The COVID-19 pandemic has exerted a significant impact on every aspect of humanity. Its profound effect on the respiratory and circulatory systems has been documented in severe levels of morbidity and mortality worldwide. Whilst the extent to which the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus may adversely affect brain functioning remains under investigation, the impact on psychiatric morbidity during similar previous outbreaks has been clear.
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The first novel pandemic to emerge in the 21st century was the outbreak of severe acute respiratory syndrome (SARS) in 2003. Immediately following the outbreak, reports of increased psychiatric morbidity of SARS survivors began to emerge.
Although prevalence rates varied by condition, one series of studies found that almost half of patients hospitalized for SARS met the criteria for at least one diagnosable mental health condition one month after discharge. One cohort study studying psychiatric illness over 30 months post-SARS reported a cumulative incidence of any diagnosable mental health disorder of 59%, most commonly post-traumatic stress disorder (PTSD) and depression.
The current global outbreak of COVID-19 is unprecedented in modern times. The repercussions of the disease are stark: widespread acute illness and death, economic instability, and the implementation of strict public health strategies to manage the spread. Together, these lead to intense psychological and social stressors, severely impacting mental health.
The impact of COVID-19 on mental health
In the early stages of the COVID-19 pandemic, researchers highlighted the importance of monitoring the rates of depression, anxiety disorders, self-harm and suicidal behaviors across general and vulnerable populations, including front-line health care workers.
Measures taken to mitigate the spread of the disease such as national lockdowns and social distancing have negatively impacted employment and the economy, and increased social isolation and loneliness. Fear of contracting the virus, experiences of bereavement, and uncertainty about the future have compounded these stressors.
The impact on the general population
Given the adverse mental health outcomes that have followed previous epidemics, the specific stressors and the unparalleled magnitude of the COVID-19 health crisis, population-based studies began to emerge early in the pandemic.
One of the first pieces of research into the psychological impact of the disease was a Chinese cross-sectional study that measured PTSD, depression, anxiety, and stress. In the immediate aftermath of the outbreak, more than half of the participants rated the psychological impact of COVID-19 as moderate or severe. One-third reported moderate or severe symptoms of anxiety, 17% reported depressive symptoms and 8% reported moderate to severe levels of stress. The same researchers repeated the surveys in a second study, and although scores on the PTSD measure had reduced, they were still above the clinically significant cut-off for a diagnosis. Levels of stress, anxiety and depression remained the same over the four-week period.
Although the Chinese studies were able to demonstrate the prevalence of mental health symptomology over four weeks, they did not compare these scores to pre-pandemic scores in similar populations.
A large-scale self-report study in the United States, however, which measured the prevalence of psychological distress in adults in April 2020 provided a comparison with scores pre-COVID-19 in 2018. Approximately 14% of respondents reported symptoms of severe psychological distress, an increase of 10% compared to findings in 2018. Symptoms of distress were higher among younger adults, women, and those in the lowest household income bracket.
In the United Kingdom, a longitudinal analysis of adults was measured in three waves across six weeks. Across all three time points, levels of suicidality, depression and anxiety were much higher than established population norms. On average, approximately 1 in 4 adults reached the diagnostic thresholds for depression and anxiety compared to 1 in 20 compared to pre-COVID-19 general population studies. Suicidal ideation was reported by 10% of the sample, compared to pre-COVID rates of 3%. Over time, rates of suicidal ideation increased, anxiety decreased, and depression remained stable.
Population studies have identified subgroups who appear to be at higher vulnerability to mental distress following COVID-19:
- People with pre-existing mental health conditions may worsen because of additional psychological and social stressors, or reduced access to mental health services.
- Those from a more socially and economically deprived background.
- Women and younger adults.
The impact on healthcare workers
Particular attention has been paid to the mental health of frontline healthcare staff during the pandemic. Overwhelming workloads, high patient mortality, depleted resources, and feeling inadequately supported whilst fearing contagion may increase burnout and psychological distress. Research from the SARS pandemic found significant levels of psychiatric morbidity among healthcare staff, double the level usually found in population studies.
One Chinese study of healthcare workers found that over 70% reported psychological distress, 50% reported clinically significant symptoms of depression and 45% reported significant symptoms of anxiety. These results have been replicated in numerous subsequent studies, with a recent review of 14 studies reporting, on average, a near-identical prevalence of mental health difficulties overall. Several risk factors for psychological distress among healthcare workers include:
- Being female
- Being a nurse
- Experiencing stigma
- Utilizing maladaptive coping mechanisms
References
- McGinty EE, Presskreischer R, Han H, Barry CL. Psychological Distress and Loneliness Reported by US Adults in 2018 and April 2020. JAMA. 2020;324(1):93–94. doi:10.1001/jama.2020.9740
- Mak, I. W., Chu, C. M., Pan, P. C., Yiu, M. G., & Chan, V. L. (2009). Long-term psychiatric morbidities among SARS survivors. General hospital psychiatry, 31(4), 318–326. https://doi.org/10.1016/j.genhosppsych.2009.03.001
- O'Connor, R. C., Wetherall, K., Cleare, S., McClelland, H., Melson, A. J., Niedzwiedz, C. L., O'Carroll, R. E., O'Connor, D. B., Platt, S., Scowcroft, E., Watson, B., Zortea, T., Ferguson, E., & Robb, K. A. (2020). Mental health and well-being during the COVID-19 pandemic: longitudinal analyses of adults in the UK COVID-19 Mental Health & Wellbeing study. The British journal of psychiatry : the journal of mental science, 1–8. Advance online publication. https://doi.org/10.1192/bjp.2020.212
- Vizheh, M., Qorbani, M., Arzaghi, S. M., Muhidin, S., Javanmard, Z., & Esmaeili, M. (2020). The mental health of healthcare workers in the COVID-19 pandemic: A systematic review. Journal of diabetes and metabolic disorders, 1–12. Advance online publication. https://doi.org/10.1007/s40200-020-00643-9
- Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., & Ho, R. C. (2020a). Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. International journal of environmental research and public health, 17(5), 1729. https://doi.org/10.3390/ijerph17051729
- Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., McIntyre, R. S., Choo, F. N., Tran, B., Ho, R., Sharma, V. K., & Ho, C. (2020b). A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain, behavior, and immunity, 87, 40–48. https://doi.org/10.1016/j.bbi.2020.04.028
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