Mental health burden of COVID-19.

Dear Editor,

An often-overlooked side effect of local and global disasters is the psychiatric repercussions on individuals in the community. The current global pandemic has infected every continent; inequities due to socioeconomic status have been demonstrated in infection rates and clinical outcomes (1,2). In the past few years, health care providers faced Public Health Emergencies of International Concern (PHEIC) with recent events including the 2009 H1N1 influenza pandemic, the 2012 Middle East Respiratory Syndrome outbreak, the 2014 Ebola epidemic and the 2015/16 Zika virus.

The mental health effects that impact the community are particularly important to recognize for general practitioners (GPs) who are largely responsible for managing these illnesses. The psychological and mental health effects are varied and include anger, anxiety, post-traumatic stress, avoidance behaviour, fear of infections, frustration and boredom, financial pressures and lingering stigma even post-pandemic (3–5). As a lot of GP practices are closed and taking calls from patients, it is increasingly important to recognize some of the possible telehealth options that GPs can offer their patients. This provides a tool for patients to receive access to vital medical expertise without the need to have a face-to-face contact. This is particularly useful for vulnerable patients and the elderly as it allows them to reduce their exposure to the virus. With the UK beginning to ease off the initial lockdown, it is important to learn from this event, as well as from previous pandemics, to appropriately organize interventions in future lockdowns.

Mental health impact on the general public and patients in primary care

The persistent effects of global or local disasters can lead to psychological problems for the public and health care providers likewise. Research from previous pandemics such as the H1N1 influenza in 2009 and Severe Acute Respiratory Syndrome (SARS) in 2003 highlighted the immense fear, panic and resultant psychological impact on the populace (5). Following the COVID-19 outbreak, a web-based survey conducted in China highlighted an increase in symptoms of generalized anxiety disorder (6). The research identified that younger people are at increased risk, partly due to the time spent on social media. Another survey examining the UK population found that one in two people felt down, depressed or hopeless about the future potentially putting 41% of the nation’s mental health at risk (7). These mental health problems likely stem from ‘hypochondriacal concerns’ and other psychosocial elements related to economic, socialization and isolation issues (6).

Furthermore, patients and health care workers with other mental health conditions such as depression and somatoform disorders have reported worsening of symptoms along with relapses (8,9). Mortality has also been predicted to be higher in these individuals with concomitant COVID-19 infection (10).

With the stock market crashing and the ever-increasing likelihood of a recession, millions of people may lose their jobs. A lack of financial support in such circumstances will only worsen the psychological health of the public. In the USA, where health insurance is often tied to employment, this can lead to a greater level of stress and solutions can only be sought through changing state and government policy. On the other hand, in places such as the UK, where health care is freely available, times such as these can lead to resources being stretched and indeed, the use of new innovative technologies may help to reduce the burden on public health resources, through the provision of psychotherapies both by online humans and artificial intelligence algorithms (11). It should be noted however that many of these applications are not free. All these factors create a recipe for major psychosocial disturbances in society. Now more than ever it is important that mental health matters are appropriately addressed and accounted for in this time of societal distress. Indeed, this is a great concern for primary care physicians.

Mental health impact on healthcare professionals

The carers are at great risk for psychological distress during pandemics. Evidence from the SARS and H1N1 outbreaks highlights the mental health burden on health professionals (12,13). A study conducted during the SARS outbreak in 2003 examining the psychological state of hospital staff found that being quarantined was the biggest predictor for the development of acute stress disorder. Furthermore, these staff including doctors, nurses and physician assistants who were quarantined were more likely to report detachment from others, anxiety, irritability, insomnia and subsequently suffered from deterioration in work performance and reluctance to work (14). Indeed, similar trends are also being reported with COVID-19 and the addressing of these issues is essential for a healthy workforce (15–17).

Solutions

Health care workers

Perhaps one of the key failures in this pandemic has been data collection in real time, especially for mortality data from different sources, but the challenges of an unprecedented crisis, as well as lack of preparation of the public health system may be hindering factors.

The immense pressure that medical staff are under whilst combatting the coronavirus is clear. A detailed plan involving online courses, group activities, assistance with accommodation and food, provision of leisurely activities to ease stress and detailed instructions on reducing the risk of contracting the disease should be implemented to reduce stress. It is important to ensure the health workers are not overworked and shift-based rotas be implemented ensuring adequate rest periods. Furthermore, in the UK, many companies aided health workers through the provision of free food, services, products, and accommodation. This was particularly helpful because it provided a site away from family and thus alleviates the stress of transmitting the virus to family members, many of whom may be vulnerable. Whilst this may be useful in the short term and provides good publicity for companies, it is not a sustainable option and thus governments should plan funding to companies to allow these schemes to be available for longer durations, and if further lockdowns are required, as necessary.

Public

There are three main priorities from a mental health perspective that should be incorporated into public health planning:

Prevent an increase in mental health burden

Protect people with pre-existing mental health disorders

Provide appropriate public mental health interventions to both members of the public and health professionals.

Similarly, lessons can be learned to provide effective psychological management for members of the public. As a lot of normative patterns are disrupted due to the quarantine, it is important to establish a sense of normalcy. This can include simple measures such as having a regular, healthy sleeping pattern. Explaining to patients that, despite the quarantine, it is important to have regular time away from others within the same house, which can be helpful for some individuals. Others may require prompting to be more open and engage with individuals in the same household. For those living in isolation, contacting friends and families regularly is essential, and for those who do not have people whom they may contact, GPs should ensure that regular contact is maintained with vulnerable patients. GPs, however, are already stretched for time, and as such, the mass volunteering scheme that the UK has implemented can allow volunteers within the society to keep in contact with people who are at risk of being isolated. Other simple interventions such as exercise and relaxation techniques should also be encouraged to improve mental wellbeing. If gyms and public parks are closed, these activities should be encouraged at home. Hence, public health bodies must emphasize the importance of having a healthy routine at home, and staying connected to others via phone and text messaging. Institutions will also need to set up online platforms to provide psychological therapies and counselling for patients, family members and other individuals impacted by this pandemic.

Tele-technologies employing video consultation may prove to be very beneficial in conducting remote consultations in accordance with current isolation guidelines (18). Given the widespread use of the Internet and video call technologies, this will not be difficult be difficult to implement. In fact, video consultations are already routinely conducted through mobile health applications (19). Online psychological therapies are well recognized, with cognitive behavioural therapy (CBT) widely used for numerous psychiatric conditions. Thus, patients currently receiving in person CBT should receive this therapy online. Furthermore, patients being seen for other non-mental health issues should be screened and tested for anxiety, social isolation, financial insecurity and general state of mind.

Conclusion

This is an unprecedented situation and it is important to be malleable in our response. The mental health of those on the front lines rightfully need to be highlighted. However, the widespread nature of this pandemic is going to affect all corners of society. Hence, being proactive in finding active solutions to mitigate and improve mental health should be a high priority of public health bodies and physicians.

Declaration

Funding: none.

Ethical approval: not applicable.

Conflict of interest: none.