A review on Psychological Impact of Disease Outbreaks and how to respond to the impacts of COVID-19

Abstract:

Disease outbreaks have been known to cause substantial devastation in the world. The impact of such outbreaks on mental health have been documented but unfortunately these haven’t been mainstreamed into emergency response preparedness. Low-income countries (LIC) are the most disadvantaged in this front especially considering mental health care hasn’t been much developed with countries having limited capacity for psychological support. These are put to test at times of such crisis when far reaching mental distress is caused with need for remedy.

To correlate research findings, proposals and recommendations from different sources on mental health and the impact of disease outbreaks on mental health, we did desktop review of literature sources to establish some of the findings and align them with the current COVID-19 outbreak. These have then been used to propose feasible approaches that can be used to mitigate the immediate, sustained and long-term psychological impacts of this disease outbreak while at the same time cushioning the public from mental health problems.

Key words: Mental health, Pandemic, Psychological support, Capacity Building and Advocacy.

Background:

Mental health is a state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community[1]. An individuals’ mental wellbeing is influenced by a myriad of factors such as social, psychological, and biological factors. Among the explicit contributors to poor mental health are rapid social change, stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyle, physical ill-health and human rights violations.

With coronavirus disease (COVID-19) outbreak there have been concerns of mental health impacts of this disease outbreak. Ranging from the anxiety and apprehension of outbreak in different countries, media reporting, infection of a close relative, caring for the sick to disruption of lifestyles are piling pressure on the well-being of individuals. The first case been reported in Wuhan China on 28th December 2019, the National Health Commission of China released guiding principles of the emergency psychological crisis interventions on 26th January 2020[2]. These were meant to guide in provision of mental health services to the affected, provide psychological crisis intervention for people in need and to actively prevent, mitigate and try to control the psychosocial impact of the epidemic. This level of response is a clear pointer of the growing recognition of mental health as a critical aspect of human health and well-being. The World Health Organization (WHO) also as a follow up to this released “Mental health and psychosocial considerations during the COVID-19 outbreak.[3]

COVID-19 is causing great devastation to the global systems both in developed and developing economies. The difference is that for developed countries, certain structures which were already in place need slight augmentation to serve the current situation unlike for developing countries where these structures do not exist and at best are segregated.

The mental health landscape in African countries have been poorly developed. This is as accounted for by Prof. Ndetei et al. where there is an estimated treatment gap of 85% in low-income countries compared with 35% to 50% in high-income countries[4]. This current pandemic presents insurmountable psychological impacts to a wide range of individuals by attacking the core of the livelihoods. This is from loss of jobs, disruption of social networks, heightened anxiety and uncertainty among others.

Through this paper, we are keen to argue out the impact of disease outbreaks on mental health of different populations from the onset of an outbreak through to the end and residual consequences to be felt. We will share anecdotal recommendations on how better to drive advocacy and capacity building for mental health in low-income countries sustainably. This is cognizant of the fact that when disease outbreaks occur, the immediate and automatic response is to prevent spread of infection and to heal those who fall sick[5].

Fear, Anxiety and Panic associated with knowledge of the disease outbreaks: media reporting

With the outbreak of the disease first reported in Wuhan, China all over the world people got alarmed on the nature of the virus and the impact it was causing. With growing media coverage and rapid spread all over the world, anxiety levels sparked. This led to irrational stockpiling of essential goods including hygiene products e.g. sanitizers, toilet papers, masks among others causing shortages in supermarkets[6][7]. These frantic responses have a clear pointer to the psychological impact of such disease outbreaks.

Individuals who cannot afford to purchase such supplies may feel disadvantaged and undergo pressure associated with feelings of heightened risk of exposure. These psychological impacts can lead to physical health consequences as these people present with depressive symptoms in certain circumstances.

