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      “Pandemic fear” and COVID-19: mental health burden and strategies

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          Abstract

          In the wake of the September 11 attack in the United States and the Kiss Nightclub fire in Brazil, psychological assistance task forces for victims and their families were quickly organized. However, during pandemics it is common for health professionals, scientists and managers to focus predominantly on the pathogen and the biological risk in an effort to understand the pathophysiological mechanisms involved and propose measures for preventing, containing and treating the disease. In such situations, the psychological and psychiatric implications secondary to the phenomenon, both on an individual and a collective level, tend to be underestimated and neglected, generating gaps in coping strategies and increasing the burden of associated diseases.1,2 Although infectious diseases have emerged at various times in history, in recent years, globalization has facilitated the spread of pathological agents, resulting in worldwide pandemics. This has added greater complexity to the containment of infections, which has had an important political, economic and psychosocial impact, leading to urgent public health challenges.2-6 HIV, Ebola, Zika and H1N1, among other diseases, are recent examples.1 The coronavirus (COVID-19), identified in China at the end of 2019, has a high contagion potential, and its incidence has increased exponentially. Its widespread transmission was recognized by the World Health Organization (WHO) as a pandemic. Dubious or even false information about factors related to virus transmission, the incubation period, its geographic reach, the number of infected, and the actual mortality rate has led to insecurity and fear in the population. The situation has been exacerbated due to the insufficient control measures and a lack of effective therapeutic mechanisms.5,7,8 These uncertainties have had consequences in a number of sectors, with direct implications for the population’s daily life and mental health. This scenario raises a number of questions: is there a fear/stress pandemic concomitant with the COVID-19 pandemic? How can we evaluate this phenomenon? To understand the psychological and psychiatric repercussions of a pandemic, the emotions involved in it, such as fear and anger, must be considered and observed. Fear is an adaptive animal defense mechanism that is fundamental for survival and involves several biological processes of preparation for a response to potentially threatening events. However, when it is chronic or disproportionate, it becomes harmful and can be a key component in the development of various psychiatric disorders.9,10 In a pandemic, fear increases anxiety and stress levels in healthy individuals and intensifies the symptoms of those with pre-existing psychiatric disorders.11 During epidemics, the number of people whose mental health is affected tends to be greater than the number of people affected by the infection.12 Past tragedies have shown that the mental health implications can last longer and have greater prevalence than the epidemic itself and that the psychosocial and economic impacts can be incalculable if we consider their resonance in different contexts.11,12 Since the economic costs associated with mental disorders is high, improving mental health treatment strategies can lead to gains in both physical health and the economic sector. In addition to a concrete fear of death, the COVID-19 pandemic has implications for other spheres: family organization, closings of schools, companies and public places, changes in work routines, isolation, leading to feelings of helplessness and abandonment. Moreover, it can heighten insecurity due to the economic and social repercussions of this large-scale tragedy. During the Ebola outbreak, for example, fear-related behaviors had an epidemiological impact both individually and collectively during all phases of the event, increasing the suffering and psychiatric symptom rates of the population, which contributed to increases in indirect mortality from causes other than Ebola.13 Currently, ease of access to communication technologies and the transmission of sensational, inaccurate or false information can increase harmful social reactions, such as anger and aggressive behavior.14 Diagnostic, tracking, monitoring and containment measures for COVID-19 have been established in several countries.6 However, there are still no accurate epidemiological data on disease-related psychiatric implications or their impact on public health. A Chinese study provided some insights in this regard. Approximately half of the interviewees classified the psychological impact of the epidemic as moderate to severe, and about a third