We explore the global evidence of major health crisis potential impacts and the factors influencing the mental health outcomes among the population during the outbreak of COVID-19. Preparation measures for a COVID-19 focus on rapid quarantine of social isolation and economic concerns have risen metal health considerations that become an integrated part of the pandemic outbreak. This outbreak of novel Coronavirus disease (COVID-19) pandemic is swayed an overall 213 countries, areas or territories, with over 2,921,439 confirmed cases and 203,289 confirmed deaths reported till 26 April 2020. This created a lot of strain and fear; fear of falling ill and dying of being infected leading to heightened levels of insurmountable psychological pressure. This scrutiny attempt to assess the widespread outbreaks of COVID-19 on mental health professionals, healthcare workers and general population in association with adverse mental health sequelae like generalized anxiety disorder (GAD), depressive symptoms, insomnia, panic attacks, post-traumatic stress disorder, OCD, suicidal behavior, delirium, psychosis, harmful alcohol consumption, and drug use. There is a need for more evocative exploration to intensify awareness to address the potential psychological and behavioral risks that will remain elevated as long as the COVID-19 pandemic continues in the community. In conclusion, incessant surveillance of the subsyndromal mental health problems for outbreaks should be part of galvanized global action during the quarantine.
Academic Editor: Raul Isea, Fundación Instituto de Estudios Avanzados -IDEA, Venezuela.
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2020 Ravinder Yadav, et al.
The authors have declared that no competing interests exist.
The societal impact of pandemic recrudescence is more than a medical phenomenon, causing inevitable mental health effects on the general population, medical practitioners, as well as on the infected individuals. Individuals with mental illness and witnessed medical practitioners may be particularly highly vulnerable to perceived menace followed by anxiety-related behaviors and other major health concerns. The increased wield of masks as appropriate protective measure1 but an incongruous shortage of protective paraphernalia cause exhaustion and fret in a densely populated country like India. The unavailability of basic protection measures like masks and sanitizers endangers worldwide health workers2 especially with a robust healthcare infrastructure of India.
On 17th February 2020 Dr. Zhi-Ming Liu, the President of Wuhan Wuchang Hospital in Hubei province divulge the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) as a possible emergency, whereas the infection spread across the globe in a rapid pace, on the 30th January 2020, the COVID-19 declared as a global health emergency2,3. According to Baud et al., 2020 the mortality statistics are underestimated4, however, the WHO report revealed the mortality rate to be between 3–4 %3. COVID-19 pandemic is an age-associated chronic condition, in support of this Centers for Disease Control and Prevention5 reported the severe outcomes among those 85 years plus and 80% of all United States COVID-19 deaths were among adults 65 years or older. Older adults are more vulnerable to this pandemic but mental health impacts can be particularly strenuous for patients with cognitive decline or dementia6. In 2003, approx. a 30% increase in suicide in those aged 65 years and older; 50% remained anxious after recovery; and 29% of health-care workers experienced emotional perturbation at the time of SARS epidemic7,8,9.
The knowledge & attitudes with sufficient resources typically influence the degree of adherence to manage or attenuate pandemics’ effects on the perceived state of health. The resilience training program for medical practitioners in the preparation of pandemic seen as a way of protecting strategies like timely addressing of fears and worries among the medical team10; education and preparation; ensuring fairness and addressing ethical concerns; and ardent information on medical staff's redeployment to high-risk areas have incorporated at the outbreaks of the influenza pandemic and the exposed case of COVID-19. Despite this fact, the lack of sufficient resources to manage or attenuate pandemics has underlying effects on mental health conditions11 regarding the older people and frontline female nurses reporting extremely frightening prodrome include PTSD, depression, and grief are of abiding concern.
This virus is also known to be transmitted by mildly ill or pre-symptomatic infected persons, which pose a challenge to control compared to the middle east respiratory syndrome (MERS) and SARS pandemics12. The results are consistent with studies on the SARS outbreak which demonstrated that 18%-57% of medical providers experiencing bewilderment at the onset, during, and after the affliction13. As of 26th April 2020, a total of 2,921,571 cases has been reported from 210 countries and territories around the world; also, there are 203,299 confirmed deaths across the globe with 1,881,221 active cases, out of 97% (1,823,354) in mild condition and 3% (57,867) in critical condition. To date, Indian Govt. has registered over 26,496 confirmed cases and 824 deaths attributable to this disease. On March 15, 2020, Psychiatric Times accessed that the outbreak of the pandemic has collision on the existing illnesses and leads to an emergence of mental symptoms among the all age group14. The pandemic is possibly related to the interplay of both spread of the disease and the occurrence of mental disorders during and after the outbreak. An online survey reported approx. 80 % of candidates felt the need and 75 % agreed on the necessity for substantive advice from cognoscente and aficionado15. About 1/3rd participants having indecorous social behavior owing to the emotional and other psychological issues during this pandemic15.
