|Year : 2020 | Volume
| Issue : 2 | Page : 83-89
Psychological dimensions of COVID-19: Perspectives for the practicing clinician
Angela Paric, Lakshmi Ravindran, Arun Ravindran
Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
|Date of Submission||22-May-2020|
|Date of Decision||06-Jun-2020|
|Date of Acceptance||10-Jun-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Arun Ravindran
Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8
Source of Support: None, Conflict of Interest: None
For most individuals, the coronavirus disease 2019 (COVID-19) pandemic is a novel and anxiety provoking experience. With ongoing outbreaks in many regions around the globe, it has led to worldwide social distancing measures, travel restrictions, job and financial losses, and depletion of resources. In addition, morbidity and mortality of the infection with mental health sequelae including health-related anxiety, depression, and traumatic-related conditions are common. Such adverse mental health consequences clearly have a bidirectional relationship with the infection's presence, and thus, there is a need to recognize and address such complications to optimize care. The perspectives outlined here are based on a review of literature regarding past infectious outbreaks, current experiences with the ongoing pandemic, and their effects on psychological well-being and clinical practice. They attempt to provide a framework that integrates the mental, physical, and social domains of the COVID-19 pandemic and their interrelationships. Thus, it is recommended that management includes a psychological component, and evidence supports the use of psychoeducation and social support groups to mitigate the adverse psychological effects of the pandemic. Virtual delivery of such interventions is becoming a reality, although efforts to address the COVID-19 outbreak largely remain a work in progress with global collaboration and innovation. The lessons learned from the COVID-19 pandemic may provide valuable information to overcome the psychological impact of future infectious disease outbreaks.
Keywords: Clinical practice, coronavirus disease 2019, COVID-19, mental health, pandemic, psychological well-being
|How to cite this article:|
Paric A, Ravindran L, Ravindran A. Psychological dimensions of COVID-19: Perspectives for the practicing clinician. Int J Non-Commun Dis 2020;5:83-9
|How to cite this URL:|
Paric A, Ravindran L, Ravindran A. Psychological dimensions of COVID-19: Perspectives for the practicing clinician. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Jul 10];5:83-9. Available from: http://www.ijncd.org/text.asp?2020/5/2/83/288248
| Introduction|| |
Disease outbreaks have influenced human health and behaviors for millennia. One of the earliest known pandemics scoured Athens in 430 B.C. and resulted in a significant loss of life. While its biological cause remains unidentified, its horrific impact on Athenian society, which included collective distress, panic, isolation behaviors, and irrational efforts to overcome disease, has been well described. Interestingly, pandemics are sufficiently spaced apart, with distinct biological profiles, that they appear to instigate unique consequences for psychological, physical, and social domains among the affected. The current worldwide spread of the coronavirus disease 2019 (COVID-19) is no exception in this regard. While the morbidity and mortality of the physical illness remain the focus, there is also significant concern about both the immediate- and long-term psychological impact of COVID-19.,, Since the onset of the pandemic, several well-researched manuscripts have already been published on the outbreak, emphasizing its multifaceted impact on mental health.,,,,, This review hopes to provide a synopsis of published literature, with a focus on assessment, presentation, and management of psychological sequelae of the outbreak, as well as interventions (e.g., quarantine) that may be helpful to physicians (e.g., in primary care) and nonphysician clinicians working on the frontlines.
