Covid-19: Mental health consequences of pandemic need urgent research, paper advises
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1515 (Published 16 April 2020) Cite this as: BMJ 2020;369:m1515Read our latest coverage of the coronavirus pandemic
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Dear Editor,
I believe that not only are patients’ mental health are affected by the COVID 19 pandemic, but the health care workers as well who deliver care to these individuals as well. Health workers are first line fighters treating patients with COVID 19. Daily, they at risk of being infected and are exposed to long and distressing work hours to meet patient care needs. Research conducted by Zhang et al., revealed that health care workers during COVID 19 had a high prevalence of severe insomnia, anxiety, depression, somatization and obsessive compulsive symptoms(Zhang, 20200). The nature of care and the new way of working are potentially very stressful for staff. The health care team are not only experiencing an increase in the volume and intensity of work, but they have to accommodate new protocols for the ‘new norm’.
Nurses worldwide are adjusting to provide end of life care more frequently as there is more rapid deterioration in the patient within their care than they are used to. As it relates to the new restrictions placed on hospital regarding visits by relatives means that the nurses are frequently standing in for relatives.
The health care team are faced with more patients at emergency rooms dying from COVID 19; the nurse patient ratio is also affected putting even more workload on the already overworked team, nurse who do not own their own means of transportation are faced with stigma while commuting to and from work. All these stressors can contribute to a breakdown in the mental health of any individual if this is not safeguarded.
The health care team will have to incorporate coping strategies to lessen or prevent any adverse psychological impact associated with the pandemic by ensuring adequate rest and respite during work or between shifts, eating sufficient and healthy food, engaging in physical activity, and staying in contact with family and friends as well as seeking counselling. These interventions will help to boost the morale and mental health of the team and then they will be able to deliver the care that is expected of them by the patients and their relatives. The patients and their relative should also receive information from the health care facility as well regarding counselling sessions and educational material to increase their knowledge about COVID 19 which will help to minimize the impact of the psychological stress of the unknown associated with the pandemic.
Reference
Zhang, W. R., Wang, K., Yin, L., Zhao, W. F., Xue, Q., Peng, M., ... & Chang, H. (2020). Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China. Psychotherapy and psychosomatics, 89(4), 242-250.
Competing interests: No competing interests
Dear Editor,
Suicide incidences by in-ward COVID-19 patients have been frequently reported from Indian COVID-care centers (1). These incidences indicated mental stress in COVID-19 patients is a real issue at these centers and needs to be addressed (2). Multiple patients specific and health system-related factors could have contributed to these suicide incidences. The COVID-19 pandemic has put tremendous pressure on hospitals and healthcare workers (HCWs) which may have affected the quality of the patient care and access to the individual patients. There has been a lot of social stigma and apprehension of life loss associated with COVID-19 which can make the patients unduly stressed (3). In some COVID-19 patient new onset of psychiatric symptoms also has been reported (4); disease-induced anxiety, sleep deprivation, physical weakness, and depression may be contributory causes for the patient suicides (5). No direct human contact (without personal protective covering) in hospital wards also may be a contributor to the mental stress in the COVID-19 patients. Additionally, owing to the high risk of contracting the viral infection, to a certain extent hesitation by HCWs to provide affectionate care to the COVID-19 patients is understandable.
Regular mental counseling of the in-ward COVID-19 patients may make them feel cared thus can reduce their apprehension. Some patients may truly require therapeutic management of their psychiatric symptoms which can be screened out during counseling. As death risk in younger age patients and those without co-morbidities is very low, providing the patients with correct information about their personal health status and limited life risk may also reduce their anxiety. As the risk of contracting viral infection and shortage of medical staffs may be a real challenge for providing direct mental counseling, using virtual facilities and telepathy for this seem feasible options hence should be availed to in-ward COVID-19 patients.
References
1. Another Covid-19 patient dies by suicide in Patna AIIMS | Deccan Herald [Internet]. [cited 2020 Jul 31]. Available from: https://www.deccanherald.com/national/east-and-northeast/another-covid-1...
2. Suicide case highlights importance of counselling for COVID-19 patients - The Hindu [Internet]. [cited 2020 Jul 31]. Available from: https://www.thehindu.com/news/national/karnataka/suicide-case-highlights...
3. Banerjee D. How COVID-19 is overwhelming our mental health. Nat India Retrieved March. 2020;26(March):2020.
4. Varatharaj A, Thomas N, Ellul MA, Davies NWS, Pollak TA, Tenorio EL, et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. The Lancet Psychiatry [Internet]. 2020 Jun [cited 2020 Jul 15];0(0). Available from: www.thelancet.com/
5. Montemurro N. The emotional impact of COVID-19: From medical staff to common people. Brain, Behavior, and Immunity. Academic Press Inc.; 2020.
