Public mental health: A key factor in dealing with COVID-19

Here, a group of seasoned experts discuss the important role of prevention and reduction of mental stress in the general population and in sensitive groups in the context of the COVID-19 pandemic

This article aims to point out the important role of prevention and reduction of mental stress in the general population and in sensitive groups in the context of the coronavirus disease 2019 (COVID-19) pandemic.

Methods: This article includes the analysis and evaluation of studies and recommendations from organisations such as the World Health Organization (WHO), that have examined the public psychological consequences of epidemics/pandemics and their impact on the further course.

Results: fear-related behaviours can adversely affect the course of epidemics. Past outbreaks of infectious diseases (Ebola and Zika virus) have shown that maladaptive behaviour, related to increased psychological stress and anxiety, can interfere with the implementation of treatment strategies and actions and can contribute to a further spread. Hereby, strategies for dealing with infectious diseases, that include the suppression of fear, can trigger a vicious circle in which fear and suppression mutually reinforce each other.

Conclusion: The COVID-19 pandemic poses an immense challenge to governments, health systems and people, with an uncertain outcome, which is associated with a significant burden of mental health in the population. In line with WHO recommendations, national guidelines and preventive measures should include the psychological consequences, the acceptance and normalisation of fears and the promotion of resilience in the population in dealing with COVID-19 to counteract a further spread.

German Chancellor Angela Merkel called COVID-19 the biggest challenge for the public since World War II. Indeed, the World Health Organization (WHO) declared COVID-19 to be a global pandemic impacting at least 208 countries/areas with nearly 1.8 million confirmed cases and more than 110,000 fatalities worldwide (as of 14 April 2020) (1). While the outbreak started in Wuhan in the Chinese province of Hubei, the bulk of confirmed cases and fatalities are now outside of the country with Italy, Spain and the U.S. as the global epicentres surpassing China as the country with the highest number of cases and fatalities.

What is COVID-19?

COVID-19 is caused by a novel single-stranded enveloped RNA virus, the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the seventh known human coronavirus. In contrast to other coronaviruses causing mainly the common cold, i.e. 229E, OC43, NL63 and HKU1, SARS-CoV-2 is similar to the zoonotic severe acute respiratory syndrome coronavirus (SARS-CoV) from 2002 and the Middle East respiratory syndrome coronavirus (MERS-CoV) from 2012, causing acute infectious pneumonia. Like SARS and MERS, SARS-CoV-2 is considered to have originated in bats (as it shares 89-96% nucleotide identity with bat coronavirus), which moved to an intermediate host (likely a Malayan pangolin, which shares 91% nucleotide identity) and then to humans (2).

Since the coronavirus pandemic has been spreading rapidly across the world and confronted governments, healthcare systems and people with an immense challenge with an uncertain outcome, it is inducing a substantial degree of public mental stress. Cognitive and emotional stress responses during an infectious disease outbreak can include the permanent rumination about one’s own health and the health of family members and friends, anxiety, and agitation as well as loneliness or isolation. This, in turn, can also translate into physical and behavioural symptoms such as aches and pain, sleep disturbances, alcohol and drug use and self-harm or suicidal behaviour.

Mental health concerns

In particular, measures to slow the spread of COVID-19 such as social distancing, curfews, travel bans, the shutdown of businesses and closing of public institutions heavily affect peoples’ interpersonal daily life, usual activities, and routines. Especially affected are sensitive groups such as healthcare providers, older people with chronic diseases, children and teenagers and people with mental health conditions, suspected to be at higher risk to experience mental disorders (or severe symptoms) such as anxiety, depressive disorders, and post-traumatic stress disorder (PTSD).

Herein, a major concern includes issues of service access and continuity for people with chronic diseases and existing mental health conditions, along with increased mental stress of frontline workers. Therefore, it is vital to implement concrete actions that reduce the mental and somatic burden, for example, by ensuring that people with existing health conditions can continue with their treatment to prevent the onset of new or worsening symptoms or that frontline workers who are at higher risk getting infected get sufficient support.