| Infectious Disease Outbreaks and Mental Health: What Does History Tell Us?|| |
It is intuitive that infectious disease outbreaks lead to psychological distress in the general population. Although symptoms are generally transient, they can persist in vulnerable individuals with long-term sequelae. For example, in 2013, the Ebola virus disease (EVD) began its spread in West Africa and has since been linked to persistent fatigue, cognitive difficulties, depression, and anxiety long term among those who survived., These symptoms are further compounded by stigma that often leads to societal rejection of survivors,, as well as those who lost immediate family members and friends to the disease, causing significant distress. There is one such report of suicide in Gulu, Uganda, that was purportedly linked to depression, following widowhood and stigma of EVD. It is well documented that the emotional trauma following Ebola is severe enough to lead to posttraumatic stress disorder (PTSD). A report from Sierra Leone notes that among EVD survivors (n = 74), 71% experienced arousal and re-experiencing reactions, and 21% reported clinically significant posttraumatic reactions within weeks of discharge from an Ebola treatment center. Similarly, symptoms of anxiety and depression and an increased risk of PTSD were identified in a significant proportion of subjects affected by H1N1., An HIV-positive diagnosis is also frequently linked to PTSD. As with previous natural and artificial disasters, PTSD is foreseen as a likely significant health concern following the COVID-19 pandemic.
Furthermore, in some individuals, the COVID-19 pandemic may precipitate extreme physiological and psychological responses that contribute to the development of other stress-related conditions and, in particular, acute stress reaction/disorder or adjustment disorder.,, These conditions are rapid in onset, often of brief duration, and generally self-limiting in comparison to PTSD and depression. At least a subgroup of individuals with these conditions transition into PTSD and depressive disorders. Information on their prevalence, disease characteristics, and outcomes is limited, tempered by differences in the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases systems. However, these conditions are highly relevant to infectious disease outbreaks because of their high frequency of occurrence.
While pandemics clearly trigger stress-related mental illness among infected individuals as well as the general population, there is good evidence that an existing mental illness is associated with increased likelihood of infection.,, This phenomenon has been attributed in part due to several shared risk factors, including social adversity, compromised immunity,, and genetic vulnerability, among others., Such increased vulnerability to and mortality from infections and noncommunicable diseases has mostly come from cohorts of patients with depression.,, In their landmark longitudinal study of 976,398 Danish participants, Andersson et al. confirmed the association between depression and an increased risk of bacterial and viral infections via several routes. The increased risk occurred in the year following the onset of depression and persisted over time. Since altered immune functioning is a characteristic of depression and other mental disorders, it has been proposed as a mechanism increasing susceptibility to infection.
The bidirectional relationship between physical disease and mental illness is complicated by the social consequences of infection and measures to control it. Quarantine, the strictest form of social isolation, befalls individuals who are suspected or confirmed to have been exposed to the infection, including healthcare workers. Reports of the impact of quarantine on the mental state document symptoms of irritability, insomnia, depression, and the development of stress-related conditions. Quarantine has led to lawsuits against the institution imposing social distancing measures  and can be distressing enough to lead to self-harm and suicide. Following quarantine, individuals have also been noted to display avoiding crowds behaviors for fear of contracting the disease (e.g., avoiding crowds and warry of those displaying symptoms of infection). Paradoxically, less stringent measures of social distancing may also trigger emotional distress and contribute to the emergence of mental illness. This is, of course, not surprising as social support, connectedness, and group memberships contribute to mental and physical well-being. As a corollary, low perceived social support and reduced social group participation are often detrimental to overall health, having been linked to increased mortality, cardiovascular disease, and depression.
Evidently, and as has long been known, there is a bidirectional relationship between infectious disease and mental illness that is further affected by the social consequences of both afflictions. This tripartite relationship, fitting with the biopsychosocial model of health, should be considered in the clinical context of infectious disease outbreaks to facilitate optimal management.
| What Conceptual Framework and Strategic Approaches Can Help Us Understand the Psychological Dimensions of the COVID-19 Pandemic?|| |
The accumulating literature suggests that four key perspectives need to be taken into account to evaluate the psychological dimensions of disease outbreaks including COVID-19:
- Distress resulting from quarantine and safe distancing measures and their implications for social functioning
- Psychological and biological consequences of repeated exposure to outbreak-related stressors, both immediate and distant
- Contribution of existing mental and physical illnesses to overall health, social functioning, and risk of infection
- Long-term sequelae contributing to adverse social determinants (e.g., poverty) and their impact on mental and physical illness.