Competing interests: No competing interests
Dear Editor,
The COVID 19 pandemic is a new and never seen before infectious disease caused by the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The disease spread rapidly to other parts of the globe, including India, in a short time from its origin in the Wuhan province of China (1). As the wave of COVID-19 pandemic engulfed the whole world, it not only had a massive impact on society as an entire but affected individuals at every level. The COVID-19 pandemic has caused an unprecedented human and health crisis. As per its current trend, this pandemic has a varied effect on our health system and has pushed it to the limits. The society has been put under lockdown to contain the viral spread while the global economy has taken a significant setback worldwide (2). Measures taken by different nations have triggered an economic downturn. At this point, there is an acute uncertainty about how long the pandemic will last, and nobody can predict its severity. The latest Global Financial Stability Report shows that the financial system has already felt a dramatic impact, and further intensification of the crisis could affect global financial stability (3). Soon after the outbreak of COVID-19, prices of risk assets have fallen sharply. Signs of stress have also emerged in major short-term funding markets, including the global market for U.S. dollars.
These changes have contributed to an economic recession due to the current COVID-19 pandemic. Peeping into history, the last economic downturn in Finland (1990) and the recent global financial crisis (2007–2009) negatively impacted the health of people, who were mostly affected by job insecurity (3,4) . The current pandemic came as a shock for most of the nations and the major economies across the world have been negatively impacted in one way or the other. Furthermore, it is estimated that the GDP growth would drop to 3-6% (depending on the country) in a mild scenario and a median decline in GDP in 2020 is expected to be -2.8% (according to a study where a sample from 30 countries was taken) (5). The fall in GDP can be more than 10-15% in the worst-case scenario. (5)
This economic crisis will have a far-reaching effect on the health and well-being of the people. (2) The magnitude of effect will depend on the course of the pandemic and no accurate predictions can be made at this point. Unemployment decreased job security, and economic hardships as a consequence of this pandemic will have repercussions on individual health and health care in general (6,7). Reduced job security and reduced financial security also has a terrible impact on our mental health. (8) Besides unemployment, lockdown can affect self-esteem, cause deterioration in physical health, and have other consequences. (9) Also, psychological stress can be caused by these economic instabilities. Unemployment can lead to psychological disorders like depression, alcohol abuse, and suicide as a result of financial strain and the absence of social security. (10) Depression, anxiety disorders, and suicide are strongly linked to adverse life situations like job loss. In addition, recessions can be equally stressful for those still in the workplace as the options and choices become narrower, and they fear the prospect of losing their jobs and experiencing financial difficulties. (12) Economic crises can also put an additional burden on the government expenditure on mental health services as poor mental health services can contribute to worse health outcomes. Private health care will become expensive as insurance coverage of people will drastically decline because of recession. (12)
The widespread nature of the COVID-19 pandemic requires the enforcement of durable and longer-lasting containment measures—actions that may lead to a further tightening of global financial conditions. The disaster due to this pandemic offers excellent potential to social capital, and it shifts our mindset from money to monetary component of life and its offer prospect for re-orientation. The extended-enduring effects of this pandemic are not possible to be adequately estimated yet. Economic recessions at regional, national or global seem to be unavoidable. The mental health impact on the high risk and vulnerable population may take weeks or months to become apparent. The challenge our health system has to face will require managing these individuals with concerted efforts both from psychiatrists and health system at large.
The mental health issues after an economic crisis due to COVID 19 and any other pandemics will be varied. Still, the risks can, to a large extent, be avoided by policy measures. Need for further research in the area of mental health, particularly in those countries where the mental health infrastructure is less developed is the need of the hour. Besides this, measures like providing debt relief and avoiding expenditure cuts in services for people affected by pandemic will be helpful. Strengthen social integration, and social protection can be a protective factor. Early screening of mental health and timely action can go a long way in improving the quality of people affected by economic crises.
References:
1. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. The Lancet. 2020 Feb 15;395(10223):470-3.
2. Burdorf A, Porru F, Rugulies R. The COVID-19 (Coronavirus) pandemic: consequences for occupational health. Scandinavian Journal of Work, Environment & Health. 2020 Mar 31.
3. Karanikolos M, Heino P, McKee M, Stuckler D, Legido-Quigley H. Effects of the global financial crisis on health in high-income OECD countries: A narrative review. Int J Health Serv 2016;46:208-40. https://doi.org/10.1177/0020731416637160
4. Torá I, Martínez JM, Benavides FG, Leveque K, Ronda E. Effect of economic recession on psychosocial working conditions by workers’ nationality. Int J Occup Environ Health 2015;21:328-32. https://doi.org/10.1080/10773525.2015.1122369
5. Fernandes, Nuno, Economic Effects of Coronavirus Outbreak (COVID-19) on the World Economy (March 22, 2020). Available at SSRN: https://ssrn.com/abstract=3557504 or http://dx.doi.org/10.2139/ssrn.3557504.
