The Mental Health Toll of COVID-19

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The physical health impacts of COVID-19 have been well highlighted in the media. However, less discussed are the consequences that the stress of a pandemic in general – and quarantine measures in particular – have on mental health. Research from Australia shines a light on how the current pandemic has affected mental health, specifically the conditions of social isolation and loneliness.

Social Isolation & Loneliness

Drs. Ben Smith and Michelle Lim reviewed the psychological and social implications of COVID-19, principally the impact of the pandemic on social isolation and loneliness associated with social distancing1. In a survey conducted by the Australian Bureau of Statistics, 28% of women and 16% of men felt lonely due to the pandemic2. This survey also found that loneliness was the most frequent stressor linked to the pandemic2. Additionally, another survey found that COVID-19 increased stress and anxiety levels in 47% of participants and caused 24% of people to feel isolated3. Interestingly, while these numbers generally represent an increase in mental health issues, earlier surveys found that a quarter of respondents were lonely and 16% felt socially isolated, suggesting that these mental health issues were not uncommon prior to COVID-19.

The increased prevalence of both social isolation and anxiety are concerning as they have been linked to depression and cognitive decline. Mental health issues have also been tied to increased rates of cardiovascular disease and early death4. Unfortunately, there is little knowledge on how to effectively treat social isolation. Current strategies include befriending programs, group therapy, and shared activity programs such as exercise classes, but these are challenging during times in which physical isolation is necessitated. In order to treat mental health conditions during a pandemic, further studies must be conducted to test therapies that can be delivered while maintaining quarantine.

Quarantine & Mental Health

The mental health implications of quarantine measures are not unique to the COVID-19 pandemic. In one study published in 2013, it was found that children who were quarantined or isolated had post-traumatic stress scores that were 4-times higher than similarly aged children who were not isolated5. The study also found that the prevalence of post-traumatic stress disorder increased to a similar level in parents whose children were isolated5. Generally speaking, studies on the mental health impact of quarantine have reported a high occurrence of psychological distress symptoms, low mood, and irritability6. Of note is that longer quarantines have been associated with poorer mental health, such as avoidance behaviour, anger, and post-traumatic stress symptoms6.

A Pandemic of Stress

Quarantine and social isolation are not the only mental stressors during this pandemic: concerns over the health effects of COVID-19 can negatively impact mental health. In a survey conducted by Wang and colleagues, 75% of participants were concerned about their families contracting COVID-19, and 54% rated the psychological impact of the outbreak as moderate to severe7. Moderate or severe anxiety was reported in 29% of survey respondents, and 17% had moderate to severe depressive symptoms7. Negative impacts on mental health have been seen in previous pandemics, such as the 2009 H1N1 outbreak, where over 10% of participants in a study reported felling panicked, very depressed, or emotionally disturbed8.

Economic pressures, which have marked the COVID-19 pandemic, can negatively impact mental health9. Financial loss can result in a decline in mental well-being, higher rates of mental disorders, and suicidal behaviour9. Studies linking economic challenges to poor mental health suggest that the current pandemic will negatively impact the mental health of individuals around the world for some time to come.

Youth Are Not Immune

Groups that may be overlooked when thinking about mental health during the pandemic are children and young adults. The relatively low morbidity and mortality rates seen in these cohorts may give the impression that they are largely immune to the consequences of COVID-19. But early studies suggest that in terms of their mental health, young people may be just as vulnerable as older adults. The loss of peer contact can negatively impact a child’s wellbeing9. Furthermore, a preliminary study of children ages 3-18 found that the most common problems they experienced were clinginess, irritability, distraction, and a fear of asking questions regarding the current pandemic10. Additionally, a survey of college students found that almost a quarter suffer from anxiety as a result of the COVID-19 pandemic11. In young adults anxiety levels correlated with fear regarding the economic influences of the pandemic, as well as the influence of COVID-19 on daily-life11.

The Mental Health of Healthcare Workers

A key group of concern for mental health issues is healthcare workers, as they are at the frontlines of the pandemic. Healthcare workers have worries about infecting their families and high stress levels when dealing with severely ill patients12. As a result, healthcare workers are experiencing high psychological pressure and are at risk of developing mental health problems12.

Among the mental health conditions increasing in healthcare workers are anxiety and stress disorders. A survey of 1,257 frontline healthcare workers in China in early February found that 72% of workers reported symptoms of distress, 45% had symptoms of depression, and one-third experienced insomnia13.

Outside of the stress of direct patient care, healthcare workers may have negative thoughts because they know more could have been done to treat patients if they had sufficient resources14. This feeling is known as a “moral injury” and it has been linked to mental health conditions such as depression and post-traumatic stress disorder14. Reports of insufficient medical supplies, equipment, and personal protective equipment by frontline healthcare workers during the COVID-19 pandemic have created environments that are ideal for the development of feelings of guilt that may lead to moral injury and increased rates of mental illness.

Surviving COVID-19

Patients who survive COVID-19 are at increased risk for developing mental health issues. Previous data from SARS and MERS outbreaks, combined with early data from COVID-19 patients, finds that patients infected with coronavirus may experience delirium, confusion, agitation, and altered consciousness15. In COVID-19 patients a stunning 96% showed post-traumatic stress symptoms and almost one-third had depression16. Patients with pre-existing psychiatric conditions reported a worsening of their mental health with COVID-1916.

