Mental health in the age of COVID-19

The COVID-19 (coronavirus 2019) pandemic has posed significant challenges to many people across the world. There has been substantial loss of life, illness and infirmity, financial devastation, and extensive changes to social norms. With 14.9 million confirmed cases and over 615 thousand deaths stemming from COVID-19 worldwide (as of 22/07/2020) [1], feelings of anxiety, fear, panic, and despair are explicable reactions to this pandemic. Given the public health emergency surrounding COVID-19, it is crucial that governments and health care systems focus on addressing the medical aspects of COVID-19. While the physical health components of COVID-19 must be dealt with, it is also important that the associated mental health consequences are not overlooked.

High levels of anxiety, depression, and feelings of vulnerability are common in public health emergencies such as epidemics and pandemics. In the severe acute respiratory syndrome (SARS) epidemic of 2003, suicide increased by 30% in individuals aged 65 years and older [2]. Concerns were also reported by healthcare workers, with 29% reporting emotional distress [3]. Likewise, in the H1N1 Influenza A pandemic of 2009, 10% to 33% of the community experienced heightened anxiety, with perceived vulnerability reaching as high as 30% [4].

Similar trends have been noted for COVID-19, with preliminary research indicating high levels of anxiety, depression, stress, negative feelings, and poorer wellbeing within the general population [5]. These psychological issues are further exacerbated in vulnerable populations where there is a greater level of negative impact [6]. Due to underlying mental and/or physical health conditions, unemployment, or employment in high risk professions (e.g., essential workers), vulnerable populations are more susceptible to psychological distress and mental health problems. Some of these populations are detailed below.

Impact of COVID-19 on vulnerable populations

The elderly and individuals with disabilities

Elderly individuals are more susceptible to contracting COVID-19 due to underlying health conditions (e.g., cardiovascular disease, lung disease, diabetes, and neurocognitive impairment) and weakened immune systems [7]. Likewise, people with severe or profound disability (e.g., progressive neurological conditions) [8] are also at heightened risk [9]. Given their increased susceptibility to COVID-19, residents of aged-care and supported accommodation homes have undergone lockdown in many parts of the world. While these lockdowns serve to protect health care systems from being overwhelmed, isolation from family and friends places the elderly and disabled at increased risk of anxiety, depression, and loneliness [10,11].

Individuals with pre-existing mental illness

Individuals with pre-existing, severe mental illness (e.g., schizophrenia, schizoaffective disorder, major depressive disorder, and bipolar affective disorder) may be at risk of relapsing or having their conditions exacerbated during the COVID-19 pandemic. Due to mass quarantine restrictions, individuals with severe mental illness may have limited access to regular mediation, care, and routine services [12]. Furthermore, heightened levels of stress, despair, and loneliness during quarantine can lead to relapse of mental illness due to increased rumination, reduced ability to cope with stress, and non-compliance with medication [12]. People with severe mental illness may also develop further complications such as post-traumatic stress disorder (PTSD) symptoms and depression, with symptoms potentially lasting for several years [13].

Additionally, individuals with obsessive compulsive disorder (OCD) may be particularly distressed during the COVID-19 pandemic. OCD patients with contamination concerns (i.e., fear of contracting germs and becoming unwell, compulsive washing, and obsessing over potentially contaminated objects), may constantly wash their hands or frequently check their temperature to monitor for signs of fever. As a result of obsessive fears over contracting COVID-19 and associated compulsive behaviours (e.g., hand washing and temperature checking), those with contamination concern OCD may experience significant distress over this pandemic.

Individuals with underlying physical illness

Individuals with underlying physical illness, such as those who are immunocompromised (e.g. cancer patients) or chronically ill (e.g., individuals with cardiovascular disease) may experience increased feelings of anxiety and depression in response to COVID-19 [5]. Of the people who have died from COVID-19, a large number have been reported to be suffering from cardiovascular disease or diabetes [14]. Given that people with underlying physical illness are at increased risk of contracting the COVID-19 virus and acquiring it in a more severe form, [14] it is explicable that they are experiencing greater levels of fear, anxiety, and stress regarding their physical health.

Homeless, unemployed, and low socioeconomic status individuals

Many individuals who are homeless experience chronic physical (e.g., high blood pressure) and mental illness (e.g., schizophrenia), have less access to health care, and engage in high rates of drug and alcohol use [15]. Lockdowns in response to COVID-19 may hinder the delivery of homelessness support services, and affect the ability of homeless individuals to receive medical and mental health treatment [15]. Furthermore, quarantine and isolation may negatively impact the mental health of individuals experiencing homeless, as many have fears regarding involuntary hospitalisation and incarceration [16].

