Over 12,000 years of human history, pandemics have killed an estimated 300 to 500 million people, with the bubonic plague eliminating an estimated 60% of the European population during the Middle Ages. Despite modern advances in medicine, COVID-19 has caused more than 1 million reported deaths (as of late-September) in less than a year. Aside from the death toll, the pandemic has caused significant emotional, physical, and economic problems around the world. But even in the midst of this crisis nations have an opportunity to share and learn from each other’s experiences.
The emerging literature measures the impact of traumatic stressors related to COVID-19, as well as the effects of less severe types of stress exposures. The coronavirus has already led to diverse mental health problems, including anxiety, depression, PTSD, and other trauma and stress-related disorders. Different groups have met DSM-5’s traumatic exposures qualifying criteria for PTSD during the pandemic: those who have themselves suffered from serious COVID-19 illness and potential death; individuals witnessing others’ suffering and death as family members and healthcare workers; individuals learning about the death or potential death of a family or friend due to the virus; and individuals experiencing extreme exposure to aversive details (journalists, first responders, medical examiners, and hospital personnel).
Moreover, studies have explored other stressors adding to individuals’ emotional burdens, such as social isolation, unemployment and economic losses, and working from home while caring for children and other family members. Among healthcare workers, strains include lack of personal protective equipment (PPE), fears of virus exposure, burnout, patients perishing despite heroic efforts to save them, and facing difficult decisions about which patients should receive limited resources. A few studies have examined posttraumatic stress symptoms (PTSS), as well as anxiety, depression and other symptoms, and substance use in the general population during the pandemic.
More time is needed, of course, to conduct and publish systematic investigations on mental health sequelae, such as formal psychiatric diagnoses. Studies generally have been conducted through diverse internet platforms, which may affect generalizability. Methods and validated rating scales vary.
At the same time, it is not too soon for clinicians to read the emerging literature and base treatments on the latest research. We will explore some representative international studies of various groups affected by the coronavirus, as well as protective factors and suggested interventions to help those in need (Figure 1).
Highly exposed individuals
Much of the current research emerges from China, the first country confronted by the pandemic. Among medical caregivers, a study of nurses in China exposed to the coronavirus found a PTSD incidence of 16.8%, with highest scores in avoidance symptoms.1 Job satisfaction was associated with lower PTSD symptom scores and positive coping. The authors recommend supporting nurses who are having difficulty coping with their work by providing counseling and improved job satisfaction.
A web-based, cross-sectional survey of more than 7000 Chinese individuals in February 2020 found health care workers had the highest rate of poor sleep, and those younger than age 35 had more mood and anxiety symptoms.2 Overall, 35.1% of respondents reported anxiety symptoms, 20% depressive symptoms, and 18.2% poor sleep quality.
Other international studies have examined stress responses in health care workers treating coronavirus patients. A study of 900 health professionals caring for hospitalized COVID-19 patients in Singapore and India found relatively low symptoms of anxiety (15.7%), depression (10.6%), and stress (5.2%).3 However, among health care workers reporting these issues, more than half had symptoms in the moderate to extremely severe levels. In addition, 67% of respondents reported physical symptoms, especially headache, lethargy, anxiety, and insomnia, suggesting a somatic expression of distress. United Kingdom military health care workers were assessed for the effects of inadequate safety equipment on their mental health during the COVID-19 medical response. Those with inadequate equipment had greater odds of having common mental health disorders (2.49), PTSD (2.99), poorer global health (2.09), and emotional problems (1.69).4