Fear-related behaviour

Previous findings have shown that epidemics and more pandemics cause significantly increased levels of perceived stress in the total population and that the availability of political and societal coping strategies to adequately deal with an outbreak is negatively correlated with the epi-/pandemic event frequency (3). In addition, the Ebola virus outbreak from 2014 has shown that fear-related behaviours played an important role in shaping the outbreak (4). In this setting, maladaptive behaviours related to mental stress were shown to interfere with the implementation of treatment strategies and actions to stop a further spread.

The authors concluded that future directions should necessarily include the onset, operation, and the perpetuation of maladaptive fear-related behaviours to redirect behavioural responses in a manner that reduces harm and promotes resilience. Accordingly, China and other countries introduced emergency psychological crisis interventions, designed to reduce the mental health burden of the public and sensitive groups such as healthcare workers and to increase resilience (5). Key elements of such programmes, irrespective of the exact form, should include the acceptance and normalisation of fears and negative emotions since acute psychological stress is a logical consequence in the case of such an event. Importantly, it has been demonstrated in the case of the Zika virus outbreak that suppression of fear showed a self-reinforcing cycle in which fear increased the use of suppression and suppression increased the intensity of the fear responses (6).

Moreover, since fear is driven by myths and misinformation by erroneous news reports and social media and the public misunderstanding of health messages, providing reliable, accurate, and comprehensible information is important to counteract fear. In general, stress-reducing interventions and actions should target the enhancement of social support systems, reduction of stigma and discrimination associated with the epidemic, maintenance of normality and a healthy lifestyle as far as possible and use of the psychosocial service systems, for example, telephone-based and internet-based counselling for healthcare workers, patients, families and the public (5).

Mental stress in response to the unpredictable future of this epidemic is not only believed to increase in maladaptive behaviours, symptoms, and disorders, but to directly limit the capacities of the public to competently deal with this outbreak, which likely further increase infection rates and fatalities. Thus, as recommended by the WHO and other health organisations, interventions that specifically address public mental health issues, in particular, in sensitive groups such as frontline workers, are vital and should be introduced into national public health emergency systems to strengthen resilience and to empower the efforts to contain and eradicate COVID-19 (7).

Conflict of Interest

None.

References

1. World Health Organization, 2020. https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd (last accessed 14 April 2020).
2. Clerkin KJ, Fried JA, Raikhelkar J et al. Coronavirus Disease 2019 (COVID-19) and Cardiovascular Disease. Circulation 2020. doi:10.1161/CIRCULATIONAHA.120.046941. doi:10.1161/CIRCULATIONAHA.120.046941.
3. Pan American Health Organization. Protecting Mental Health During Epidemics, 2006. https://www.paho.org/en/documents/protecting-mental-health-during-epidemics (last accessed 27 March 2020).
4. Shultz JM, Cooper JL, Baingana F et al. The Role of Fear-Related Behaviors in the 2013-2016 West Africa Ebola Virus Disease Outbreak. Curr Psychiatry Rep 2016; 18: 104. doi:10.1007/s11920-016-0741-y.
5. Bao Y, Sun Y, Meng S et al. 2019-nCoV epidemic: address mental health care to empower society. Lancet 2020; 395: e37-e38. doi:10.1016/S0140-6736(20)30309-3.
6. Dillard JP, Yang C, Li R. Self-regulation of emotional responses to Zika: Spiral of fear. PLoS One 2018; 13: e0199828. doi:10.1371/journal.pone.0199828.
7. World Health Organization. Mental health and COVID-19, 2020. http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance/coronavirus-disease-covid-19-outbreak-technical-guidance-europe/mental-health-and-covid-19 (last accessed 28 March 2020).

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Thomas Münzel

Professor Dr. med. Chief of Cardiology

University Medical Center Mainz Department of Cardiology

Phone: +49 (06131) 17 7250

Email: tmuenzel@uni-mainz.de

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Andreas Daiber

Department of Cardiology

University Medical Center of the Johannes Gutenberg-University Mainz, Germany