Individuals who are unemployed and/or of low socioeconomic status, are also at increased risk of poor mental health due to financial distress and job insecurity. The COVID-19 pandemic will seriously impact on mental health through heightened unemployment, poverty, and economic instability [5]. Increased rates of distress, anger, anxiety, and depression have been associated with financial loss and job insecurity [13].

Frontline health care professionals, emergency services personnel, and essential workers

Frontline health care professionals (e.g., nurses, general practitioners, intensive care specialists, and physicians), emergency services personnel (e.g., ambulance officers, paramedics, and police officers), and essential workers (e.g., care home workers, janitorial and sanitation workers, and grocery store workers) are at increased risk of developing mental health problems due to the COVID-19 pandemic. Health care professionals are particularly vulnerable due to long working hours, high patient loads, limited access to personal protective equipment and medication, death of patients and colleagues from COVID-19, inability to give optimal patient care, and isolation from family and friends [6,17].

Research from previous epidemics has identified substantial psychological illness among frontline health care professionals. In the SARS epidemic of 2003, nurses who were stationed at SARS hospital units experienced greater levels of insomnia and depression compared to nurses stationed at non-SARS hospital units [17]. These symptoms were also reported to be associated with nurses directly involved in SARS patient care [17]. Furthermore, a substantial number of frontline health care professionals have been noted to experience PTSD symptoms, even three years after the 2003 SARS outbreak [17].

Other frontline and essential workers are expected to experience elevated levels of anxiety, stress, and fear during the COVID-19 pandemic, with their mental health and wellbeing being negatively impacted [17]. In particular, frontline and essential workers may find themselves more anxious and stressed due to being exposed to significant performance pressures (e.g., grocery store workers attending to panic buying customers) and overwork (e.g., paramedics attending to numerous COVID-19 patients, police officers patrolling biosecurity checkpoints and quarantine zones) [17].

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Managing mental health during the COVID-19 pandemic

For both the general population and vulnerable populations, it is essential that mental health is adequately managed during the COVID-19 pandemic. While vulnerable populations will require greater support and access to mental health services during this period, the general population will also benefit from mental health advice and support. Some suggestions are provided below [18].

Self-care strategies

Engagement in regular physical activity and exercise: Regular exercise can help improve mood and reduce stress and anxiety levels. It can also assist in improving sleep. Exercise releases neurotransmitters such as endorphins, serotonin, and dopamine which help in improving mood and reducing stress.

Maintenance of a regular sleep routine: Getting up and going to bed at regular times and sticking to a consistent sleep schedule will help maintain good mental health. Disrupted sleep has been linked to diminished mental wellbeing, irritability, tiredness, and poorer concentration.

Maintenance of a healthy diet: Having a well-balanced diet consisting of nutritious foods will assist in maintaining a sense of health and wellbeing. According to the Australian dietary guidelines,[19] a balanced, nutritious diet consists of plenty of vegetables, legumes, and fruits along with wholegrain cereals such as rice, pasta, noodles, and breads. It is also suggested to include lean proteins such as meat, poultry, fish, and/or other alternatives along with low-fat varieties of milk, cheese, and yoghurt. Lastly, it is recommended to drink plenty of water and limit intake of processed foods containing high levels of saturated fat, added salt and sugar, and alcohol.

Avoidance of alcohol, tobacco, and drugs: Tobacco use increases the risk of lung disease. Given that COVID-19 affects the lungs, tobacco users are at a higher risk of complications from COVID-19 infection. Use of alcohol and drugs as coping strategies is not advised as it will worsen mental health. Medication should only be used as prescribed by a registered medical practitioner.

Engagement in relaxation exercises: Relaxation techniques such as deep breathing, meditation, progressive muscle relaxation, and mindfulness can help relax the mind and body and manage symptoms of anxiety and depression.

Setting goals and priorities: Setting reasonable goals and priorities can help prevent feelings of being overwhelmed. By setting achievable short-term and long-term goals, individuals will be able to maintain a sense of control and structure over their lives.

Keeping in contact with family and friends: Keeping in social contact with family and friends can help alleviate feelings of stress, loneliness, and isolation. While it may not be possible to catch up face-to-face, phones, social media, and video conferencing services such as FaceTime or Zoom can help people keep in touch.

Seeking help

Telehealth – Seeking support from a General Practitioner: For individuals who are struggling with their mental health, it is important that they seek help. Booking an appointment with a General Practitioner is advisable as they will be able to discuss treatment options for anxiety, depression, and other mental health concerns. Some General Practitioners may provide the option of phone, video, or online consultations. Once an initial assessment has been conducted, General Practitioners can make referrals to a psychologist or psychiatrist for mental health treatment.