reported moderate to severe anxiety.15 Similar data have been reported in Japan, where the economic impact has also been dramatic.11 Another study reported that patients infected with COVID-19 (or suspected of being infected) may experience intense emotional and behavioral reactions, such as fear, boredom, loneliness, anxiety, insomnia or anger,11 as has been reported about similar situations in the past.16 Such conditions can evolve into disorders, whether depressive, anxiety (including panic attacks and post-traumatic stress), psychotic or paranoid, and can even lead to suicide.17,18 These conditions can be especially prevalent in quarantined patients, whose psychological distress tends to be higher.16 In some cases, uncertainty about infection and death or about infecting family and friends can potentiate dysphoric mental states.11,18 Even among patients with common flu symptoms, stress and fear due to the similarity of the conditions can generate mental distress and worsen psychiatric symptoms.15,19 Despite the fact that the rate of confirmed vs. suspected cases of COVID-19 is relatively low and that the majority of cases are considered asymptomatic or mild, as well as that the disease has a relatively low mortality rate,20,21 the psychiatric implications can be significantly high, overloading emergency services and the health system as a whole. In conjunction with actions to help infected and quarantined patients, strategies targeting the general population and specific groups must be developed, including health professionals who are directly exposed to the pathogen and have high stress rates.22 Although some protocols for clinicians have been established, most health professionals who work in isolation units and hospitals are neither trained to provide mental health assistance during pandemics1,17 nor receive specialized care. Previous studies have reported high rates of anxiety and stress symptoms, as well as mental disorders, such as post-traumatic stress, in this population (especially among nurses and doctors), which reinforces the need for care.22,23 Other specific groups are especially vulnerable in pandemics: older adults, the immunocompromised, patients with previous clinical and psychiatric conditions, family members of infected patients and residents of high-incidence areas. In these groups, social rejection, discrimination, and even xenophobia are frequent.17 Providing psychological first aid is an essential care component for populations that have been victims of emergencies and disasters, but there are no universal protocols or guidelines for the most effective psychosocial support practices.24 Although some reports on local mental health care strategies have been published, more comprehensive emergency guidelines for such scenarios are unknown,1,17,19 since previous evidence refers only to specific situations.24 In Brazil, a large developing country with pronounced social disparity, low education levels and humanitarian-cooperative culture, there are no parameters for estimating the impact of this phenomenon on the population’s mental health or behavior. Will it be possible to implement effective preventive and emergency actions aimed at the psychiatric implications of this biological pandemic in broad spheres of society? Specifically for this new COVID-19 scenario, Xiang et al., suggest that three main factors should be considered when developing mental health strategies: 1) multidisciplinary mental health teams (including psychiatrists, psychiatric nurses, clinical psychologists and other mental health professionals); 2) clear communication involving regular, accurate updates on the COVID-19 outbreak; and 3) establishing safe psychological counseling services (for example, via electronic devices or apps).17 Finally, it is extremely necessary to implement public mental health policies in conjunction with epidemic and pandemic response strategies before, during and after the event.13 Mental health professionals, such as psychologists, psychiatrists and social workers, must be on the front line and play a leading role in emergency planning and management teams.1 Assistance protocols, such as those used in disaster situations, should cover areas relevant to the individual and collective mental health of the population. Recently, the WHO25 and the U.S. Center for Disease Control and Prevention26 published a series of psychosocial and mental health recommendations, several of which are included in Box 1. This is in line with longitudinal data from the WHO demonstrating that psychological factors are directly related to the main causes of morbidity and mortality in the world.25 Thus, increased investment in research and strategic actions for mental health in parallel with infectious outbreaks is urgently needed worldwide.1 Disclosure The authors report no conflicts of interest.