Only a few studies of mental health problems among hospitalized COVID-19 patients have been published, with more to come. A study of hospitalized but stable patients found a high prevalence of posttraumatic stress symptoms (PTSS) (96.2%).5 A chart review of hospitalized COVID-19 patients in Spain found more than half of the 841 patients hospitalized with COVID-19 had a neurological symptom. Of these, nonspecific neurological symptoms were identified, as well as disorders of consciousness (19.6%), mostly in elders and in severe COVID-19; myopathy (3.1%); dysautonomia (2.5%) and other less frequent symptoms.6 Neuropsychiatric symptoms were reported by 19.9% of these patients, including insomnia, anxiety, depression and psychosis; these were not associated with disease severity.6
Some studies have drawn inferences based on other severe respiratory viruses. A meta-analysis of long-term clinical outcomes for ICU survivors of adult severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) revealed PTSD prevalence in 39%, depression in 33%, and anxiety in 30% beyond 6 months after discharge, as well as reduced lung function and reduced exercise capacity.7 Italian experts also concluded that we might anticipate similar outcomes in COVID-19 survivors.8
Acute respiratory distress syndrome (ARDS) in ICU survivors of COVID-19 may occur, with an expected survival rate of approximately 25%. ARDS survivors may experience persistent fatigue and poor exercise tolerance, pain and weakness, neurological sequelae, and the psychological effects of prolonged ICU stays, as noted in MERS and SARS patients. Stressors included immobility, separation from family and friends, prolonged sedation, anxiety about health conditions and survival, and subsequent job loss. The authors emphasized the need to identify PTSD (anticipated in up to 30% of ARDS survivors) and other mental health problems, and to provide appropriate and timely multidisciplinary therapy that should continue after discharge.8 A literature review of studies linking panic disorder with SARS patients suggested that aggravation of panic attacks is highly likely in COVID-19 survivors in the face of prominent respiratory symptoms, as panic may be triggered by fear conditioning to abnormal breathing problems.9 The authors urged monitoring for panic as well as OCD, PTSD and GAD.
Exposure to non-traumatic stress
There are some mental health care advocates who believe the general population may be suffering from various levels of vicarious traumatization, although strictly speaking this would not qualify for PTSD’s Criterion A for trauma exposure. Along these lines, in mid-August the CDC published a large US web-based survey of more than 5000 adults (Table),10 in which 40.9%, endorsed at least one adverse mental or behavioral health problem related to the pandemic. Symptoms of a trauma- and stressor-related disorder were reported by 26.3%, symptoms of anxiety or depression by 30.9%, substance use to cope by 13.3%, and serious consideration of suicide in the prior days by 10.7%. Suicidal ideation was significantly higher for younger respondents aged 18 to 24 years (25.5%), minority groups (Hispanics 18.6% and blacks 15.1%), non-paid caregivers for adults (30.7%), and essential workers (21.7%). The authors stressed the need to identify at-risk individuals and to develop policies to address health inequities: increasing resources for identifying mental health problems and offering new treatment options, including telehealth treatments.10
In a study of among home-quarantined youth in China during the first month of the coronavirus outbreak, 12.8% had PTSS levels consistent with PTSD, with PTSS and distress associated with negative coping styles.11 Symptom levels were expected to increase with time as quarantine continued. This is important since a formal diagnosis of PTSD requires symptoms to persist more than a month.
In another online survey conducted early during the Wuhan outbreak, researchers looked at anxiety and depression symptoms (rather than specific PTSS) in relation to social media exposure (SME) to news about COVID-19. The study, which included of approximately 5000 adults in China, found high SME was positively associated with higher odds of reporting anxiety and a combination of depression and anxiety, compared to low SME.12 A longitudinal survey of the general population in China during the initial outbreak and 4 weeks later found the mean Impact of Events (IES) Scores above the cut-off scores for PTSD symptoms at both times, with moderate to severe stress, anxiety, and depression levels.13
Results of an Italian cross-sectional, web-based survey showed a relatively high percentage (29.5%) of PTSS related to the pandemic, suggesting that the pandemic itself could be considered a traumatic event.14 Similarly, an online survey of almost 3500 people in Spain found symptoms of PTSD (15.8%), depression (18.7%), and anxiety (21.6%), with loneliness the strongest predictor of symptoms.15 Other factors associated with these problems were female gender, previous mental health or neurological problems, having physical symptoms similar to the virus, or having a close relative infected.