To prevent the transmission of pestilential diseases among individuals and communities, effective quarantine, isolation, and preventive social distancing as a public health measure16,17.The World Health Organization and Centers for Disease Control and Prevention recommend 14 days quarantine and social distancing, as, the COVID-19 pneumonia infection is believed to spread person to person primarily through droplets from the nose or mouth18,19. (WHO, 2020; Del Rio C & Malani PN, 2020). As in the 14th century, quarantine was one of the fewest known measures during the plague epidemics5 but later on became as imperative components in addressing cholera and the current pandemic5,17,20.
Mental health outcomes of quarantine and isolation reviews reported a high burden of mental health conditions among 33% of the participants21 among general population22 and healthcare providers21,23. Although quarantine and isolation are adopted for protecting the physical health from infectious diseases, it is essential to consider the mental health implications for those individuals who experience such restrictions. People quarantined in earlier outbreaks of infectious diseases and increased social isolation following the pandemic outbreak have reported a perfect storm to harm people's mental health. Distress and initiating fear of falling sick or dying is expected to spark perpetual aggravating conditions in caregivers of affected individuals, which are expected to escalate day by day during this pandemic. Ultimately the outbreaks have the clinical outcome that can affect people with pre-existing mental illness and precipitating new psychiatric symptoms in those without mental illness.
Early identification and separation of suspected cases are the counteractive measures combating the pandemic24 and have a large influence on the degree of adherence on the medical teams and the population at large25. Due to the exaggerated rumors of the infection, there are perpetuations of the psychological trauma of bereaved families and victims are claimed longer than the general public avoided them, and were socially isolated even after being cured26. A study done by Deblina Roy et al., 2020 found about 72 % of participants reported aggravating mental health issue include intemperately worried being contaminated, approximately 40 % of the participants were paranoid and 12 % of the participants had sleeping difficulty concerned with the personal protective measures of themselves and their close ones during the ongoing pandemic15. People with less access to health care27 and homelessness have chronic mental and physical conditions28 along with high rates of substance abuse29.
Framing Mental Health Risk Provoke by Novel Coronavirus
In support of this generalized fear and impede behavior was common among the public during the early phase of the manifestation of SARS and 2014 Ebola outbreaks30,31. Besides, lots of studies have documented several psychiatric co-morbidities with innumerable emotional distress during the outbreaks of SARS and Ebola32 such as posttraumatic stress disorder, anxiety-related symptoms caused by SARS33; depression34, psychomotor excitement, delirium, and psychotic symptoms35, insomnia, and boredom cognate with quarantine following the infectious disease outbreaks and natural disasters like hurricanes, floods, and earthquakes36,37,38. Further, 25% of the general population will be affected by the intensity and content of encompasses of mental disorders affected by considering mood disorders and anxiety during their lifetime39.
The perpetual stigma can rise the pernicious stereotypes which may lead to cognitive distress and long term mental health disorders that prevent the worldwide population from seeking immediate healthcare measures by which symptoms frequently become serious and long-lasting. Symptoms like suicidality, anxiety, and stigmatization impacted the wellbeing22,40,41that tend to be common in high-risk persons, especially survivors42,43, affected individuals22,23,40, frontline healthcare workers and professionals44. Worthwhile the delayed effects presume the prolonged suffering is also manifested as post-traumatic stress, physically expressed anxiety, abuse of alcohol, and other addictive substances, perhaps it needs more time to determine and illicit the abuse. Compared with the general population the clinicians showed a higher intrusion sub-score and medical practitioners face burnout after the cessation of the incidence of such infections32due to several reasons include long working hours, physical fatigue, risk of infection, and separation from families45.
