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      COVID-19 and mental health: A review of the existing literature

      research-article
      Asian Journal of Psychiatry
      Elsevier B.V.
      COVID-19, Anxiety, Depression, Stress, Public health

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          Highlights

          • Subsyndromal mental health concerns are a common response to the COVID-19 outbreak.

          • These responses affect both the general public and healthcare workers.

          • Depressive and anxiety symptoms have been reported in 16–28% of subjects screened.

          • Novel methods of consultation, such as online services, can be helpful for these patients.

          • There is a need for further long-term research in this area, especially from other countries

          Abstract

          The COVID-19 pandemic is a major health crisis affecting several nations, with over 720,000 cases and 33,000 confirmed deaths reported to date. Such widespread outbreaks are associated with adverse mental health consequences. Keeping this in mind, existing literature on the COVID-19 outbreak pertinent to mental health was retrieved via a literature search of the PubMed database. Published articles were classified according to their overall themes and summarized. Preliminary evidence suggests that symptoms of anxiety and depression (16–28%) and self-reported stress (8%) are common psychological reactions to the COVID-19 pandemic, and may be associated with disturbed sleep. A number of individual and structural variables moderate this risk. In planning services for such populations, both the needs of the concerned people and the necessary preventive guidelines must be taken into account. The available literature has emerged from only a few of the affected countries, and may not reflect the experience of persons living in other parts of the world. In conclusion, subsyndromal mental health problems are a common response to the COVID-19 pandemic. There is a need for more representative research from other affected countries, particularly in vulnerable populations.

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          Most cited references29

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          Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China

          Background: The 2019 coronavirus disease (COVID-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. Research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. The aim of this study was to survey the general public in China to better understand their levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak. The data will be used for future reference. Methods: From 31 January to 2 February 2020, we conducted an online survey using snowball sampling techniques. The online survey collected information on demographic data, physical symptoms in the past 14 days, contact history with COVID-19, knowledge and concerns about COVID-19, precautionary measures against COVID-19, and additional information required with respect to COVID-19. Psychological impact was assessed by the Impact of Event Scale-Revised (IES-R), and mental health status was assessed by the Depression, Anxiety and Stress Scale (DASS-21). Results: This study included 1210 respondents from 194 cities in China. In total, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. Most respondents spent 20–24 h per day at home (84.7%); were worried about their family members contracting COVID-19 (75.2%); and were satisfied with the amount of health information available (75.1%). Female gender, student status, specific physical symptoms (e.g., myalgia, dizziness, coryza), and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (p < 0.05). Specific up-to-date and accurate health information (e.g., treatment, local outbreak situation) and particular precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05). Conclusions: During the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. Our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the COVID-19 epidemic.
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            Mental health care for medical staff in China during the COVID-19 outbreak

            In December, 2019, an outbreak of a novel coronavirus pneumonia occurred in Wuhan (Hubei, China), and subsequently attracted worldwide attention. 1 By Feb 9, 2020, there were 37 294 confirmed and 28 942 suspected cases of 2019 coronavirus disease (COVID-19) in China. 2 Facing this large-scale infectious public health event, medical staff are under both physical and psychological pressure. 3 To better fight the COVID-19 outbreak, as the largest top-class tertiary hospital in Hunan Province, the Second Xiangya Hospital of Central South University undertakes a considerable part of the investigation of suspected patients. The hospital has set up a 24-h fever clinic, two mild suspected infection patient screening wards, and one severe suspected infection patient screening ward. In addition to the original medical staff at the infectious disease department, volunteer medical staff have been recruited from multiple other departments. The Second Xiangya Hospital—workplace of the chairman of the Psychological Rescue Branch of the Chinese Medical Rescue Association—and the Institute of Mental Health, the Medical Psychology Research Center of the Second Xiangya Hospital, and the Chinese Medical and Psychological Disease Clinical Medicine Research Center responded rapidly to the psychological pressures on staff. A detailed psychological intervention plan was developed, which mainly covered the following three areas: building a psychological intervention medical team, which provided online courses to guide medical staff to deal with common psychological problems; a psychological assistance hotline team, which provided guidance and supervision to solve psychological problems; and psychological interventions, which provided various group activities to release stress. However, the implementation of psychological intervention services encountered obstacles, as medical staff were reluctant to participate in the group or individual psychology interventions provided to them. Moreover, individual nurses showed excitability, irritability, unwillingness to rest, and signs of psychological distress, but refused any psychological help and stated that they did not have any problems. In a 30-min interview survey with 13 medical staff at The Second Xiangya Hospital, several reasons were discovered for this refusal of help. First, getting infected was not an immediate worry to staff—they did not worry about this once they began work. Second, they did not want their families to worry about them and were afraid of bringing the virus to their home. Third, staff did not know how to deal with patients when they were unwilling to be quarantined at the hospital or did not cooperate with medical measures because of panic or a lack of knowledge about the disease. Additionally, staff worried about the shortage of protective equipment and feelings of incapability when faced with critically ill patients. Many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies. Finally, they suggested training on psychological skills to deal with patients' anxiety, panic, and other emotional problems and, if possible, for mental health staff to be on hand to directly help these patients. Accordingly, the measures of psychological intervention were adjusted. First, the hospital provided a place for rest where staff could temporarily isolate themselves from their family. The hospital also guaranteed food and daily living supplies, and helped staff to video record their routines in the hospital to share with their families and alleviate family members' concerns. Second, in addition to disease knowledge and protective measures, pre-job training was arranged to address identification of and responses to psychological problems in patients with COVID-19, and hospital security staff were available to be sent to help deal with uncooperative patients. Third, the hospital developed detailed rules on the use and management of protective equipment to reduce worry. Fourth, leisure activities and training on how to relax were properly arranged to help staff reduce stress. Finally, psychological counsellors regularly visited the rest area to listen to difficulties or stories encountered by staff at work, and provide support accordingly. More than 100 frontline medical staff can rest in the provided rest place, and most of them report feeling at home in this accomodation. Maintaining staff mental health is essential to better control infectious diseases, although the best approach to this during the epidemic season remains unclear.4, 5 The learning from these psychological interventions is expected to help the Chinese government and other parts of the world to better respond to future unexpected infectious disease outbreaks.
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              Online mental health services in China during the COVID-19 outbreak

