Dr Julian Eaton, public health psychiatrist, Mental Health Director at CBM International and Assistant Professor at the Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, talks about the mental health and psychosocial aspects of the outbreak of COVID-19 (recorded 2nd March 2020).Â
SPEAKER 1: Dr. Eaton, what can you tell us about the potential mental health
effects of COVID-19 outbreak?
SPEAKER 2: Well, what we do know is that during infectious disease
outbreaks there are always increased levels of anxiety and worry among the
population. It's also well-recognised that there are increased rates of
diagnosable mental illnesses. This is due to the fear of personal or family
infection and illness, as well as the wider consequences on the community, for
example, of restriction of movements, or closure of schools and workplaces,
or concerns about accessing basic needs such as food or water.
At the population level, at its most extreme, panic can lead to negative
behaviours that can themselves impede public health efforts to contain spread
of infection or effective interventions for treatment for those in need. For
example, people not complying properly with isolation or quarantine
measures. Of course, anxiety, fear, and even distress are an appropriate
reaction to extreme circumstances, uncertainty, or threat.
The experience of past outbreaks has shown that the great majority of people
are very resilient and able to cope very well in such circumstances, and in fact
show great resourcefulness, supporting others in their communities and
recovering well after emergency is over. With respect to coronavirus, or
COVID-19, there's no evidence of direct effects on the brain of this condition.
But it's worth remembering that any infection can affect thinking and
behaviour if sufficiently severe.
SPEAKER 1: What about those living in communities where there are cases
of COVID-19? How might they react?
SPEAKER 2: There are a number of effects that living in a community at risk
from the spread of an infectious disease can have on emotional well-being,
mental health, and behaviour. And this will become worse as a sense of the
infection being close-by gets worse. All people are likely to have increased
anxiety around contracting the condition, and by extension, concern for their
families and community members.
This is likely made worse by uncertainty about risk from infection itself, and
the impact on the lives of families and communities. At the collective level,
these understandable concerns can lead to a more damaging sense of fear if
not managed well, which limit outbreak control measures. Mass media like TV,
radio, newspapers or social media, and other forms of communication and
information exchanged can amplify fear if not managed well.
SPEAKER 1: So we've seen some major interventions in this outbreak, in
terms of quarantine. How can they affect mental and psychosocial health, and
how might people react?
SPEAKER 2: The effects on people's lives of infection control measures such
as extended quarantine can be really distressing. The separation from loved
ones and opportunity to carry out normal social activities, travel, or work
responsibilities. With extensive quarantine in place, as in some sites with the
coronavirus response, it can be difficult for people to access basic needs.
For example, if shops are closed or amenities aren't functioning, the recent
rapid review identified some factors that tended to make outcomes worse.
This included longer quarantine duration, uncertainty and fear of infection,
frustration or boredom, inadequate information, and difficulty in accessing
supplies. And in the longer term, financial loss and stigma all contributed to
worse outcomes. This is particularly the case for those who are relatively
isolated or made vulnerable due to illness, disability, or difficulties in self-care.
SPEAKER 1: So what do we need to do to better address the mental health
impacts of outbreaks like COVID-19?
SPEAKER 2: Mental health and psychosocial support should form a part of
emergency planning and response measures. As early as possible, a rapid
assessment of the context of mental health and psychosocial support needs
and resources should be carried out, and a strategy put in place. With actors
in mental health and psychosocial support coordinated, there's an integral part
to response mechanisms throughout. Such approaches have been developed for emergencies and disasters, and can be found in the reference list to this interview. We should make actions voluntary through persuasion, shared
understanding, and common ownership, as forced measures tend to raise
suspicions and resentment.
SPEAKER 1: What could be done to reduce anxiety and distress associated
with this ongoing outbreak?
SPEAKER 2: There are a lot of practical things that can be done. Firstly,
promote easy communication between families and people who can offer
support in communities. So for that, keeping telephone and internet services
open for social media is important. Secondly, facilitate access to basic needs
like food and water, heat and electricity, as consistently and reliably as
possible. Communicating clearly with people how they can access these
needs, if necessary.
Thirdly, specifically identify people at high risk. Make sure their particular
needs are met. For example, households with very young or very old people,
people with pre-existing physical or mental conditions that require particular
treatment, or people with disabilities where there's a specific adaptation
needed for them to access support. This might involve communication, for
example, for people who are deaf, hard of hearing, or blind.
Some people may require additional information in a simple form, or in a
different language. Some may need support with mobility. For example, home
visits for self-care. Identifying people with such risks and needs should be a
part of the population surveillance for those needs to be properly addressed.
In general, anxiety is made worse by a sense of loss of control. So as well as
good access to information, promoting a general sense of a common cause of
a community responsibility and a sense of being all in this together helps
community to come together and respond positively. Broad messages that are
positive to the whole of society are really important, in addition to targeting
specific groups that I've mentioned.
Most people find that informal support of families and carers is sufficient. But
it's important that people are aware of how they can access more formal
psychological support if they need it. For example, through help lines with
numbers that are widely publicised.
Also, through the same routes as people are given basic advice on public
health responses like handwashing and where to seek help, these might be
routes where you can offer reassurance, counselling, and advice on
techniques such as relaxation. There will always be a small number of people
who need more specialist mental health care. They might get this from
general health settings where general nurses and doctors can be trained in
mental health response, and also those people working in screening centres
or in contact tracing to be able to respond to people's distress when they see
them. Psychological first aid can be taught in one to two days, and provide
these front line workers, and also help line operators and trusted community
leaders, with important means to help the people they see.
SPEAKER 1: What are the likely ongoing mental health needs with this
outbreak?
SPEAKER 2: Following emergency, period, a small number of people will
have ongoing anxiety, likely to be made worse by direct exposure to traumatic
experiences. And this is more likely for health care staff, of course, who will
require more support. Also, people who've lost loved ones, or who have
themselves been survivors of infection, or who have got significant ongoing
economic or social impacts from the event. Also, people who have pre-
existing or long-lasting mental conditions will likely need ongoing care. So
these people will benefit from tailored support in the recovery phase, and
mental health services need to be able to carry on supporting these people.
Sometimes, people who are perceived as to blame for causing infection can
be stigmatised. And in the recovery phase, it's necessary to ensure that the
public have an understanding of clear facts about the epidemic, which also
provides an opportunity to improve preparation and planning for any possible
future crises. Mental health services can be sometimes very weak in
countries, and such emergencies can lead to significant increase in
prioritisation of mental health and investment in improving services.