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          Most cited references16

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          Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China

          Background: The 2019 coronavirus disease (COVID-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. Research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. The aim of this study was to survey the general public in China to better understand their levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak. The data will be used for future reference. Methods: From 31 January to 2 February 2020, we conducted an online survey using snowball sampling techniques. The online survey collected information on demographic data, physical symptoms in the past 14 days, contact history with COVID-19, knowledge and concerns about COVID-19, precautionary measures against COVID-19, and additional information required with respect to COVID-19. Psychological impact was assessed by the Impact of Event Scale-Revised (IES-R), and mental health status was assessed by the Depression, Anxiety and Stress Scale (DASS-21). Results: This study included 1210 respondents from 194 cities in China. In total, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. Most respondents spent 20–24 h per day at home (84.7%); were worried about their family members contracting COVID-19 (75.2%); and were satisfied with the amount of health information available (75.1%). Female gender, student status, specific physical symptoms (e.g., myalgia, dizziness, coryza), and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (p < 0.05). Specific up-to-date and accurate health information (e.g., treatment, local outbreak situation) and particular precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05). Conclusions: During the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. Our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the COVID-19 epidemic.
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            Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed

            The 2019 novel coronavirus (2019-nCoV) pneumonia, believed to have originated in a wet market in Wuhan, Hubei province, China at the end of 2019, has gained intense attention nationwide and globally. To lower the risk of further disease transmission, the authority in Wuhan suspended public transport indefinitely from Jan 23, 2020; similar measures were adopted soon in many other cities in China. As of Jan 25, 2020, 30 Chinese provinces, municipalities, and autonomous regions covering over 1·3 billion people have initiated first-level responses to major public health emergencies. A range of measures has been urgently adopted,1, 2 such as early identification and isolation of suspected and diagnosed cases, contact tracing and monitoring, collection of clinical data and biological samples from patients, dissemination of regional and national diagnostic criteria and expert treatment consensus, establishment of isolation units and hospitals, and prompt provision of medical supplies and external expert teams to Hubei province. The emergence of the 2019-nCoV pneumonia has parallels with the 2003 outbreak of severe acute respiratory syndrome (SARS), which was caused by another coronavirus that killed 349 of 5327 patients with confirmed infection in China. 3 Although the diseases have different clinical presentations,1, 4 the infectious cause, epidemiological features, fast transmission pattern, and insufficient preparedness of health authorities to address the outbreaks are similar. So far, mental health care for the patients and health professionals directly affected by the 2019-nCoV epidemic has been under-addressed, although the National Health Commission of China released the notification of basic principles for emergency psychological crisis interventions for the 2019-nCoV pneumonia on Jan 26, 2020. 5 This notification contained a reference to mental health problems and interventions that occurred during the 2003 SARS outbreak, and mentioned that mental health care should be provided for patients with 2019-nCoV pneumonitis, close contacts, suspected cases who are isolated at home, patients in fever clinics, families and friends of affected people, health professionals caring for infected patients, and the public who are in need. To date, epidemiological data on the mental health problems and psychiatric morbidity of those suspected or diagnosed with the 2019-nCoV and their treating health professionals have not been available; therefore how best to respond to challenges during the outbreak is unknown. The observations of mental health consequences and measures taken during the 2003 SARS outbreak could help inform health authorities and the public to provide mental health interventions to those who are in need. Patients with confirmed or suspected 2019-nCoV may experience fear of the consequences of infection with a potentially fatal new virus, and those in quarantine might experience boredom, loneliness, and anger. Furthermore, symptoms of the infection, such as fever, hypoxia, and cough, as well as adverse effects of treatment, such as insomnia caused by corticosteroids, could lead to worsening anxiety and mental distress. 2019-nCoV has been repeatedly described as a killer virus, for example on WeChat, which has perpetuated the sense of danger and uncertainty among health workers and the public. In the early phase of the SARS outbreak, a range of psychiatric morbidities, including persistent depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium, and even suicidality, were reported.6, 7 Mandatory contact tracing and 14 days quarantine, which form part of the public health responses to the 2019-nCoV pneumonia outbreak, could increase patients' anxiety and guilt about the effects of contagion, quarantine, and stigma on their families and friends. Health professionals, especially those working in hospitals caring for people with confirmed or suspected 2019-nCoV pneumonia, are vulnerable to both high risk of infection and mental health problems. They may also experience fear of contagion and spreading the virus to their families, friends, or colleagues. Health workers in a Beijing hospital who were quarantined, worked in high-risk clinical settings such as SARS units, or had family or friends who were infected with SARS, had substantially more post-traumatic stress symptoms than those without these experiences. 8 Health professionals who worked in SARS units and hospitals during the SARS outbreak also reported depression, anxiety, fear, and frustration.6, 9 Despite the common mental health problems and disorders found among patients and health workers in such settings, most health professionals working in isolation units and hospitals do not receive any training in providing mental health care. Timely mental health care needs to be developed urgently. Some methods used in the SARS outbreak could be helpful for the response to the 2019-nCoV outbreak. First, multidisciplinary mental health teams established by health authorities at regional and national levels (including psychiatrists, psychiatric nurses, clinical psychologists, and other mental health workers) should deliver mental health support to patients and health workers. Specialised psychiatric treatments and appropriate mental health services and facilities should be provided for patients with comorbid mental disorders. Second, clear communication with regular and accurate updates about the 2019-nCoV outbreak should be provided to both health workers and patients in order to address their sense of uncertainty and fear. Treatment plans, progress reports, and health status updates should be given to both patients and their families. Third, secure services should be set up to provide psychological counselling using electronic devices and applications (such as smartphones and WeChat) for affected patients, as well as their families and members of the public. Using safe communication channels between patients and families, such as smartphone communication and WeChat, should be encouraged to decrease isolation. Fourth, suspected and diagnosed patients with 2019-nCoV pneumonia as well as health professionals working in hospitals caring for infected patients should receive regular clinical screening for depression, anxiety, and suicidality by mental health workers. Timely psychiatric treatments should be provided for those presenting with more severe mental health problems. For most patients and health workers, emotional and behavioural responses are part of an adaptive response to extraordinary stress, and psychotherapy techniques such as those based on the stress-adaptation model might be helpful.7, 10 If psychotropic medications are used, such as those prescribed by psychiatrists for severe psychiatric comorbidities, 6 basic pharmacological treatment principles of ensuring minimum harm should be followed to reduce harmful effects of any interactions with 2019-nCoV and its treatments. In any biological disaster, themes of fear, uncertainty, and stigmatisation are common and may act as barriers to appropriate medical and mental health interventions. Based on experience from past serious novel pneumonia outbreaks globally and the psychosocial impact of viral epidemics, the development and implementation of mental health assessment, support, treatment, and services are crucial and pressing goals for the health response to the 2019-nCoV outbreak. © 2020 VW Pics/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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              [The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China].