6. Simou E, Koutsogeorgou E. Effects of the economic crisis on health and healthcare in Greece in the literature from 2009 to 2013: a systematic review. Health policy. 2014 Apr 1;115(2-3):111-9.
7. Bofinger P, Dullien S, Felbermayr G, Fuest C, Hüther M, Südekum J, di Mauro BW. 18 Economic implications of the COVID-19 crisis for Germany and economic policy measures. Mitigating the COVID Economic Crisis: Act Fast and Do Whatever.:167.
8. Cerami c, santi g, galandra c, dodich a, cappa s, vecchi t, crespi c. Covid-19 outbreak in italy: are we ready for the psychosocial and economic crisis? Baseline findings from the longitudinal psycovid study.
9. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395:912-20.
10. Mathers CD, Schofield DJ (1998). The health consequences of unemployment: the evidence. Med J Aust 168:178-83.
11. Berk M, Dodd S, Henry M (2006). The effect of macroeconomic variables on suicide. Psychol Med 36(2):181-9. 8 Herbert J (1997). Stress, the brain and mental illness. BMJ 315(7107):530-535.
12. WHO (2009). Financial crisis and global health: report of a high-level consultation. Geneva: World Health Organization. Available: http://www.who.int/mediacentre/events/meetings/2009_financial_crisis_rep...
Competing interests: No competing interests
The research highlighted by Mahase paints a bleak picture of the future state of the population’s mental health(1). Undoubtedly, healthcare professionals on the frontline against COVID-19 are under an extreme amount of pressure, including final year medical students who are being fast-tracked into interim foundation posts. Barely out of medical school, these young doctors will face an unprecedented transition into a NHS at breaking point.
The mental health of keyworkers is paramount and I believe final year medical students may not be armed with coping strategies to deal with the stress. Strengthening students’ mental health should be a compulsory part of a university degree course, especially medicine. Currently individuals are presumed to be of sound health until proven otherwise, however mental health support services in universities lack a clear distinction from those dealing with academic performance. Academic advisors are a source of pastoral support for students in medical school. However one UK medical school sees these same advisors mark their student’s portfolio, the passing of which is a mandatory part of the degree. This potential source of support is effectively taken away from the student, as the relationship resembles that of an examiner.
The current pandemic has been a catalyst for mental health recognition amongst NHS staff, surely now is the time to incorporate education surrounding students own mental health into medical school syllabi. Weekly classes allowing students to voice concerns regarding their course or work-life balance should become compulsory from year one in order to protect and maintain their mental health. By fifth year, students should recognise when their own mental health is suffering, be well versed in self-help strategies, and confident in accessing support services. Applications of these strategies at degree level across the healthcare workforce will change the past culture of staying quiet and dealing with emotions individually for future generations.
Everyone’s mental health has scope for deterioration, and by addressing individual needs at an earlier stage the healthcare system will be more resilient in future public health emergencies.
1. Mahase E. Covid-19: Mental health consequences of pandemic need urgent research, paper advises. BMJ [Internet]. 2020 Apr 16 [cited 2020 Apr 18];369:m1515. Available from: http://www.bmj.com/lookup/doi/10.1136/bmj.m1515
Competing interests: No competing interests
Dear Editor
For 12 years I was editor of the Journal of Public Mental Health. There was never equality of esteem between physical and mental health needs, in Health Planning, despite strenuous efforts by initiatives like Every Mind Matters or Equally Well. The present pandemic would be a good time to improve the evidence base to prevent mental illness, to help patients, families and professionals deal with exhaustion and loss, and to manage the consequences of trauma for which few people were prepared.
To borrow the language of Game of Thrones:
a) There is something coming called Winter, and it sounds pretty scary,
b) Winter is here and it is even worse than I feared,
c) Winter is going to last for EVER !
During my career in public health (including emergency planning and researching both Suicide and PTSD), we missed many opportunities to develop and roll-out evidence-based training for either professionals or communities facing mass casualty events.[1] To get this right in the future will take a trans-disciplinary, international effort. Planning for that new collaboration should start as soon as possible, while the collective experience and urgency are still fresh in our minds.
1] Caan W. When science and politics are worlds apart. Guardian online 14 April,
available at https://www.theguardian.com/world/2020/apr/14/when-science-and-politics-...
(Subsequently printed in the Guardian's Journal section).
Competing interests: See Caan W. Lack of public health resources leaves us all vulnerable. BMJ 2019;364:l110.
Research warning of the potential major adverse mental health implications of the covid-19 pandemic rightly highlights frontline staff as one group who may be disproportionately affected [1,2], yet the mental wellbeing of medical students is also at risk.