People without having pre-existing mental health conditions also anticipate a considerable increase in Agoraphobia (avoiding crowds)23, helplessness symptoms, Similarly the swine flu pandemic evoked anxiety46following excessive worry about contracting Covid-19 among the public significantly. In due course identifying post-traumatic stress disorder and increased anxiety levels have been detrimental to pregnant women, parents, and children. For instance, those who have asymptomatic transmission can trigger or potentiate additional fear, anxiety, and mental breakdown. Various psychological vulnerability factors motivate people to practice prophylactic diet of vinegar, kimchee, turnips and smoking cigarettes, additionally, today's digital technology can bridge social distance and at the same time the ever-spreading rumors via social media that escalate the adjusted odds ratio47 of trepidation and prompt to adopt false cures to protect themselves during the Covid-19 public health emergency. The pooled standardized mean difference for anxiety was 1.45 (95% CI 0.56 to 2.34)48and found a significant percentage of psychiatric symptoms among healthcare workers with 29.8% stress49,50, 24.1% anxiety and 13.5% depression respectively49. In addition, study done by51, 52showed that women were more likely to have anxiety than men. In another literature review adverse maternal and neonatal outcomes with stress and anxiety concerning COVID-1953. There is evidence of a high prevalence of anxiety21, 22, 23, 40, 41, 48, 54, 55 whereas this specific mental health outcome was under-recognized in China56.
Additionally, populations include pregnant women, children, and patients with pre-existing illnesses deploy avoidant behavior, perceived dirtiness41, vigilant hand washing23, and sterilizing compulsions to fortify themselves during pandemics. This drive of removing potential sources of contamination are driven by unwanted intrusive anxiety and fear of acquiring the highly contagious Covid-19. 75 % of patients with obsessive-compulsive symptoms have intense sensory experiences (pseudo-hallucinations) and perceptual experiences would amplify Contamination obsessions57, undesirable intrusive worry and poorer insight58 could worsen the viable inhalation injuries due to overuse of toxic cleaning supplies and atopic dermatitis59,60. Warped information processing can easily be exacerbated the threat of infectious pandemics and tends to overestimate threats61 in association with increased negative behaviors in patients with obsessive-compulsive symptoms.
Depression has increased during and after quarantine, one study done in China reviewed 54% of respondents rated the moderate or severe psychological impact of the Covid-19; 29% have anxiety symptoms; and 17% have depressive symptoms62. Several psychosocial conditions affected the mental health of the wellbeing and they perceive social exclusion or felt neglected40, 41, 54, anger-hostility, fear, mood disorders41,63, loneliness, boredom, low self-esteem55 which can worsen by acknowledged privacy and freedom during isolation.
A 14-day self-quarantine may be the deterrent against an outbreak but if sequestration and social isolation occur for prolonged periods are associated with stress in adolescents and truncated sleep38. Globally, pandemic planning to incorporate preparedness and capacity for conducting prospective patient‐focused clinical research62, 64, 65 found an immediate psychological impact. Same reviewed by Linda Barratt R and colleagues about varying levels of stress found among the study participants who experienced quarantine40; inadequate supplies, difficulty securing medical care and medications are specific stressors63. It's a vulnerable interaction between biological and environmental stressors that subjectively affect decision-making. These stressors can be major precipitate and the helm of deterioration of clinical traits that impact on an already encumber health care system. As many health workers during the Ebola outbreak got infected without personal protective equipment and driven mainly by compassion66.
Post-Traumatic Stress Disorder
Medical healthcare workers notably frontline female nurses reporting increased symptoms like distress, depression, emotion disturbance, and low sleep quality45; which would lead to potential problems with treating people. In support of this23, 63 reviewed that several mental health conditions like avoidance behavior posttraumatic stress-related symptoms, alcohol use, deterioration of work performance that will last even after three years of the quarantine period. Though mass home-confinement directives raise a concern about how people will react individually and collectively, reactions5 offer valuable advice for healthcare workers to abate secondary traumatic stress, including escalated cognizance of symptoms, recline from work, engaging in self-care, recline from media coverage. A study done by the US Department of Veteran Affairs, 2008 noted the most prevalent mental health issue following a meta-analysis on disaster having high incidence rates of post-traumatic stress disorder67,68, major depressive disorders being the second most common37, and generalized anxiety disorders.