              (2020)
              Objective: An outbreak of 2019 novel coronavirus diseases (COVID-19) in Wuhan, China has spread quickly nationwide. Here, we report results of a descriptive, exploratory analysis of all cases diagnosed as of February 11, 2020. Methods: All COVID-19 cases reported through February 11, 2020 were extracted from China's Infectious Disease Information System. Analyses included: 1) summary of patient characteristics; 2) examination of age distributions and sex ratios; 3) calculation of case fatality and mortality rates; 4) geo-temporal analysis of viral spread; 5) epidemiological curve construction; and 6) subgroup analysis. Results: A total of 72 314 patient records-44 672 (61.8%) confirmed cases, 16 186 (22.4%) suspected cases, 10567 (14.6%) clinical diagnosed cases (Hubei only), and 889 asymptomatic cases (1.2%)-contributed data for the analysis. Among confirmed cases, most were aged 30-79 years (86.6%), diagnosed in Hubei (74.7%), and considered mild (80.9%). A total of 1 023 deaths occurred among confirmed cases for an overall case-fatality rate of 2.3%. The COVID-19 spread outward from Hubei sometime after December 2019 and by February 11, 2020, 1 386 counties across all 31 provinces were affected. The epidemic curve of onset of symptoms peaked in January 23-26, then began to decline leading up to February 11. A total of 1 716 health workers have become infected and 5 have died (0.3%). Conclusions: The COVID-19 epidemic has spread very quickly. It only took 30 days to expand from Hubei to the rest of Mainland China. With many people returning from a long holiday, China needs to prepare for the possible rebound of the epidemic.
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                Author and article information

                Journal
                Braz J Psychiatry
                Braz J Psychiatry
                bjp
                Brazilian Journal of Psychiatry
                Associação Brasileira de Psiquiatria
                1516-4446
                1809-452X
                03 April 2020
                May-Jun 2020
                03 April 2020
                : 42
                : 3
                : 232-235
                Affiliations
                [1 ]Centro de Pesquisa em Álcool e Drogas, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
                [2 ]Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Departamento de Psiquiatria e Medicina Legal, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
                Author notes
                Correspondence: Felipe Ornell, Centro de Pesquisa em Álcool e Drogas, HCPA/UFRGS, Rua Prof. Álvaro Alvim, 400, Bairro Rio Branco, Porto Alegre, RS, Brazil. E-mail: felipeornell@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-3881-4283
                http://orcid.org/0000-0002-2195-4407
                http://orcid.org/0000-0002-4629-1646
                http://orcid.org/0000-0001-7059-2564
                Article
                10.1590/1516-4446-2020-0008
                7236170
                32267343
                52eefb33-8fb9-4002-8f61-21b4f6908d07

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 17 March 2020
                : 19 March 2020
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