Worried well and Covid-19: Re-emergence of an old quandary.

Dear Sir,

As Covid-19 hit the world, almost all the countries are tackling it with lockdown, increased testing, and other strategies. The developed countries have passed their peak, whereas developing countries are yet to flatten the 'hammer curve'. More than 40 million tests have been carried out till now and still the demand is ever increasing. Moreover, even after the acute phase attenuates, there will be many post-pandemic psychological and psychosocial effects to be dealt with (Tandon, 2020; Chatterjee et al., 2020). As actual cases are continuing to overwhelm the health care, there is another set of people posing burden to the healthcare system, that is the 'worried well', a phenomenon referred clinically as a type of mass psychogenic illness.

. Evolution of concept

'Worried Well', as a concept, was first described during HIV, when many people visited hospitals for consultation, for being tested or for reassurance(Cochran and Mays, 1989). Pilch gave a categorical description that roughly divided these patients into three categories i.e (a) individuals not exposed in a real way, yet experiencing symptoms of the disease in question, due to anxiety, (b) individuals who may have been exposed or fear that they will get exposed due to nature of their work etc, who do not have symptoms of the illness, but may seek medical services as a preventive measure or to alleviate their anxiety and for reassurance, (c) individuals who experience anxiety or distress following traumatic events (Pilch, 2004). After the HIV epidemic attenuated, the research on this topic decreased but resurfaced recently with different diseases, namely Dementia or MCI(Verity et al., 2020) and bowel cancer screening(Chapman et al., 2016).

There are previous reports about how these are different from somatoform disorder (Smith et al., 2002) but these data should be taken with caution as most of the studies were done in general practice settings as they invariably visit physicians. Upon a medical diagnosis being ruled out, such patients are labelled 'worried well', but unfortunately with a negative connotation to it.

Relevance to COVID-19 pandemic

Worried well population poses a risk by various unintended and unintentional acts of violation of preventive measures like social distancing, thus spreading the infection, frequenting hospitals to know if they have the illness or not, overburdening the health care system (cost, manpower, diagnostic kit, gloves, personal protective equipment), buying of drugs which are being circulated as possible prophylaxis (which could actually be used for those who need it more). These individuals can unintentionally absorb a great deal of attention in their pursuit of reassurance. Their anxieties fail to be allayed by repeated negative tests. Such situations create a panic like situation and increases the burden on an already pressured health care system. Virtually all epidemics in history have noted the worried well phenomenon, but unfortunately there is also a negative connotation oftype casting associated with it (Gray et al., 2020).

The way forward

Some measures to deal such situations have been suggested in the past, like immediately imparting the right information through use of various print and broadcast media about symptoms and about who should visit the hospital and who should not. In addition various other measures have been suggested in the past like having a good 'surge capacity' (Hick et al., 2004), triage of cases(Ramesh and Kumar, 2010), having an arrangement like 'mild casualties centre' where people with mild symptoms are assessed, screened and sent to either required speciality or for counselling and to a Psychiatrist when confirmed that symptoms are psychogenic. At present, Illness anxiety disorder, anxiety NOS, somatoform disorder might be the possible differential diagnosis. So, we should differentiate them from the true worried well. A psychiatrist may treat the patient based on the differential diagnosis and when it is an established 'worried well' case, reassurance and educating should be emphasized upon.

To sum up, the basic concern in all the diseases are the same, over-utilizing the health service and resources, and should be taken seriously. Being cautious, maintaining a balance and conducting organised studies is warranted in this field, for better understanding and analysis, and to devise better management plans for any future events.

Author contribution

All the authors have contributed and approved the final manuscript.

Funding

There was no financial assistance sought in any form for this work.

Declaration of Competing Interest

Nilo.