In developing integrative strategies, learning from the past is key. Reviewing and synthesizing information from well-conducted investigations during past outbreaks, including information on interventions and their efficacy, would be fundamental. Equally, establishing new interdisciplinary research initiatives that track biological, psychological, and social well-being would be relevant. Since the onset of the COVID-19 pandemic, a number of related guidelines, perspectives, and research studies have been published.,,,, Future longitudinal studies should gather comprehensive symptom and functional assessments using validated tools, as well as expert clinical consensus and reports from individuals and focus groups with lived experience. This information is critical to understanding the long-term effects of the infectious outbreak, isolation measures, benefit of interventions, and their outcomes. Notably, with COVID-19, such assessments have been integrated into several existing research programs, some of which have reported preliminary findings on the mental health sequelae of infected subjects and the general public.,,
| What Do We Know About the Impact of COVID-19 on Mental Health?|| |
There is a worldwide consensus that the COVID-19 pandemic has and will continue to have a substantial impact on mental health.,,,,, It is also well accepted that the psychological sequelae of the outbreak will be influenced by a multitude of factors, including the duration of the pandemic, the impact of lockdown measures, and the limitation of resources. Adverse economic factors, including job losses and resource scarcity, will likely further contribute to psychological distress. Some groups of individuals are more likely to experience emotional distress during the pandemic and include those infected or exposed to the virus (e.g., healthcare workers), with biological (e.g., older adults, immune compromised individuals) and psychosocial vulnerabilities (e.g., mental health disorders) and those impacted by adverse social determinants., Furthermore, travel and hospital visitor restrictions have reduced the provision of outpatient services that form a critical part of care for people living with mental illness. Infectious outbreaks among inpatients in psychiatric wards have not been uncommon. These occurrences may be explained by confined conditions, lower awareness of infection risk, and cognitive impairment that is commonly seen among this population. Finally, reports also stress the potential negative consequences of increased media exposure during this time. Frequent, multimedia reporting on infection counts, death tolls, and ever-changing isolation measures has been suggested as fuelling panic and concern over one's own safety and that of others.,
At least three studies have been published very recently by authors from China based on their early experience evaluating the impact of COVID-19 on mental wellness.,, Qiu et al. conducted an online assessment of mental health, physical and social functioning, as well as cognitive change using the COVID-19 Peritraumatic Distress Index. Among the surveyed Chinese population (n = 52, 730), 34.43% were experiencing psychological distress. In a separate study, the prevalence of psychological distress among COVID-19 patients was understandably much higher. Bo et al. included an online assessment of attitudes toward mental health services and a screener for PTSD symptoms in stable COVID-19 patients (n = 714) in Wuhan, China. Approximately half of these subjects felt that available psychological interventions were helpful (49.8%), and the prevalence of PTSD symptoms, as measured by the PTSD Checklist, was a remarkably high 96.2%.
Among the first longitudinal study of its kind, individuals from 190 Chinese cities were surveyed during the initial days of the COVID-19 outbreak, and 4 weeks later, at its peak. Of the 1730 study participants, 333 completed surveys at both time points. Questionnaires included the Impact of Event Scale-Revised (IES-R), a measure of PTSD symptoms, and the Depression, Anxiety, and Stress Scale (DASS-21), a measure of psychological distress. After 4 weeks, participants reported a significant decrease in IES-R scores but remained above the clinical cutoff for PTSD (>24) at both time points. Paralleling this conclusion, there were no changes in DASS-21 scores over time, suggesting that depression, anxiety, and stress levels persisted among those surveyed. The study found that low risk of infection, perceived likelihood of survival, and adequacy of precautionary measures, as well as satisfaction with health information and physicians, were protective against psychological distress.
