The Covid-19 pandemic brought us something on a global scale that hasn’t been seen before — social distancing. While, on the one hand, this is coming at a time when there are tools for people to keep in touch with each other — texting, social media, video conferencing, telecommute opportunities — on the other hand, this new normal can have mental health consequences.
“The worldwide Covid-19 pandemic, and efforts to contain it, represent a unique threat, and we must recognize the pandemic that will quickly follow it — that of mental and behavioral illness — and implement the steps needed to mitigate it,” Sandro Galea, MD, from Boston University School of Public Health, and colleagues wrote in JAMA Internal Medicine.
Theirs is one of three viewpoint articles looking at the mental health effects of the pandemic.
Galea and colleagues noted the dearth of data on the mental health effects of epidemics, especially social distancing.
“However, large scale disasters, whether traumatic (e.g., the World Trade Center attacks or mass shootings), natural (e.g., hurricanes), or environmental (e.g., Deepwater Horizon oil spill), are almost always accompanied by increases in depression, posttraumatic stress disorder (PTSD), substance use disorder, a broad range of other mental and behavioral disorders, domestic violence, and child abuse,” they wrote.
Consider these statistics Galea and colleagues lay out:
- In the aftermath of Hurricane Ike 5% of the population met the criteria for major depressive disorder.
- 1 in 10 met the criteria for major depressive disorder a month after 9/11.
- Alcohol use increased in New Yorkers after the 9/11 attacks.
- After the Deepwater Horizon spill the surrounding communities reported increases in depression and anxiety.
- PTSD, depression and anxiety increases were noted after the SARS epidemic.
“In the context of the Covid-19 pandemic, it appears likely that there will be substantial increases in anxiety and depression, substance use, loneliness, and domestic violence; and with schools closed, there is a very real possibility of an epidemic of child abuse,” Galea and colleagues noted.
This pandemic is so unprecedented that finding clear guidance on population level prevention is difficult. But the viewpoint authors suggested three steps that may help with proactively dealing with the mental health fallout of Covid-19:
- Digital Technology: Use digital technologies to help bridge social distance, such as replacing physical worship services, exercise classes, and other activities with virtual services or classes, and use virtual workplaces so people do not feel isolated working from home. For those who are homeless, or those with known mental illness, extra efforts should be made to connect with them. Galea and colleagues also noted that there should be remote opportunities for outreach and screening for mental illness and loneliness, as well as support provided.
Helping children maintain their daily routines both for school and social interaction is also important “to mitigate the effect of short- and long-term sheltering in place,” they wrote.
- Surveillance Mechanisms: Galea and colleagues noted that it is important that surveillance, reporting, and intervention be set in place, particularly in regard to domestic violence and child abuse. “Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems,” they wrote.
- Bolster the Mental Health System: The Covid-19 pandemic is challenging from a physical as well as a mental health perspective. “Stepped care, the practice of delivering the most effective, least resource-heavy treatment to patients in need, and then stepping up to more resource-heavy treatment based on patients’ needs, is a useful approach,” they wrote. “Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support. Even small signs that someone cares could make a difference in the early stages of social isolation. Telemedicine mental health visits, group visits, and delivery of care via technology platforms will be important components of stepped care for both acute crisis management and more routine communication and support.”
Mark A. Reger, PhD, with the VA Puget Sound Health Care System, Seattle, and the Department of Psychiatry and Behavioral Sciences University of Washington, and two colleagues from the Department of Psychology, Florida State University, Tallahassee, noted in their article that social distancing could lead to an increase in suicides.
They explained that economic stress, social isolation, and health-associated risk factors can combine to increase suicides during times such as this, but they also noted that there are opportunities for prevention.
Reger and colleagues wrote that social distancing means physical distancing but echoed much of what Galea and colleagues said: “Efforts can be made to stay connected and maintain meaningful relationships by telephone or video, especially among individuals with substantial risk factors for suicide,” they wrote.
And, the mobilization of telehealth during this time is key, they added.
