Is a mental health pandemic the next threat?

With the medical community now fully engaged in fighting the effects of the COVID-19, it's easy to forget our mental health may also be under attack.

Editor's note: Written at the height of the first wave of the pandemic, this article first flagged the crucial connections between COVID-19 and mental health. Six months later, this discussion continues to be even more relevant.

In a very short time, we've moved from being completely unaware of the coronavirus to a place where nearly a third of our entire world population is living under some form of lockdown to prevent its spread.

Our fundamental way of life has been altered. Commuting, schooling and socialising are replaced by the monotony of staying and working from home without any clear end in sight.

In such stressful circumstances, being fearful and anxious might become the norm. When do these understandable reactions to extraordinary happenings become something that a person needs help with? In this article, we'll discuss how much our mental health is affected, and what we might expect when the pandemic recedes.

When worry leads to worse consequences

Fear of the unknown is a potent cause of distress in most people1. During this crisis, it is therefore entirely reasonable for people to be scared for themselves, their loved ones and their future.  There are plenty of potential sources of worry:

  • Fear of being infected
  • Fear of infecting loved ones
  • Coping with uncertainty
  • Dealing with a sense of no control
  • And many more… 

As each country moves beyond peak infections, more fears emerge such as dealing with loss, concerns about money and the economy, unemployment and other effects of a "social recession" caused by imposed isolation orders2.

On 24 March 2020, The Guardian in the UK forecast a “pandemic of severe mental health disorders” following the virus pandemic. Is there good evidence for this?

In China, one study looked at almost 5000 adults in 31 provinces at the end of January before the virus peaked. Even then, the study reported high rates of depression (48%) and anxiety (23%)3. Interestingly, they found that high use of social media was associated with greater anxiety. While connectivity can help us keep in touch, it also enables bad news and misreporting to spread quickly, although the effect was not universal4. A recent UK survey in the general population showed that fears about the practical challenges of the pandemic – becoming mentally unwell and isolation (with consequent loneliness) – were the dominant concerns.

Studies of previous epidemics suggest that mental anxiety and depression that are severe enough to need treatment will return to normal levels after an epidemic, but post-traumatic stress disorder (PTSD) requires longer recovery time.  After Sierra Leone reported 14,000 cases of Ebola which led to 3,900 deaths, one survey showed that even a year after the infection's outbreak, 48% had at least one symptom of anxiety or depression, though only 6% would have met the criteria for clinical depression or anxiety, a value that is similar to figures outside of the epidemic5. With Sierra Leone still recovering from a long-running civil war, around 16% had some form of PTSD.6

A Japanese study of the swine influenza pandemic in 2009 reported “overwhelming fear” in the public at a time of considerable economic and social disruption. In Hong Kong, 503 adults were surveyed by telephone seven times over a year during the same pandemic7. Some 19% reported panic, low mood or mental disturbance at the height of the pandemic, which decreased to 3% 10 months later.

PTSD is important to watch

Common disorders are likely to increase and will vary over time and by country. However, we can largely expect that the excess will disappear with time as the news becomes more positive and our lives return to a semblance of normal.

What we should all be on the lookout for are signs of PTSD. We have seen that PTSD can remain with people long after the initial trigger has passed.

Psychological effects of containment strategies

The efforts to contain the spread of COVID-19 through social distancing and isolation may create other unintended consequences that lead to mental distress such as increasing loneliness and fear.

A UK survey of the public found that about one-third reported more anxiety or a lower mood in the week following guidance to stay at home. While it is too early to fully understand the effects of this quarantine, studies of similar events show that effects can range from anger or confusion, all the way to post-traumatic symptoms. Of concern is that specific risk factors for today's crisis are similar to those that have been seen before in quarantines: a long duration, no set ending and limited information. Distress can be minimised when the quarantine is voluntary and of short and known duration.

In addition, the current and future economic downturn is likely to also create more long-term effects on mental health.

Effects from contracting COVID-19

It's too early to know the psychosocial effects of having suffered from COVID-19, but previous epidemics suggest an increased long-term risk of PTSD and mood disorders in those who were ill enough to require admission to hospital9.

Effects on care givers

A survey of 1,563 health care professionals (HCPs) in China found that 73% were unusually stressed, 51% were depressed, 45% anxious, and 36% had insomnia10. Wuhan authorities declared that deterioration in HCPs’ mental health will be considered as “work-related injuries”.

It's not surprising that HCPs who received adequate rest and believed they had sufficient personal protection equipment (PPE) were less distressed. The many reports of doctors and nurses dying are accompanied by continued reports of insufficient PPE11,12. More recently, distressing reports of multiple deaths in care homes show that care workers in those facilities are faced with similar risks.