| What Key Elements Should Clinicians Include in the Psychological Assessment of COVID-19 Subjects and Those Exposed to the Outbreak?|| |
The clinician would be well advised to take into account the interrelationship between mental, physical, and social domains when evaluating the psychological state of COVID-19 subjects. Broadly, they fall under these groups:
- Direct impact of the infection on the mental state
- Systematically screen for general symptoms of depression and anxiety. Subsyndromal presentations are the rule rather than the exception. Somatic anxiety symptoms may be hard to differentiate from manifestations of the infection
- Thoroughly evaluate stress-related conditions including acute stress disorder and PTSD, as well adjustment disorder
- Evaluate the contribution of any preexisting physical and mental illness to the current mental state. It would be relevant to determine the impact of medications for any physical symptom on the mental state.
Influence of mental state and function on susceptibility to the viral infection and its course
- Mental illness and psychological distress can contribute to increased susceptibility to infection
- Psychological distress and maladaptive personality traits may lead to impaired adherence to treatment and impact presentation of infection
- The biological and behavioral characteristics of mental disorders may modify risk of infection (e.g., altered immune functioning and changes in social behavior)
- Psychotropic medications may have adverse drug–drug interactions with antiviral treatments.
Impact of psychosomatic factors to mental state
- The experience of the COVID-19 infection with its stigma has significant adverse impacts and is distressing
- Social distancing measures are known to have significant mental health repercussions contributing to psychological distress
- May trigger or perpetuate mental illness in the vulnerable.
To address each perspective above, specific COVID-19-related inquiries may include, but are not limited to, the following themes: exposure to disease (via employment, family, friends), job loss, use of precautionary measures against infection, feelings of uncertainty and health-related anxiety, media exposure, source of health information, coping methods (including substance use), interruptions to social group memberships, and perceived availability of social support.,
| What Forms of Interventions Were Found to Be Helpful in Alleviating Psychological Symptoms Associated With Infectious Disease Outbreaks?|| |
Several therapeutic strategies have been used, evaluated, and found to effectively reduce psychological distress and prevent more complex mental health consequences during past infectious outbreaks. These include psychoeducation, social support groups, cognitive behavioral therapy, psychosocial art programs, and psychological first aid, among others.,, Several less specific hospital- and community-based mental health interventions with peer support elements have often been employed and adapted to include workshops regarding outbreak-specific mental health difficulties (e.g., sleep disturbances, stress, and health anxiety).,
Psychological first aid has been used extensively in the past and may be helpful at the current time to provide rapid psychological and social support to individuals suffering from acute stress following a crisis. It can be utilized by a trained lay person to help affected individuals and is claimed to have ease of adaptation to local contexts and cultures. Although its potential is recognized, its effectiveness needs more careful evaluation. There is significant literature supporting the benefit of several other psychosocial and psychoeducational interventions. For example, International Medical Corps developed and implemented a successful and cost-effective community-based social reconnection group in Mawah, Liberia, to aid in recovery from EVD. Program facilitators were locals with experience working in conflict and postconflict settings and from the disciplines of social work and psychiatric nursing. The intervention consisted of sessions to build trust and cohesion, encourage exchange of EVD experiences, as well as unearth and build strengths, values, and coping skills. Culturally significant practices were integrated and included Town Hall discussions, music, and dance. The intervention was well received by participants, and future plans include the development of a means to assess and refer individuals with mental health disorders. Several unique cellphone and web-based psychosocial interventions have also been implemented to aid HIV/AIDS sufferers and are well reviewed by Muessig et al. Participation led to increased social and emotional support, as well as improved knowledge transfer of HIV/AIDS and infection prevention methods. In response to COVID-19, China has already made significant progress with the implementation of online mental health services, which include counseling and mental health education.