“Unfortunately, tele-mental health treatments for individuals with suicidal ideation have lagged far behind the telehealth field,” Reger and colleagues noted. “Opportunities to increase the use of evidence-based treatments for individuals with suicidal thoughts have been noted for years, especially in rural settings, but fear of adverse events and lawsuits have paralyzed the field. Disparities in computer and high-speed internet access must also be addressed. Research, culture change, and potentially even legislative protections are needed to facilitate delivery of suicide prevention treatments to individuals who will otherwise receive nothing.”
They also noted that screening and prevention procedures should be implemented, as access to care has decreased during the pandemic, making options such as remote delivery of care potentially useful.
“For example, some brief contact interventions (telephone-based outreach) and the Caring Letters intervention (in which letters are sent through the mail) have reduced suicide rates in randomized clinical trials. Follow-up contact may be especially important for individuals who are positive for Covid-19 and have suicide risk factors,” Reger and colleagues noted. They also emphasized that the media should follow reporting guidelines and include the National Suicide Prevention Lifeline (1-800-273-TALK) in reports.
Optimistically, Reger and colleagues noted that the Covid-19 pandemic might have a silver lining: historically, suicide rates dropped after disasters such as the 9/11 attack in 2001, which they argued may have to do with “the so-called pulling-together effect, whereby individuals undergoing a shared experience might support one another, thus strengthening connectedness… Epidemics and pandemics may also alter one’s views on health and mortality, making life more precious, death more fearsome, and suicide less likely.”
The Lesson from China
Yu-Tao Xiang, MD, PhD, from the Unit of Psychiatry, Institute of Translational Medicine, University of Macau, China, and colleagues, writing in JAMA Psychiatry, outlined some of the lessons learned from China, particularly that mental health crisis interventions should be integrated into the general deployment of disease prevention and treatment.
“More than 20 specific guidelines and expert consensus for mental health services for the Covid-19 outbreak were disseminated by the end of February 2020 to provide timely guidance for frontline health care professionals,” Xiang and colleagues wrote. “External mental health expert teams in other provinces were also established to provide emergency mental health services in Hubei province, China. In addition, widespread adoption of online public education, psychological counseling, and hotline services have been set up for those in need.”
According to Xiang and colleagues, there are three points that should be taken from the Chinese experience with Covid-19:
- China should proactively share its protocols for emergency mental health services with other countries affected by the pandemic.
- Organizations such as the Psychiatric Association and the Pacific Rim College of Psychiatrists should develop crisis psychological intervention guidelines and “organize expert teams to coordinate mental health resources and provide timely advice to different countries affected by the Covid-19 pandemic.” They also noted that there should be epidemiologic studies to find out how various subgroups — such as the elderly, survivors, etc. — have been impacted by the pandemic.
- “[L]eading academic organizations equipped with mental health expertise on crisis mental health interventions (e.g., the American Psychiatric Association in the U.S.) should readily share their experiences and guidelines with low- and middle-income countries that are also affected by the Covid-19 pandemic,” they wrote.
As social distancing continues during the Covid-19 pandemic, experts warned that mental health issues such as depression, loneliness, and even suicide may increase.
Using virtual technology, including tele-mental health services, will be key in both providing treatment and prevention.
Candace Hoffmann, Managing Editor, BreakingMED™
Galea disclosed no relevant relationships.
Reger disclosed no relevant relationships.
Xiang reported that the study was supported by the National Science and Technology Major Project for investigational new drugs, the Beijing Municipal Science & Technology Commission, and the University of Macau.
Cat ID: 423
Topic ID: 87,423,932,730,933,125,190,926,192,927,423,52,55,150,151,928
Galea S, et al “The mental health consequences of Covid-19 and physical distancing: The need for prevention and early intervention” JAMA Intern Med 2020; Published online April 10 DOI: 10.1001/jamainternmed.2020.1562.
Reger MA, et al “Suicide mortality and coronavirus disease 2019 — A perfect storm?” JAMA Psychiatry 2020; Published online April 10 DOI: 10.1001/jamapsychiatry.2020.1060.
Xiang Y-T, et al “Joint international collaboration on combat mental health challenges during the coronavirus disease 2019 pandemic” JAMA Psychiatry 2020; DOI: 10.1001/jamapsychiatry.2020.1057.