The concept of moral injury is another important factor to consider. This might occur when HCPs are required to make potential life-altering clinical care decisions in the face of insufficient resources, such as ventilators or ICU beds. Studies already show a detrimental effect on wellbeing for doctors in Italy and China forced into making such difficult choices.

Effects on those with pre-existing mental health disorders

A UK survey of 2,000 people, most of whom had experienced a mental illness, showed similar concerns (fear and loneliness) to those in the UK public survey mentioned above, but this group had added concern about adequate access to mental health services. An obvious concern is for people with obsessive compulsive disorder who are dealing with their existing compulsions even as the world's narrative focuses on germs and contamination and emphasises the importance of frequent hand washing.  Some agencies and charities have sought to mitigate the risk of compulsive washing and provide support while maintaining the important balancing act of a public health strategy.

Protecting your mental health

Respondents to both UK surveys mentioned reported they were helped by these positive habits:

  • Staying connected
  • Keeping busy and active
  • Relaxing in different ways
  • Moderating media use
  • Sticking to a routine 

Maintaining social connections, including many of the video calling and social apps now available, is the primary way to cope. Where possible, people should stay active, exercise and leave home for short periods. Psychological first aid to help excessive anxiety and panic is available, and can include different forms of relaxation therapy, particularly mindfulness techniques, as well as cognitive behaviour therapy, now readily delivered over the internet.

We can conclude with due caution that we are unlikely to see a "pandemic of mental disorders" on the horizon, but additional research is needed. International mental health and neurology experts published a call to action for mental health science with recommendations on how to best research the effects of the pandemic on mental health and the brain, and a more detailed review of present knowledge8.

With expert opinion from Prof Peter White, a psychiatrist and Swiss Re clinical medical officer. Prof White is Emeritus Professor of Psychological Medicine at Queen Mary University of London.  His previous research has included post-infectious psychiatric disorders.

Contributing editor: Susan Imler, Global L&H Communications

Useful sources:

https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_2

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext

https://www.nhs.uk/oneyou/every-mind-matters/coronavirus-covid-19-staying-at-home-tips/

https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults#looking-after-your-mental-wellbeing

References

  1. Schimmenti, A., Billieux, J. & Starcevic, V. The four horsemen of fear during the COVID pandemic. Clin. Neuropsychiatry 17, 45–49 (2020).
  2. Holmes, E. A. et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The lancet. Psychiatry (2020) doi:10.1016/S2215-0366(20)30168-1.
  3. Liu, S. et al. Online mental health services in China during the COVID-19 outbreak. The Lancet Psychiatry 7, e17–e18 (2020).
  4. Hu, W., Su, L., Qiao, J., Zhu, J. & Zhou, Y. Countrywide quarantine only mildly increased anxiety level during COVID-19 outbreak in China. medRxiv 2020.04.01.20041186 (2020) doi:10.1101/2020.04.01.20041186.
  5. Jalloh, M. F. et al. Impact of Ebola experiences and risk perceptions on mental health in Sierra Leone, July 2015. BMJ Glob. Heal. 3, (2018).
  6. James, P. B., Wardle, J., Steel, A. & Adams, J. Post-Ebola psychosocial experiences and coping mechanisms among Ebola survivors: a systematic review. Trop. Med. Int. Heal. 24, 671–691 (2019).
  7. Yeung, N. C. Y., Lau, J. T. F., Choi, K. C. & Griffiths, S. Population responses during the pandemic phase of the influenza A(H1N1)pdm09 epidemic, Hong Kong, China. Emerg. Infect. Dis. 23, 813–815 (2017).
  8. Khairat, S., Meng, C., Xu, Y., Edson, B. & Gianforcaro, R. Interpreting COVID-19 and Virtual Care Trends: A Call for Action. JMIR public Heal. Surveill. (2020) doi:10.2196/18811.
  9. Duan, L. & Zhu, G. Psychological interventions for people affected by the COVID-19 epidemic. The Lancet Psychiatry 7, 300–302 (2020).
  10. Zhu, Z. et al. COVID-19 in Wuhan: Immediate Psychological Impact on 5062 Health Workers. medRxiv 2020.02.20.20025338 (2020) doi:10.1101/2020.02.20.20025338.
  11. Shanafelt, T., Ripp, J. & Trockel, M. Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. Jama (2020) doi:10.1001/jama.2020.5893.
  12. Ying, Y. et al. Mental health status among family members of health care workers in Ningbo, China during the Coronavirus Disease 2019 (COVID-19) outbreak: a Cross-sectional Study. medRxiv 2020.03.13.20033290 (2020) doi:10.1101/2020.03.13.20033290.

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