Mental health support services: Mental health support services such as Beyond Blue, Lifeline, Headspace, and Sane are important organisations that provide mental health support and guidance. Individuals who are experiencing mental health problems will be able to receive one-on-one, confidential counselling along with helpful mental health information.

Community and government resources: For vulnerable individuals who may not have access to family, friends, or other support networks, community and government resources are crucial lifelines during the COVID-19 pandemic. Support agencies and other community support services can provide health and wellbeing, housing, and financial assistance. These services can be accessed by engaging local government and community agencies (e.g., Homelessness Support Services, Services Australia).

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Summary

The COVID-19 pandemic has resulted in significant challenges across the world. Widespread death, illness, and financial devastation has significantly impacted on the mental health of the population. Due to the COVID-19 pandemic, vulnerable populations such as those with mental and/or physical health conditions, unemployed individuals, or individuals in high risk professions are susceptible to developing mental health problems. It is crucial that both the general population and vulnerable populations, have access to mental health support during this challenging time.

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References

1. Johns Hopkins Coronavirus Resource Center. ‘COVID-19 Map’. Accessed 22 July 2020. https://coronavirus.jhu.edu/map.html.

2. Yip PS, Cheung YT, Chau PH, Law YW. 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. doi:10.1027/0227-5910/a000015.

3. Nickell LA. Psychosocial effects of SARS on hospital staff: Survey of a large tertiary care institution. Canadian Medical Association Journal 2004; 170:793-98. doi:10.1503/cmaj.1031077.

4. Bults M, Beaujean DJMA, Richardus JH, Voeten HACM. Perceptions and behavioral responses of the general public during the 2009 Influenza A (H1N1) pandemic: A systematic review. Disaster Medicine and Public Health Preparedness 2015; 9:207-19. doi:10.1017/dmp.2014.160.

5. Holmes EA, et al. Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science. The Lancet Psychiatry 2020; 7:547–60. doi:10.1016/S2215-0366(20)30168-1.

6. Javed B, Sarwer A, Soto EB, Mashwani Z. Impact of SARS-CoV-2 (Coronavirus) pandemic on public mental health. Frontiers in Public Health 2020; 8:292. doi:10.3389/fpubh.2020.00292.

7. Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. The Lancet Public Health 2020; 5:256. doi:10.1016/S2468-2667(20)30061-X.

8. Australian Institute of Health and Welfare. People with disability in Australia 2019 - in brief. Canberra: Australian Institute of Health and Welfare, 2019.

9. Australian Government Department of Health. Coronavirus (COVID-19) advice for people with disability’. Australian Government Department of Health, 2020. https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/advice-for-people-at-risk-of-coronavirus-covid-19/coronavirus-covid-19-advice-for-people-with-disability.

10. Santini ZI, et al. Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): A longitudinal mediation analysis. The Lancet Public Health 2020; 5:62-70. doi:10.1016/S2468-2667(19)30230-0.

11. Macdonald SJ, et al. The invisible enemy: Disability, loneliness and isolation. Disability & Society 2018; 33:1138-59. doi:10.1080/09687599.2018.1476224.

12. Muruganandam P, Neelamegam S, Menon V, Alexander J, Chaturvedi, SK. COVID-19 and severe mental illness: Impact on patients and its relation with their awareness about COVID-19. Psychiatry Research 2020; 29:113265. doi:10.1016/j.psychres.2020.113265.

13. Brooks SK, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet 2020; 395:912–20. doi:10.1016/S0140-6736(20)30460-8.

14. The impact of COVID-19 on people with cardiovascular disease and other chronic illnesses HMRI. Accessed 17 July 2020. /news-article/impact-covid-19-people-cardiovascular-disease-and-other-chronic-illnesses

15. Committee on Health Care for Homeless People. Homelessness, health, and human needs. Washington, DC, USA: National Academies Press, 1987. https://www.ncbi.nlm.nih.gov/books/NBK218232/pdf/Bookshelf_NBK218232.pdf

16. Tsai J, Wilson M. COVID-19: A potential public health problem for homeless populations. The Lancet Public Health 2020; 5:186-87. doi:10.1016/S2468-2667(20)30053-0

17. Dubey S, et al. Psychosocial impact of COVID-19. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 2020;14:779-88. doi:10.1016/j.dsx.2020.05.035.

18. Beyond Blue. Coping with isolation and being at home - Beyond Blue. Accessed 21 July 2020. https://coronavirus.beyondblue.org.au/managing-my-daily-life/coping-with-isolation-and-being-at-home.html.

19. National Health and Medical Research Council. Dietary guidelines for Australian adults. Canberra: Australian Government. 2013.