somatoform disorders were significantly over-represented among those expressing moderate or severe concerns.
Against this background, and as the COVID-19 pandemic continues to spread around the world, we hypothesize a number of psychological impacts that merit consideration now rather than later.
In the first instance, it should be recognized that, even in the normal course of events, people with established mental illness have a lower life expectancy and poorer physical health outcomes than the general population. As a result, people with pre-existing mental health and substance use disorders will be at increased risk of infection with COVID-19, increased risk of having problems accessing testing and treatment, and increased risk of negative physical and psychological effects stemming from the pandemic.
Second, we anticipate a considerable increase in anxiety and depressive symptoms among people who do not have pre-existing mental health conditions, with some experiencing post-traumatic stress disorder in due course. There is already evidence that this possibility has been under-recognized in China during the current pandemic.
Third, it can be anticipated that health and social care professionals will be at particular risk of psychological symptoms, especially if they work in public health, primary care, emergency services, emergency departments, and intensive or critical care. The World Health Organization has formally recognized this risk to healthcare workers, so more needs to be done to manage anxiety and stress in this group and, in the longer term, help prevent burnout, depression, and post-traumatic stress disorder.
There are several steps that can and should be taken now to minimize the psychological and psychiatric effects of the COVID-19 pandemic. First, while it might be ostensibly attractive to re-deploy mental health professionals to work in other areas of healthcare, this should be avoided. Such a move would almost certainly worsen outcomes overall and place people with mental illness at disproportionate risk of deteriorations in physical and mental health. If anything, this group needs enhanced care at this time.
Second, we recommend the provision of targeted psychological interventions for communities affected by COVID-19, particular supports for people at high risk of psychological morbidity, enhanced awareness and diagnosis of mental disorders (especially in primary care and emergency departments), and improved access to psychological interventions (especially those delivered online and through smartphone technologies). These measures can help diminish or prevent future psychiatric morbidity.
Finally, there is a need for particular focus on frontline workers including, but not limited to, healthcare staff. In the USA, the Centers for Disease Control and Prevention offer valuable advice for healthcare workers in order to reduce secondary traumatic stress reactions, including increased awareness of symptoms, taking breaks from work, engaging in self-care, taking breaks from media coverage, and asking for help. This kind of advice needs to be underpinned by an awareness of this risk among employers, enhanced peer support, and practical assistance for healthcare workers who find themselves stressed and feeling excessive personal responsibility for clinical outcomes during what appears to be the largest pandemic of our times.
Even in this emergency circumstance, or especially in this emergency circumstance, we neglect mental health at our peril and to our long-term detriment. The global community is concerned about Coronavirus disease 2019 (COVID-19) and its long-term consequences. It is going to impact various spheres of life such as the economy, industries, global market, agriculture, human health, health care, etc. At present, the focus of States and the World bodies such as the World Health Organization (WHO) is on controlling and mitigating the impact of this pandemic by identifying, testing, treating infected people, developing drugs, vaccines, and treatment protocols. However, despite such efforts to defeat this pandemic, we are not very sure what direction the pandemic will take in the coming days.
The WHO has also expressed its concern over the pandemic’s mental health and psycho-social consequences. It speculates that new measures such as self-isolation and quarantine have affected usual activities, routines, and livelihoods of people that may lead to an increase in loneliness, anxiety, depression, insomnia, harmful alcohol, and drug use, and self-harm or suicidal behavior. The lockdowns around the world have led to an increase in cases of domestic violence where women and children who live with domestic violence have no escape from their abusers during quarantine. The recent survey by the Pakistan Psychiatric Society shows a twenty percent increase in mental illnesses since the coronavirus outbreak in Pakistan. Psychologists and mental health professionals speculate that the pandemic is going to impact the mental health of the population globally with the increase in cases of depression, suicide, and self-harm, apart from other symptoms reported globally due to COVID 2019. The closing of outlets selling alcohol has also led to withdrawal symptoms and suicides by alcohol addicts, reported in states in Pakistan. They speculate about the chances of developing neurotic disorders such as generalized anxiety disorder and obsessive-compulsive disorders (OCD) in large population groups.