Norris and colleagues found incidents of acute stress disorder concerning the severity of crisis exposure instantaneous aftermath of a disaster37. In another study done by National Governors Association Center, 2006 found 28.9% with PTSD and 31.2% with depression during a SARS outbreak in Toronto, Canada69. Similarly in another study it revealed that 25% of the patients showed signs of PTSD and 15.6% with depression among the survivors of SARS34. Diagnostic and statistical manual of mental disorders, 2013 states that life-threatening viral infection does not meet the current criteria for a diagnosis of PTSD70, however, other psychopathology, such as depressive and anxiety disorders, may ensue. Peril factors for mental health issues are high among children include poor mental health before a crisis36 and stress with exhibit disruptive behaviors (aggression & outbursts of anger) and regressive behaviors may be more insidious among elementary children71, Whereas middle-aged adults, females, and those of lower socioeconomic status are more prone to PTSD67, 68.
While many people associate with PTSD but not all individuals are affected in the same manner, the medical practitioners developing brief/acute to PTSD72. As everyone witnessed or experienced a traumatic event differently, their intrusive memories and recurrent dreams are few of the deleterious symptoms73. According to Suedfeld, aggravated stressful events create a desire to seek out the company of others, especially those who are undergo a homogeneous level of anxiety and trauma74. Psychological and psychiatric needs should be conceded as a part of pandemic management and another study reviewed approx. 57% of the participants reported momentous distress anxiety, anger, confusion, and PTSD during the isolation and quarantine63. On another side, study reviewed that people with entrenched neurosis have a lower life expectancy and poorer physical health outcomes74.
Call for Action
The available literature has notably highlighted the emergence need for the predominant assistance measure like psychological crisis intervention for tremendous psychological problems during COVID 19. In the acute phase of an outbreak, when health systems prioritize testing might also need intact psychological counseling and psychiatric screening plays a pivotal role in response to patient care. The essential measures are adopted differently from individual to individual based on the level of severity and diligent outcome of baseline mental health breakdown. A practical plan to provide enough essential services different subpopulations like medical practitioners, frontline nurses, health care workers, and public health agencies in the address to their psychological state to help them in strengthening personal resilience and professional performance.
The traumatized outbreak has a profound socioeconomic burden as financial loss or financial stress, loss, unemployment, homelessness76,77,78, discrimination, and stigmatization23, 79. As not enough services are available for the medical practitioners dealing with infected patients to address their symptoms like anxiety, depression, suicidality80 and post-traumatic stress disorder7,8. The associated with psychological distress and symptoms of mental illness81 need a plethora of effective intervention programs to manage the needs of specific populations82 and precautionary measures83.
Unfortunately, the pandemic has unique challenges in terms of the necessary preventive measures, specific treatment, and vaccines. This challenging pandemic outbreak exacerbates anxiety, psychosis-like symptoms, and non-specific mental issues that health education and awareness of causality & progression will be effective prevention of disease spread84. With the above objective, we need to fill the lacunae in the existing literature to resolve a vigorous and multifaceted response.
Substantial evidence from the past studies regarding the pertinent need for strong social support systems in the periods before, during, and after the traumatic event85 bolster the mental health following the courteous and rational communication. A study showed the urge for intense training of healthcare professionals to overcome their erudition and spurious believes during the Ebola outbreak in 201586. Following the H1N1 epidemic and Ebola virus outbreak in 2015, it was seen that the healthcare professionals and the general public have an intense urge for training and serious awareness of pandemic84,86. In review positive attitudes and better awareness among health professionals. One web-study done on the Chinese population found a high prevalence of GAD and poor sleep quality under no statistical significance difference between the prevalence of GAD with 35.1%, 20.1% depression, and 18.2% sleep respectively87.
Though several online mental health services like telemedicine psychological counseling and awareness program have been constructed across different countries or areas, however, chaotic management and coordination could result in the inefficiency of the services. The adverse effect of the COVID-19 is overwhelming, could need multidisciplinary mental health science to priorities the social, psychological, and neuro-scientific aspects of this pandemic. Crucially, the psychotherapeutic treatments leveraged the functional capacity using cognitive and behavioral mechanisms to protect against the sustained feelings of self-harm, and emotional problems88,89. Many of the anticipated consequences of quarantine63 are strongly associated with experience low levels of anxiety90, sustained feelings of loneliness and suicide attempts across the lifespan91,92leads to exhaustion of resources during epidemics/pandemics. The limited knowledge with unconcerned attitudes has high-level coordination potential fallout of an economic downturn on mental health including alcohol and substance misuse, gambling, anxiety, and fear in the public44,81. There should be a need for more enforcement on the awareness to mitigate distress and assess the exhibiting signs of the behavioral and emotional responses.