The public is gripped by fear of the novel coronavirus of 2019 (COVID-19) and by worry over whether the health system will be able to treat them or their loved ones should they become ill. Consequently, clinical and public health efforts have focused on acute medical care needs of those who are severely affected, while containing the virus’s spread in the population. Urgent priorities have included expanding hospitals’ capacities to care for sick patients and equipping health care providers to meet the unprecedented medical demands while keeping them safe. Meanwhile, concerted efforts are underway to validate diagnostic tests and bring them to scale while developing effective acute and preventive treatments, including vaccines.
Understandably, much less attention has been paid to the mental health consequences of the pandemic. Yet while the urgent emphasis is and should be on containing the virus and its physical threat, when the pandemic has subsided and we begin to resume normal life, it is the psychological sequelae that will emerge and persist for months and years to come.
During the acute crisis, everyone, to varying degrees, will experience fears of infection, somatic concerns, and worries about the pandemic’s consequences. Compounding personal distress are the disruption of usual daily routines and the social isolation imposed by the “stay at home orders” adopted by most US states. Longer periods of physical isolation, especially if experienced as involuntary, without an adequate and convincing explanation, or accompanied by financial losses can compound risks of adverse mental health consequences of physical isolation.
People with pre-existing or constitutional vulnerabilities to psychiatric disorders including anxiety, depression, obsessional symptoms, substance use, suicidal behavior, and impulse control disorders will be especially vulnerable to stress-related symptom exacerbations.
While we know these psychological effects are permeating the population, we do not yet know their extent or impact. We have previously experienced naturally occurring and human-made disasters, but nothing in our lifetimes compares to the scope of the COVID-19 crisis. The last comparable event was the Spanish Flu Pandemic of 1918. Subsequent epidemics including polio, HIV, Ebola, MERSA, SARS, and Swine Flu, though in some cases more virulent, were much smaller in scale, shorter and less disruptive to society.
While the polio and HIV epidemics may bear some similarities to COVID-19, they did not approach the magnitude of population-wide psychological impact. Therefore, studies of the mental health effects of recent epidemics offer limited guidance about after-effects of the COVID-19 pandemic. Similarly, recent disasters, such as Hurricane Katrina or 9/11, were more constrained in space and time than the COVID-19 pandemic.
Perhaps a better comparison is to the Great Depression of the early 1930s. This economic crisis caused a population-wide experiential trauma of the US population whose form and severity varied with individual constitution and circumstances. Psychological and behavioral reactions that exceeded clinical diagnostic thresholds were reflected as increase in rates of suicide. In a variety of contexts, economic crises have been found to be associated with an increase in depression. Increased rates of depression, anxiety, substance use, and PTSD disorders have been found to follow natural disasters, such as earthquakes, hurricanes, tsunamis, or floods. If similar patterns hold for the COVID-19 pandemic, long after the physical threat of infection has subsided, psychological sequelae—inducing or exacerbating mental disorders in vulnerable people, and behavioral effects of persistent distress within the general population—will be a major consequence.
Meeting the mental health challenge
The up-tick in incidence of various mental disorders and cumulative psychological stress our population will endure will further strain the mental health and primary care systems and expose limitations of its infrastructure, work force, and accessibility. Should national rates of specific conditions (like depression, suicidal behavior) increase, it will add to the trend of steadily rising national rates of suicide that we’ve seen over the past two decades.
To stem this tide, efforts should begin with those who are at increased risk of adverse mental health outcomes including patients with pre-existing mental disorders vulnerable to such stressors. Such persons may need adjustments in their treatment and increased frequency of contact with their mental health providers.
Others include people who reside in high COVID-19 prevalence areas, who live with someone affected by COVID-19, who have a family member or close friend who has died of COVID-19, who are socially isolated and who have little available emotional support. Adverse mental health consequences of social isolation can be mitigated by keeping the period of isolation as short as is consistent with personal and public health safety, providing accurate information concerning the rationale and personal and public health benefits of physical isolation, and improving social communication. Alongside negative effects, there may also be some countervailing positive mental health effects of living through a pandemic. One study of the SARS epidemic found that most individuals reported caring more about their family’s feelings during the SARS period than before it.
Health care professionals, especially those whose work brings them into close contact to patients infected with COVID-19, are also vulnerable to adverse mental health consequences. Feelings of futility, working with inadequate personal protective equipment, extensive involvement in end-of-life care without being able to connect patients and their families, and practicing outside their areas of confident clinical expertise can result in psychological stress.
For health care professionals, mitigating adverse mental health effects involve ensuring adequate protective personal equipment, access to COVID-19 testing, providing education concerning the disease, and training in COVID-19 management. It may also include providing emotional and physical support, developing more flexible work schedules, and a commitment to support and care for workers who become ill.
During the pandemic, health care professionals have been celebrated for their bravery and commitment to patient care. Yet the pandemic has also created a sobering moral dilemma as an innate desire to preserve their own lives and awareness of their vulnerability to the disease conflicts with their call to duty and identity as healers. Thus, stress management and counselling may need to include discussions of ethical principles and practices.
Increased primary care mental health surveillance through routine screening for depression, anxiety, and substance use coupled with greater availability of mental health services within primary care will enable larger numbers of affected individuals to receive mental health treatment within a familiar primary care context. In some practices, it may be feasible to train medical nurses and social workers in brief evidence-based psychotherapy techniques to manage complicated grief, adjustment disorders, and mild to moderate depression.
Psychiatry is particularly suited to use of virtual methods of providing mental health services. While telemedicine technology has existed for almost three decades, it took the impetus of the COVID-19 crisis to overcome the inertia of practitioners and health systems, and relax the regulatory, legal, and reimbursement impediments to utilization. Effecting the changes needed to sustain the use of telemedicine coming out of this pandemic should be a priority.
The COVID-19 pandemic presents new challenges to health and mental health care delivery. In the US, national, state, and local governments alongside the private health care sector have important roles to play in increasing the availability of mental health care in hard hit and underserved areas. Developing support groups and peer counseling services, crisis helplines, expanding services and enhancing accessibility through the use of telemedicine, and formalizing linkages between primary care and specialty mental health services may help address some of the emerging mental health needs. Careful planning and integration of basic mental health services into outpatient primary care will be critical to minimizing the adverse mental health effects of the COVID-19 pandemic.