Overemphasis on consistent hand washing (for twenty seconds) may affect a significant population group globally considering people are not aware of when and how many times to wash. In such a scenario, many people are washing their hands at a regular interval. It is a sanitary fight against an invisible virus and sources of infection. In such a scenario, OCD and related maladaptive behaviors particularly due to consistent promotion of handwashing to mitigate the coronavirus infection and its spread is a serious concern. Besides mood-related and emotional outbursts especially panic, fear, avoidance and fear in meeting other people, fear of death (Thanatophobia), fear of getting isolated, stigmatization, fear of even not getting essential items, food, etc., may have their psychological manifestations. In many states, due to anxieties, people have been hoarding essential items which have led to shortages. Millions of People have lost their jobs. People employed in the informal and unorganized sectors are worst hit as they are struggling for, food, shelter, and their livelihoods which created uncertainty leading to depression, suicide, self-harm, etc. The lockdown may be an important strategy to break the chain of transmission. But it has also created boredom and monotony among office goers and children. In many households, children who end up staying indoors become restless and, in some cases, violent. Many households have even closed windows and doors due to wrong notions regarding the infection.
Interestingly the Coronavirus pandemic has another feature in this age of social media, where people are getting overloaded with rumors and misinformation which are not authentic and verified. Such rumors and unauthenticated information create fear, anxiety, and stress with a sudden and near-constant stream of news reports about an outbreak. In Pakistan, many people got exposed to positive people or to those who traveled abroad and who are at risk. However, they are not coming forward for testing due to social stigma and social isolation. They are scared and fearful that they will be blamed, isolated, and taken away from their family members. It is important that these people receive counseling from psychologists and other mental health professionals that they have not done anything wrong, and this is just a protocol to mitigate and control the pandemic. Their doubts need to be clarified; they deserve social and psychological support, counseling, compassion, and kindness in such a distressful situation. Such stigma and social isolation have negatively impacted HIV prevention in the past and we need to learn from that. The stigma associated with mental health problems may cause reluctance to seek support.
To date, over one hundred thousand people have died worldwide, and we do not know how many more will die due to this pandemic. In such a scenario, providing psycho-social support and helping bereaved family members is important. Children may respond to stress in different ways such as being clingier, anxious, withdrawing, angry or agitated, bedwetting, etc. Children need adults’ love and attention during difficult times. They need extra time and attention. It is important to keep children close to their parents and family and avoid separating children and their caregivers to the extent possible. If separation occurs (e.g. hospitalization) regular contact (e.g. via phone) and re-assurance are required reported by World Health Organization in 2020. Particularly young children who have lost their parents are more vulnerable. Every child experiencing such loss needs a safe and supportive environment, guidance, and help to express their feelings such as fear and sadness.
The mental and psychological well-being of healthcare providers is another concern. Healthcare providers are continuously working in fearful, stressful, resource-constrained settings where they are under the continuous threat of getting exposed and infected. In such a condition the healthcare providers’ mental health and psychosocial well-being are as important as managing the health of the infected population. The WHO has issued thirty-one-point guidance for mitigating these problems. These include guidelines to safeguard the mental health of the population of different age groups affected with COVID-19 with a special focus on children, women, and service providers, suggesting measures to mitigate anxiety, depression, stigma, etc.
There are various resources available online which can be helpful in managing and coping with the stress arising out of the pandemic. It is important for people to take care of themselves, their family members, and friends. Helping others to cope with their stress makes the community stronger. Nevertheless, the biggest challenge in mitigating mental health consequences of the COVID 19 pandemic is the lack of mental health professionals, practitioners, counselors, and health facilities where one can approach for such help. It is going to be a real challenge for a country like Pakistan where only 0.29 Psychiatrists, 0.07 Psychologists, and 0.36 other paid mental health workers are available per 100,000 people reported by World Health Organization in 2018. In such a situation, it is important to evolve a simple counseling package that can be delivered by givers at home or in the hospital. The package should contain a number of dimensions, such as being empathetic and supportive to all those who are affected. They need to listen with compassion and kindness. Establishing online mental health and counseling services at hospitals, community health care centers, and university departments of psychology could be an opportunity to address such a crisis.
China has been implementing emergency psychological crisis interventions to reduce the negative psychosocial impact on public mental health. However, challenges exist. One can hope that States will learn a lesson from this pandemic and recognize public mental health as an important priority area that needs to be formally integrated into public health preparedness and emergency response plans.