Due to the recency of the COVID-19 pandemic, there are minimal data on the long-term effects of COVID-19 on mental health. However, in previous epidemics such as SARS, post-illness patients presented with anxiety, post-traumatic stress disorder, and insomnia15. Thus, it is likely that COVID-19 patients, more so those who were critically ill, may suffer from mental health conditions even after recovering from the infection15.

Solutions

The question remains, given the likely rise in mental illness in the following months and years, how does society deal with the mental health issues associated with COVID-19?

One measure that is already in place is telepsychiatry and telehealth, which allow patients to receive the help they need without having to compromise their physical safety9. In China, psychological crisis intervention guidelines have been created for COVID-19 survivors17. It will be critical to implement and maintain easily accessible crisis interventions and mental health services even after the end of the pandemic to prevent long-term declines in mental health9.

Although telemedicine and increased mental health support services are considerable and time-consuming programs, there are small actions that can aid in this crisis. One such act is personally contacting friends and family members who are at risk, so they know they have a support system in a time of crisis17. Furthermore, getting in contact with those who appear to be suddenly avoiding others is critical, as avoidance is a symptom of trauma14. While face-to-face contact may be limited in some areas because of physical distancing guidelines, telephones and video conferencing systems provide a means for social interactions that are critical for maintaining mental health.

What Needs to Be Done

At present there is limited information on the long-term mental health impact of COVID-19 in patients, healthcare workers, and the general public. To gather more information, future studies must be conducted to determine the prevalence of mental health disorders, whether they are related to the illness itself or interventions like physical distancing and quarantines, as well as effective ways to treat these conditions9. Education and resources must also be provided to the public so they are able to identify and deal with mental health issues, as there will be a high demand for mental health services.

References

  • 1. Smith, B. J., & Lim, M. H. (2020). How the COVID-19 pandemic is focusing attention on loneliness and social isolation. Public Health Research & Practice. 30(2), 3022008. DOI: 10.17061/phrp3022008
  • 2. Australian Bureau of Statistics (2020). Household Impacts of COVID-19 Survey. Link here
  • 3. Marlay B., Attenborough, J., & Kutcher, V (2020). “Living in limbo”: the views and experiences of young people in Australia at the start of the COVID-19 pandemic and national response. UNICEF. https://www.unicef.org.au/Upload/UNICEF/Media/Documents/UNICEF-COVID-19-Living-in-Limbo-2020.pdf
  • 4. American Heart Association. Mental Health and Well-Being. Link here
  • 5. Sprang G, Silman M. (2013). Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster Med Public Health Prep. 7(1), 105-110. DOI:10.1017/dmp.2013.22
  • 6. Brooks SK, Webster RK, Smith LE, et al. (2020). The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 395(10227), 912-920. DOI:10.1016/S0140-6736(20)30460-8
  • 7. Wang C, Pan R, Wan X, et al. (2020). Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health. 17(5), 1729. DOI:10.3390/ijerph17051729
  • 8. Gu J, Zhong Y, Hao Y, et al. (2015). Preventive behaviors and mental distress in response to H1N1 among university students in Guangzhou, China. Asia Pac J Public Health. 27(2), NP1867-NP1879. DOI:10.1177/1010539512443699
  • 9. Fegert, J. M., Vitiello, B., Plener, P. L., & Clemens, V. (2020). Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child and Adolescent Psychiatry and Mental Health. 14, 20. DOI: 10.1186/s13034-020-00329-3
  • 10. Jiao WY, Wang LN, Liu J, et al. (2020). Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic. J Pediatr. 221, 264-266.e1. DOI:10.1016/j.jpeds.2020.03.013
  • 11. Cao W, Fang Z, Hou G, et al. (2020). The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Res. 287, 112934. DOI:10.1016/j.psychres.2020.112934
  • 12. Chen Q, Liang M, Li Y, et al. (2020). Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry. 7(4), E15-E16. DOI: 10.1016/S2215-0366(20)30078-X
  • 13. Lai, J., Ma, S., Wang, Y., Cai, Z., et al. (2020). Factors Associated with Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 3(3), e203976. DOI:10.1001/jamanetworkopen.2020.3976
  • 14. Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020). Managing mental health challenges faced by healthcare workers during COVID-19 pandemic. BMJ. 368, m1211. DOI: 10.1136/bmj.m1211
  • 15. Rogers, J. P., Chesney, E., Oliver, D., Pollak, T. A., McGuire, P., Fusar-Poli, P., Zandi, M. S., Lewis, G., & David, A. S. (2020). Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 7(7):611-627. DOI: 10.1016/S2215-0366(20)30203-0
  • 16. Vindegaard, N., & Benros, M. E. (2020). COVID-19 pandemic and mental health consequences: Systematic review of the current evidence. Brain Behav Immun. S0889-1591(20), 30954-5. DOI: 10.1016/j.bbi.2020.05.048
  • 17. Spoorthy, M. S., Pratapa, S. K., & Mahant, S. (2020). Mental health problems faced by healthcare workers due to the COVID-19 pandemic-A review. Asian J Psychiatr. 51, 102119. DOI: 10.1016/j.ajp.2020.102119

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