Nursing home residents have been particularly vulnerable to poor health outcomes, so early in the COVID-19 pandemic many facilities adopted strict lockdown policies. However, social isolation is particularly detrimental to elders, who may have increased risk for depression, anxiety, worsening dementia, and even earlier death.16 Given these issues, the Centers for Medicare and Medicaid Services (CMS) recommended safe communal activities for locked-down nursing homes.
In Canada, researchers explored prenatal maternal distress before and during the COVID-19 pandemic.17 Women assessed during the pandemic had higher levels of depression and anxiety, with levels more likely to be clinically significant, compared to women assessed before the coronavirus. During the pandemic, dissociative and PTSD symptoms and negative affectivity were also greater, underscoring the need to carefully assess pregnant women and prevent negative, stress-related outcomes in mothers and infants.
Perhaps not surprisingly, when compared to a control population, psychiatric inpatients in China had more PTSD, anxiety, and depression symptoms; more worries about health, anger, and impulsivity; and intense suicidal ideation.18 Hospitalized psychiatric patients and their mental health caregivers are at high risk for COVID-19 infection, compounding their existing stress. This was noted early in February 2020 in Wuhan, when at least 50 inpatients with psychiatric disorders and 30 mental health professionals were diagnosed with the virus. Factors included lack of protective gear and difficulties isolating.19 Psychiatric outpatients are also vulnerable to emotional distress during a pandemic. An online survey of more than 2000 outpatients in China discovered that 20.9% of patients with preexisting psychiatric disorders had seen their symptoms get worse during the pandemic.20
How can we help individuals whose mental health has been harmed by COVID-19?
To support medical caregivers assigned to the front line during the pandemic, experts advise addressing burnout, as prolonged problems may overlap and lead to acute stress disorder and PTSD.21 Suggestions have ranged from practical measures (such as ensuring adequate PPE, handwashing, and decontamination of surfaces) to developing personnel policies that reassign at-risk medical personnel away from high-risk sites, ensure the safety of their family members, and stress the importance of self-care.22 Also recommended are providing healthcare workers access to child care services during expanded work hours and school closures. Workers should have adequate rest and breaks, be excused from less essential tasks and have regular information and feedback sessions with managers and the community. In many areas, hospitals provide telephone hotline teams trained to provide psychological assistance. Professional organizations offer physician wellness programs to provide free, confidential sessions to deal with burnout, adjustment problems, family issues and other mental health sequelae.
The increasing numbers of COVID-19 survivors who were seriously ill should be assessed for physical symptoms of chronic pain,8 with physical therapy and medications adjusted to avoid opioid dependence. ARDS survivor should receive evidence-based medications, CBT, and other psychotherapies for PTSD, panic, depression, and other mental disorders.
To combat isolation among locked-down nursing home residents, the Centers for Medicare & Medicaid Services (CMS) recommends safe communal activities such as book clubs, movies, bingo, and outdoor family visits (even in outdoor areas or parking lots) with precautions of social distancing and PPE. Some nursing homes have provided live music, parades, therapy animals, recordings and photos of loved ones, physical contact with loved ones through plastic protective barriers, and even outside physical and occupational therapy.16
Psychological first aid provided by trained community personnel might help the general population as it experiences distress during the pandemic.2 For individuals enduring fallout from personal stressors, experts have recommended expanded use of telehealth to identify and treat mental health conditions, including depression, PTSD and other trauma-related disorders, substance use disorders, and suicidal ideation. Self-help groups, 12-step programs, spiritual and religious services, interest groups, and employee groups working from home are all increasingly using interactive internet-based platforms. And it is essential for societies to provide citizens with assistance for jobs, housing, food, medical care, education, internet connections, and many other basic survival needs.
The current international pandemic and possibly future ones will challenge us and also gives us the chance to continue to learn and share with other nations, hopefully linking us cooperatively rather than polarizing us.
Phebe Tucker, MD is professor and vice chair of education, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. Christopher Czapla, MD is assistant professor and residency training director, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. Authors have no relevant financial conflicts of interest.
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