During any outbreak of an infectious disease, the population’s psychological reactions play a critical role in shaping both spread of the disease and the occurrence of emotional distress and social disorder during and after the outbreak. Despite this fact, sufficient resources are typically not provided to manage or attenuate pandemics’ effects on mental health and wellbeing. 1 While this might be understandable in the acute phase of an outbreak, when health systems prioritize testing, reducing transmission and critical patient care, psychological and psychiatric needs should not be overlooked during any phase of pandemic management. There are many reasons for this. It is known that psychological factors play an important role in adherence to public health measures (such as vaccination) and in how people cope with the threat of infection and consequent losses. 1 These are clearly crucial issues to consider in the management of any infectious disease, including Covid-19. Psychological reactions to pandemics include maladaptive behaviours, emotional distress and defensive responses. 1 People who are prone to psychological problems are especially vulnerable. All of these features are in clear evidence during the current Covid-19 pandemic. One study of 1210 respondents from 194 cities in China in January and February 2020 found that 54% of respondents rated the psychological impact of the Covid-19 outbreak as moderate or severe; 29% reported moderate to severe anxiety symptoms; and 17% reported moderate to severe depressive symptoms. 2 Notwithstanding possible response bias, these are very high proportions—and it is likely that some people are at even greater risk. During the 2009 H1N1 influenza outbreak (‘swine flu’), a study of mental health patients found that children and patients with neurotic and somatoform disorders were significantly over-represented among those expressing moderate or severe concerns. 3 Against this background, and as the Covid-19 pandemic continues to spread around the world, we hypothesize a number of psychological impacts that merit consideration now rather than later. In the first instance, it should be recognized that, even in the normal course of events, people with established mental illness have a lower life expectancy and poorer physical health outcomes than the general population. 4 As a result, people with pre-existing mental health and substance use disorders will be at increased risk of infection with Covid-19, increased risk of having problems accessing testing and treatment and increased risk of negative physical and psychological effects stemming from the pandemic. Second, we anticipate a considerable increase in anxiety and depressive symptoms among people who do not have pre-existing mental health conditions, with some experiencing post-traumatic stress disorder in due course. There is already evidence that this possibility has been under-recognized in China during the current pandemic. 5 Third, it can be anticipated that health and social care professionals will be at particular risk of psychological symptoms, especially if they work in public health, primary care, emergency services, emergency departments and intensive or critical care. The World Health Organization has formally recognized this risk to healthcare workers, 6 so more needs to be done to manage anxiety and stress in this group and, in the longer term, help prevent burnout, depression and post-traumatic stress disorder. There are several steps that can and should be taken now to minimize the psychological and psychiatric effects of the Covid-19 pandemic. First, while it might be ostensibly attractive to re-deploy mental health professionals to work in other areas of healthcare, this should be avoided. Such a move would almost certainly worsen outcomes overall and place people with mental illness at disproportionate risk of deteriorations in physical and mental health. If anything, this group needs enhanced care at this time. Second, we recommend the provision of targeted psychological interventions for communities affected by Covid-19, particular supports for people at high risk of psychological morbidity, enhanced awareness and diagnosis of mental disorders (especially in primary care and emergency departments) and improved access to psychological interventions (especially those delivered online and through smartphone technologies). 7 These measures can help diminish or prevent future psychiatric morbidity. Finally, there is a need for particular focus on frontline workers including, but not limited to, healthcare staff. In the USA, the Centers for Disease Control and Prevention offer valuable advice for healthcare workers in order to reduce secondary traumatic stress reactions, including increased awareness of symptoms, taking breaks from work, engaging in self-care, taking breaks from media coverage and asking for help. 8 This kind of advice needs to be underpinned by awareness of this risk among employers, enhanced peer-support and practical assistance for healthcare workers who find themselves exhausted, stressed and feeling excessive personal responsibility for clinical outcomes during what appears to be the largest pandemic of our times. Even in this emergency circumstance, or especially in this emergency circumstance, we neglect mental health at our peril and to our long-term detriment. Conflict of interest: None declared.
