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Coronavirus and mental health

Professor Ben Green

How is the COVID-19 outbreak affecting public mental health?

The focus of the television and press has been very much focussed on physical safety. Hourly bulletins contain alarming headlines on international death rates, and the dangers of breaking any social distancing rules and staying at home. Scant attention has been given to the psychiatric effects of these death-filled messages, sometimes stridently and aggressively put by anchor people on morning and evening chat shows, ignorant of the effects of their endlessly reiterated opinions on the vulnerable. The public mental health costs in people who have not been infected by the virus have yet to be counted on the quality of people's mental wellbeing, and increased rates of anxiety, agoraphobia, loneliness, alcohol misuse, depression, and suicide. Difficulties in accessing physical mental health care due to restrictions and service shutdowns has compounded the issue and doctors will be aware of patients who have been on waiting lists for assessments and treatment who have had their long-expected appointments cancelled.

There is likely to be a major impact on community mental health in the UK, as yet undetected and untreated. Around 7% of residents, particularly women, in Wuhan had Post Traumatic Symptoms a month after the outbreak began (Liu et al, 2020). A study in Shenzhen, China found that the overall prevalence of Generalised Anxiety Disorder was 34.0%, depressive disorder 18%, and sleep disorders 18%, Younger people were more likely to have depression than older people (Huang and Zhao, 2002).

In people who have had the virus, there is evidence of central nervous system (CNS) involvement and the exact prognosis for the brain is not clear. Examples of CNS effects include loss of smell (anosmia) and brain stem malfunction (adding to respiratory rhythm failure) (Li et al, 2020). Post-viral depression and other symptomatology are predictable outcomes. Near fatal experiences in intensive care may result in PTSD symptoms. The long-term effects of COVID-19 on the central nervous system and short term and long term antenatal and perinatal effects on neurodevelopment in babies whose mothers have had COVID-19 are also unknown, but urgent research is planned (Holmes et al, 2020).

What CNS effects are known or likely?

We know that the effects of viral brain infection can lead to fatigue and depressive syndromes (White et al, 1998) and also that past pandemics are associated with other central nervous system effects, e.g. the Spanish Flu of 1918-19 was linked to post-encephalitic Parkinsonism (McCall et al, 2008), and maternal influenza has been linked to adult psychosis in their offspring (Cai et al, 2015).

In Wuhan, the origin of the COVID-19, 36% of virus patients had CNS symptoms. This rose to 45% in patients with severe respiratory disease - dizziness, headache, anosmia, loss of taste, muscle pains / weakness, delirium, and cerebrovascular complications (Mao et al. 2019). The coronaviruses that caused the SARS in 2003 and MERS in 2012 also had CNS effects.

What are the effects of 'lockdown' on people who do not have COVID symptoms?

In the face of unremitting headlines emphasising a need to conform to social distancing guidelines and regular updates on international death figures there will be a rise in the incidence of new anxiety disorders and relapses of existing patients with anxiety or obsessive compulsive disorder. Fear of contamination is a key feature in some patients with OCD and media-added levels of fear increase the severity of symptoms. In obsessional people the fear of missing key news has led to obsessive and prolonged checking of news sources and amplified distress, leading to additional unwanted behaviours such as hoarding of food and masks (Garfin et al, 2020).

Lockdown increases feelings of loneliness and we know that loneliness is a key risk factor for depression (Green et al, 1992).

Given that school is often the first place that children and adolescents seek help, the closure of schools will mean that many cannot access help. Issues they may face include substance misuse, gambling, domestic violence, sexual abuse, overcrowding, parental unemployment, and loss of their network of friends.

Adults may be affected by loss of occupation, poverty, and isolation and rely on aberrant coping strategies such as alcohol and gambling to manage stress. Lack of routine and isolation may affect access to medicines and lead to non-compliance and consequent breakdown of mood and psychotic disorders.

Older people will be particularly affected by isolation from family and friends, loneliness, and bereavement, all of which may not be amenable to on-line solutions because of the so-called 'digital divide'.

Previous epidemics have been linked to spikes in suicide rates and preliminary studies indicate this will also be a problem with COVID (Ammerman et al, 2020 and Chan et al, 2006). The SARS epidemic in 2003 led to a 30% increase in suicide in older people (Yip et al, 2010).

What can be done initially?

