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      Online mental health services in China during the COVID-19 outbreak

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          Abstract

          At the start of 2020, the 2019 coronavirus disease (COVID-19), originating from Wuhan in Hubei province, started to spread throughout China. As a result of the rapidly increasing numbers of confirmed cases and deaths, both medical staff and the public have been experiencing psychological problems, including anxiety, depression, and stress.1, 2 Since January, 2020, the National Health Commission of China have published several guideline documents, starting with the notification of principles for emergency psychological crisis intervention for the COVID-19 epidemic on January 26, then the notice on establishing psychological assistance hotlines for the epidemic on February 2, and most recently, guidelines for psychological assistance hotlines during the COVID-19 epidemic on February 7. 3 During the severe acute respiratory syndrome epidemic in 2003, internet services and smartphones were not widely available. Therefore, few online mental health services were provided for those in need. 4 The popularisation of internet services and smartphones, and the emergence of fifth generation (5G) mobile networks, have enabled mental health professionals and health authorities to provide online mental health services during the COVID-19 outbreak. Fast transmission of the virus between people hinders traditional face-to-face psychological interventions. By contrast, provision of online mental health services is safe. To date, several types of online mental health services have been implemented widely for those in need during the outbreak in China. Firstly, as of Feb 8, 2020, 72 online mental health surveys associated with the COVID-19 outbreak could be searched for via the WeChat-based survey programme Questionnaire Star, which target different populations, including medical staff (23 of the surveys), patients with COVID-19 (one survey), students (18 surveys), the general population (nine surveys), and mixed populations (21 surveys); in Hubei province (five surveys), other provinces (15 surveys), all provinces, municipalities, and autonomous regions (36 surveys), and unspecified areas of China (16 surveys). One such multicentre survey involving 1563 medical staff, with our centre at Nanfang Hospital, Southern Medical University (Guangzhou, China) as one of the study sites, found the prevalence of depression (defined as a total score of ≥5 in the Patient Health Questionnaire-9) to be 50·7%, of anxiety (defined as a total score of ≥5 in the Generalized Anxiety Disorder-7) to be 44·7%, of insomnia to be 36·1% (defined as a total score of ≥8 in the Insomnia Severity Index), and of stress-related symptoms (defined as a total score of ≥9 in the Impact of Events Scale-Revised) to be 73·4%. These findings are important in enabling health authorities to allocate health resources and develop appropriate treatments for medical staff who have mental health problems. Secondly, online mental health education with communication programmes, such as WeChat, Weibo, and TikTok, has been widely used during the outbreak for medical staff and the public. In addition, several books on COVID-19 prevention, control, and mental health education have been swiftly published and free electronic copies have been provided for the public. As of February 8, 29 books associated with COVID-19 have been published, 11 (37·9%) of which are on mental health, including the “Guidelines for public psychological self-help and counselling of 2019-nCoV pneumonia”, published by the Chinese Association for Mental Health. Finally, online psychological counselling services (eg, WeChat-based resources) have been widely established by mental health professionals in medical institutions, universities, and academic societies throughout all 31 provinces, municipalities, and autonomous regions in mainland China, which provide free 24-h services on all days of the week. Online psychological self-help intervention systems, including online cognitive behavioural therapy for depression, anxiety, and insomnia (eg, on WeChat), have also been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for psychological crises during the epidemic. For example, individuals at risk of suicide can be recognised by the AI programme Tree Holes Rescue, 5 by monitoring and analysing messages posted on Weibo, and alerting designated volunteers to act accordingly. In general, online mental health services being used for the COVID-19 epidemic are facilitating the development of Chinese public emergency interventions, and eventually could improve the quality and effectiveness of emergency interventions.

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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 mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus

            In December, 2019, a novel coronavirus outbreak of pneumonia emerged in Wuhan, Hubei province, China, 1 and has subsequently garnered attention around the world. 2 In the fight against the 2019 novel coronavirus (2019-nCoV), medical workers in Wuhan have been facing enormous pressure, including a high risk of infection and inadequate protection from contamination, overwork, frustration, discrimination, isolation, patients with negative emotions, a lack of contact with their families, and exhaustion. The severe situation is causing mental health problems such as stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear. These mental health problems not only affect the medical workers' attention, understanding, and decision making ability, which might hinder the fight against 2019-nCoV, but could also have a lasting effect on their overall wellbeing. Protecting the mental health of these medical workers is thus important for control of the epidemic and their own long-term health. The local government of Wuhan has implemented policies to address these mental health problems. Medical staff infected with 2019-nCoV while at work will be identified as having work-related injuries. 3 As of Jan 25, 2020, 1230 medical workers have been sent from other provinces to Wuhan to care for patients who are infected and those with suspected infection, strengthen logistics support, and help reduce the pressure on health-care personnel. 4 Most general hospitals in Wuhan have established a shift system to allow front-line medical workers to rest and to take turns in high-pressured roles. Online platforms with medical advice have been provided to share information on how to decrease the risk of transmission between the patients in medical settings, which aims to eventually reduce the pressure on medical workers. Psychological intervention teams have been set up by the RenMin Hospital of Wuhan University and Mental Health Center of Wuhan, which comprise four groups of health-care staff. Firstly, the psychosocial response team (composed of managers and press officers in the hospitals) coordinates the management team's work and publicity tasks. Secondly, the psychological intervention technical support team (composed of senior psychological intervention experts) is responsible for formulating psychological intervention materials and rules, and providing technical guidance and supervision. Thirdly, the psychological intervention medical team, who are mainly psychiatrists, participates in clinical psychological intervention for health-care workers and patients. Lastly, the psychological assistance hotline teams (composed of volunteers who have received psychological assistance training in dealing with the 2019-nCoV epidemic) provide telephone guidance to help deal with mental health problems. Hundreds of medical workers are receiving these interventions, with good response, and their provision is expanding to more people and hospitals. Understanding the mental health response after a public health emergency might help medical workers and communities prepare for a population's response to a disaster. 5 On Jan 27, 2020, the National Health Commission of China published a national guideline of psychological crisis intervention for 2019-nCoV. 4 This publication marks the first time that guidance to provide multifaceted psychological protection of the mental health of medical workers has been initiated in China. The experiences from this public health emergency should inform the efficiency and quality of future crisis intervention of the Chinese Government and authorities around the world.
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              Author and article information

              Contributors
              Journal
              Lancet Psychiatry
              Lancet Psychiatry
              The Lancet. Psychiatry
              Elsevier Ltd.
              2215-0366
              2215-0374
              19 February 2020
              19 February 2020
              Affiliations
              [a ]Department of Psychiatry, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
              [b ]Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Southern Medical University, Guangzhou, China
              [c ]The Third People's Hospital of Qinghai Province, Xining, China
              [d ]Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macau Special Administrative Region, China
              [e ]Center for Cognition and Brain Sciences, University of Macau, Macau Special Administrative Region, China
              [f ]Department of Psychiatry, Renmin Hospital, Wuhan University, Wuhan, China
              [g ]Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
              Article
              S2215-0366(20)30077-8
              10.1016/S2215-0366(20)30077-8
              7129099
              32085841
              c1384da2-6adf-4c9d-8c3a-fa6bb8f0af9e
              © 2020 Elsevier Ltd. All rights reserved.

              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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