As penultimate year medical students in the UK, we are tasked by the Medical Schools Council (MSC) to continue with our education as a primary responsibility during the pandemic [3]. As many of us take up a wide variety of volunteering roles or clinical support work, we may find ourselves conflicted between a responsibility to continue learning and a desire to help.
As our more senior colleagues graduate without ceremony, lacking proper respite following their final examinations, they prepare for work as junior doctors. The potential risk to their mental health must be considered. Research on the severe acute respiratory syndrome (SARS) outbreak demonstrated that medical staff who felt vulnerable, experienced a loss of control, or underwent a change in their work were more likely to experience adverse psychological outcomes [4]. These are factors which our newly graduated colleagues will likely become exposed to in their new work environments.
Separation from family, disruption to teaching and the desire of many to volunteer has placed increased strain on the mental wellbeing of students during this time. By preparing for adverse psychological ramifications of the outbreak, medical students can seek to minimise any potential ill effects [5].
References
1. Mahase E. Covid-19: Mental health consequences of pandemic need urgent research, paper advises. BMJ 2020;369:m1515. doi:10.1136/bmj.m1515
2. Holmes, E., O'Connor, R., Perry, V., Tracey, I., Wessely, S., & Arseneault, L. et al. (2020). Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry. https://doi.org/10.1016/s2215-0366(20)30168-1
3. Medschools.ac.uk. (2020). Retrieved 16 April 2020, from https://www.medschools.ac.uk/media/2622/statement-of-expectation-medical....
4. Wong, T., Yau, J., Chan, C., Kwong, R., Ho, S., & Lau, C. et al. (2005). The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope. European Journal Of Emergency Medicine, 12(1), 13-18. https://doi.org/10.1097/00063110-200502000-00005
5. Brooks, S., Dunn, R., Amlôt, R., Rubin, G., & Greenberg, N. (2018). A Systematic, Thematic Review of Social and Occupational Factors Associated With Psychological Outcomes in Healthcare Employees During an Infectious Disease Outbreak. Journal Of Occupational And Environmental Medicine, 60(3), 248-257. https://doi.org/10.1097/jom.0000000000001235
Competing interests: No competing interests
Re: Covid-19: Mental health consequences of pandemic need urgent research, paper advises
Dear Editor
I am in complete agreement with the author in the view that COVID-19 has affected different strata of society.
According to UNICEF ‘Global Population of Children’, 2019, 16% of the world’s population consists of children between the ages of 10-19 years [1]. In an unprecedented way, COVID-19 has impacted the majority of this age group as the primary measure taken to contain the spread of the virus includes months of lockdown and shutting of schools and public spaces. According to a COVID-19 summer survey conducted by the Young Minds charity, more than 90% of the respondents agreed that COVID-19 had impacted their mental health in mild, moderate or in severe ways [2]. The public health measures undertaken by the government at both local and national levels has had a profound effect on many young individuals, especially those with pre-existing mental health conditions. Young persons have reported being more anxious, inattentive and persistently inquiring regarding COVID-19 progress [3]. With online schooling becoming the new norm, children develop uncertainty and anxiety which is attributable to disruption in their education, physical activities and opportunities for socialisation [4]. Retrogressively, during lockdown, when schools, legal and preventative services do not operate in full capacity, children are rarely in a position to report violence, abuse and harm if they themselves come from abusive homes [5,6].
It is thought a three-point action plan will help young individuals cope with the mental anxiety that is associated with COVID -19 and these steps may help alleviate the stress.
1. Renew and reinforce taskforce in places where they already exist or establish new centres in poor and socioeconomically deprived regions or in areas with high BAME population
2. Increase funding (both at local and central levels) that would help professionals to detect and meet the upsurge in mental health issues
3. Educate young individuals to understand the signs of anxiety and loneliness and help them seek professional help immediately
I firmly believe that these action points will help young individuals seek help and open up about their pre-existing or new mental health issues which may have been hidden from their close friends and family.
References:
1. UNICEF Global population of children 2100. Statista. 2019 https://www.statista.com/statistics/678737/total-number-of-children-worl...
2. https://youngminds.org.uk/about-us/reports/coronavirus-impact-on-young-p...
3. Viner RM., Russell SJ., Croker H., Packer J., Ward J., Stansfield C., Mytton O., Bonell C., Booy R. School closure and management practices during coronavirus outbreaks including COVID-19: A rapid systematic review. Lancet Child Adolesc. Health. 2020;4(5):397–404.
4. Jiao WY., Wang LN., Liu J., Fang SF., Jiao FY., Pettoello-Mantovani M., Somekh E. Behavioural and emotional disorders in children during the COVID-19 epidemic. J. Pediatr. 2020; 3476(20)30336
5. Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations. Psychiatry Res. 2020; 293:113429
6. Lee, J. Mental health effects of school closures during COVID-19. Lancet. Child Adolesc. Health, 2020; 2352-4642(20)30109-7
Competing interests: No competing interests