There needs to be a radical re-think of how news is presented to avoid major mental health impacts in the general population and particularly to avoid precipitating relapses of illness in vulnerable patients. Messages about what people should do to protect themselves should be clear and aim to increase people's confidence, rather than foster uncertainty about the future (Peters, 2013).

In the meantime anxious people should be advised to strictly limit and reduce time spent watching broadcast media or reading social posts regarding COVID, divert themselves to films, programmes or other activities with positive messages.

Promote befriending services and physical activity outdoors (agencies that seek to limit external activity should be made more aware and be sensitive to the mental health needs of vulnerable people).
Promote positive coping and resilience through appropriate community-based activities such as life-skills classes and arts-based interventions (Fancourt and Finn, 2019).
Promote positive interpretations of events and reduce repetitive negative thinking (RNT) (Hirsch et al, 2018)
Apps that focus on sleep quality, routine and hygiene will help in promoting behaviours that can protect against anxiety and depression.
Online psychiatric appointments with rapid assessment and intervention are required in the absence of face-to-face physical interviews (Wind et al, 2020).
Rapid treatment of poor sleep, lowered mood, and Post Traumatic symptoms with computerised CBT, online CBT, and antidepressants.
Rapid treatment of persecutory
or anxiety symptoms with Interpretation Training, online CBT, or short-term anxiolytics.
Evidence based interventions to limit and treat alcohol and other drug dependence.
Screening for suicidal ideation in every assessment.

References

Ammerman, B A. et al, (2020) Preliminary Investigation of the Association Between COVID-19 and Suicidal Thoughts and Behaviors in the U.S 10.31234/osf.io/68djp

Cai, L. et al (2015) Gestational Influenza Increases the Risk of Psychosis in Adults. Medicinal Chemistry, Volume 11, Number 7, 2015, pp. 676-682(7)

Chan, S M S et al, (2006). Elderly suicide and the 2003 SARS epidemic in Hong Kong. International Journal of Geriatric Psychiatry, 21, 113-118. doi: 10.1002/gps.1432

Fancourt D & Finn S
What is the evidence on the role of the arts in improving health and well-being? A scoping review.
WHO Regional Office for Europe, Copenhagen2019

Garfin DR et al. (2020)
The novel coronavirus (COVID-2019) outbreak: amplification of public health consequences by media exposure.
Health Psychol. 2020; (published online March 23.)
DOI: 10.1037/hea0000875

Green B H et al (1992) Risk factors for depression in elderly people: a prospective study
Acta Psychiatrica Scandinavica. September 1992 https://doi.org/10.1111/j.1600-0447.1992.tb03254.x

Hirsch CR et al. (2018)
Interpretation training to target repetitive negative thinking in generalized anxiety disorder and depression.
J Consult Clin Psychol. 2018; 86: 1017-1030

Holmes E A. et al. (2020) Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet: Psychiatry. Accessed April 16, 2020 DOI:https://doi.org/10.1016/S2215-0366(20)30168-1

Huang, Y & Zhao, N (2020) Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 epidemic in China: a web-based cross-sectional survey. MedRxiv.org https://doi.org/10.1101/2020.02.19.20025395.

Li YC et al (2020)
The neuroinvasive potential of SARS-CoV2 may be at least partially responsible for the respiratory failure of COVID-19 patients.
J Med Virol. 2020; (published online Feb 27.)
DOI:10.1002/jmv.25728

Liu, N. et al (2020) Prevalence and predictors of PTSS during COVID-19 Outbreak in China Hardest-hit Areas: Gender differences matter. Psychiatry Research. https://doi.org/10.1016/j.psychres.2020.112921

Mao L et al. (2020)
Neurological manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020; (published online April 10.)
DOI:10.1001/jamaneurol.2020.1127

McCall S et al. (2008)
The relationship between encephalitis lethargica and influenza: a critical analysis.
J Neurovirol. 2008; 14: 177-185

Peters GJY et al. (2013)
Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory. Health Psychol Rev. 2013; 7: S8-S31

White PD et al. (1998) Incidence, risk and prognosis of acute and chronic fatigue syndromes and psychiatric disorders after glandular fever. Br J Psychiatry. 1998; 173: 475-481

Wind TR et al. (2020)
The COVID-19 pandemic: the ‘black swan’ for mental health care and a turning point for e-health.
Internet Interv. 2020; 20100317

Yip PS et al. (2010)
The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong.
Crisis. 2010; 31: 86-92

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