              At the start of 2020, the 2019 coronavirus disease (COVID-19), originating from Wuhan in Hubei province, started to spread throughout China. As a result of the rapidly increasing numbers of confirmed cases and deaths, both medical staff and the public have been experiencing psychological problems, including anxiety, depression, and stress.1, 2 Since January, 2020, the National Health Commission of China have published several guideline documents, starting with the notification of principles for emergency psychological crisis intervention for the COVID-19 epidemic on January 26, then the notice on establishing psychological assistance hotlines for the epidemic on February 2, and most recently, guidelines for psychological assistance hotlines during the COVID-19 epidemic on February 7. 3 During the severe acute respiratory syndrome epidemic in 2003, internet services and smartphones were not widely available. Therefore, few online mental health services were provided for those in need. 4 The popularisation of internet services and smartphones, and the emergence of fifth generation (5G) mobile networks, have enabled mental health professionals and health authorities to provide online mental health services during the COVID-19 outbreak. Fast transmission of the virus between people hinders traditional face-to-face psychological interventions. By contrast, provision of online mental health services is safe. To date, several types of online mental health services have been implemented widely for those in need during the outbreak in China. Firstly, as of Feb 8, 2020, 72 online mental health surveys associated with the COVID-19 outbreak could be searched for via the WeChat-based survey programme Questionnaire Star, which target different populations, including medical staff (23 of the surveys), patients with COVID-19 (one survey), students (18 surveys), the general population (nine surveys), and mixed populations (21 surveys); in Hubei province (five surveys), other provinces (15 surveys), all provinces, municipalities, and autonomous regions (36 surveys), and unspecified areas of China (16 surveys). One such multicentre survey involving 1563 medical staff, with our centre at Nanfang Hospital, Southern Medical University (Guangzhou, China) as one of the study sites, found the prevalence of depression (defined as a total score of ≥5 in the Patient Health Questionnaire-9) to be 50·7%, of anxiety (defined as a total score of ≥5 in the Generalized Anxiety Disorder-7) to be 44·7%, of insomnia to be 36·1% (defined as a total score of ≥8 in the Insomnia Severity Index), and of stress-related symptoms (defined as a total score of ≥9 in the Impact of Events Scale-Revised) to be 73·4%. These findings are important in enabling health authorities to allocate health resources and develop appropriate treatments for medical staff who have mental health problems. Secondly, online mental health education with communication programmes, such as WeChat, Weibo, and TikTok, has been widely used during the outbreak for medical staff and the public. In addition, several books on COVID-19 prevention, control, and mental health education have been swiftly published and free electronic copies have been provided for the public. As of February 8, 29 books associated with COVID-19 have been published, 11 (37·9%) of which are on mental health, including the “Guidelines for public psychological self-help and counselling of 2019-nCoV pneumonia”, published by the Chinese Association for Mental Health. Finally, online psychological counselling services (eg, WeChat-based resources) have been widely established by mental health professionals in medical institutions, universities, and academic societies throughout all 31 provinces, municipalities, and autonomous regions in mainland China, which provide free 24-h services on all days of the week. Online psychological self-help intervention systems, including online cognitive behavioural therapy for depression, anxiety, and insomnia (eg, on WeChat), have also been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for psychological crises during the epidemic. For example, individuals at risk of suicide can be recognised by the AI programme Tree Holes Rescue, 5 by monitoring and analysing messages posted on Weibo, and alerting designated volunteers to act accordingly. In general, online mental health services being used for the COVID-19 epidemic are facilitating the development of Chinese public emergency interventions, and eventually could improve the quality and effectiveness of emergency interventions.
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                Author and article information

                Contributors
                Journal
                Asian J Psychiatr
                Asian J Psychiatr
                Asian Journal of Psychiatry
                Elsevier B.V.
                1876-2018
                1876-2026
                10 April 2020
                10 April 2020
                : 102066
                Affiliations
                [0005]Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605 006, India
                Article
                S1876-2018(20)30177-5 102066
                10.1016/j.ajp.2020.102066
                7151415
                32302935
                0520fdb1-3349-4d87-a951-646277e302c9
                © 2020 Elsevier B.V. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 26 March 2020
                : 30 March 2020
                : 31 March 2020
                Categories
                Article

                covid-19,anxiety,depression,stress,public health
                covid-19, anxiety, depression, stress, public health

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