It is well accepted that the provision of mental health services during the pandemic should be via community and online portals as opposed to hospitals, to minimize the risk of infection spread and mitigate the limitations of public transportation., Indeed, the “lockdown” has led to the creation of several web-based platforms and encouraged their use for clinical practice.,, Under exceptional circumstances, hospital-based care (for more intense form of care) may be required, warranting careful consideration of patient and staff needs and risks.
Coordination of interventions
Interventions are helpful insomuch as they are systematically organized and conducted in a unified manner across institutions and regions. In response to COVID-19, many national authorities have issued guidelines for the management of psychological issues that are precipitated and perpetuated by the infection. Healthcare establishments responded with the creation of their own frameworks to safeguard public health and ensure compliance with recommendations from higher authoritative bodies. While coordinated efforts are helping to mitigate the spread of the virus, the degree and efficacy of such efforts vary globally., Recent perspectives from Chinese researchers and clinicians suggest limited oversight from higher level authorities, with reports of individual healthcare departments planning and administering their own programs with limited communication between institutions. To further complicate the matter, there is an insufficient number of trained clinicians and other resources to address population needs, particularly in low- and middle-income countries. Thus, there is a need to train nonmedical health practitioners to recognize and manage psychological issues related to COVID-19 and for the coordinated delivery of proven interventions for mental health.,,
| How is the Pandemic Uniquely Affecting Healthcare Staff and What Measures Can Be Implemented for Their Care?|| |
The plight of physicians, nurses, and other clinical staff during the COVID-19 pandemic warrants special attention. In their pursuit to treat and eradicate the virus, healthcare workers have had to make difficult choices and personal sacrifices that have jeopardized their mental and physical health.,
At the onset of the pandemic, there was a rapid change in hospital regulations to increase capacity for COVID-19 patients and their care, as well as to prevent viral transmission to other patients. These included the reduction of elective procedures, the reassignment of surgical rooms for suspected COVID-19 patients, and the establishment of new standards for personal protective equipment. Clinical staff have had to adjust to drastically new routines while continually placing themselves at risk of infection and having to make difficult decisions, relating to the use of limited resources. Such situations are more likely to occur and common in low- and middle-income countries. Furthermore, mandatory isolation from family and friends, potential of contracting the infection, burnout, and sustaining moral injuries contribute to psychological distress and onset of mental illness. It has been suggested that early support and proper aftercare can help mitigate the negative consequences of COVID-19 on staff well-being. Such measures may involve peer support programs and team discussions regarding the emotional challenges faced, and briefing following crisis situations. However, some staff experiencing distress may avoid such discussions and need encouragement to participate, as well as more welcoming and personalized support.
| Conclusion|| |
As evidenced by rapidly emerging literature, the evolving COVID-19 outbreak presents a unique series of challenges for individuals worldwide. This is particularly true for the practicing clinicians who are tasked with identifying and managing the biological, psychological, and social consequences of viral exposure for their patients. At the same time, clinicians also face similar risks to their own well-being. To minimize patient and clinician burden, it is recommended that swift, collective action be implemented to ensure the timely, appropriate, and consistent assessment and follow-up of patients living with psychological distress and mental health disorders during the COVID-19 outbreak. The present overview provides perspectives and guidance for practicing clinicians in this regard. Continued surveys of the literature and collaborative efforts to improve patient care are strongly encouraged.
- The COVID-19 pandemic has significant implications for mental, physical, and social well-being both at the individual and societal level.
- A significant proportion of exposed individuals experience stress-related conditions that can have long-term sequelae.
- Strong interrelationships are well documented between the infectious process, psychological state, and social consequences, including disease-related stigma.
- Peer support groups, psychoeducation, cognitive behavioural therapy, and virtual options of these interventions are supported by evidence and can help mitigate the mental health consequences of COVID-19.
- Clinician well-being is impacted by direct exposure to the disease, stressful work conditions, and forced isolation. Peer support, close monitoring, and psychological interventions are recommended.
We wish to acknowledge the contributions of Sonali Amarasekera in the preparation of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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