The devastation caused by such anxiety and panic have been reported in other disease outbreaks[8] and can outlive the outbreak. It’s therefore imperative to invest in emergency response preparedness which would ideally span effective communication strategies to avert such occurrences and manage the situation as it unfolds. Media outlets should take responsibility and manage their reporting as well. When the media captures scary captions during an outbreak, this drives panic among the unaffected with negative impacts. Integrating media responsibility to the society as an integral component of media reporting as provided for under the ethical reporting guidelines[9] can help reduce anxiety levels, help in effective response coordination and address the consumer frenzy of stock-piling.

Psychological impact of infection of relatives and close associates

When an individual falls sick, close friends and relatives feel their pain. As Catherine et al. argues, the impact of disease to relatives and family was associated with the emotional, financial, relationships, livelihood and leisure time among others[10]. With a disease outbreak and compounded with the seriousness of the condition, sickness of an individual affects the family even more. There is an associated fear of being infected by the relative while out of care and love for the individual the family has to look after them. When such information gets to the neighborhood this can elicit some form of fear and discrimination against the family which compounds to psychological discomfort.

The impact is even severe when the infected individual dies. Grieving the abrupt loose of a loved one may traumatize the family with a risk of family members to develop Post-Traumatic Stress Disorder (PTSD). An example of such impact has been witnessed in Kenya following the recent death of James Onyango, a resident of Siaya County who died and was given rash burial at 2:00 AM in the night. This have had negative impacts on the relatives even to calls for exhumation of the body for a decent burial[11].

There is need to adopt measures to mitigate the impact of such adverse psychological impacts. This can be through adoption of decent burials with involvement of family members to ease their grieving process, provision of psychotherapy for the family which can leverage on local capacity i.e. social workers, traditional counsellors & elders and even religious leaders who can relate with the circumstances of the family [4]. Additionally, health workers can be part of the support team to relay information between the sick patient and the family to ensure they are part of their lives. These can be done through the integration of technological solutions with either audio or video options especially where isolation and quarantine measures are put in place [3]

Restricted and monitored family visits can also be adopted where circumstances are suitable for such an arrangement e.g. visits as those for which prisoners are normally accorded where they can get to talk to their visitors. These can be structured to ensure there is no physical contact with the patient or relative in isolation.

Psychological impact on health workers

Health workers are always at the frontline of care looking after their patients. This comes with extra emotional demand on them to support patients and their families. In the case of an outbreak, the impact is ever higher as there is compounded risk of infection to the medical practitioner, extra strain to take care of the patients and their overwhelmed relatives. A study conducted by McAlonan et al. on the immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers during SARS outbreak in 2003 found out that health workers at high risk are more prone to suffer psychological impacts than those at low risk[12]. From the study they recommend adoption of stress management protocols as part of preparation for future outbreaks.

The extra pressure that is put on healthcare workers in times of such crisis can compromise on quality of care if not managed with higher risk of disease spread even among the health workers. Health workers are also exposed to discrimination or fear in their communities out of suspicion that they may spread the disease from the hospitals. This negates the value of social structures and sense of community that health workers normally rely on for support. In such situations, family support is encouraged whether in person or through technological solutions such as video calls with loved ones. The WHO in its recommendations advocated for the adoption of a buddy system coupled with rotation between high stress and low stress stations among health workers that would help them establish coping mechanisms from among themselves [3].

The adoption of psychological support systems for health workers can safeguard the well-being of medical practitioners, improve treatment outcomes for patients and save our health systems if done right.

Stigma and discrimination associated with COVID-19: Chinese and Africans in China

Stigma and discrimination have been associated with various diseases for a long time[13]. This have been witnessed for different diseases especially with HIV/AIDS as accounted for by Brian Honnerman;

My youngest sister loved to play with other kids in the neighborhood. One day she was playing with Chris, a ten-month-old baby boy, and she was kissing Chris who was laughing. Suddenly Chris’s mum, who was watching them through the window, came running and took Chris out of my sister’s arms, saying: “Don’t ever come back here, I don’t want you to infect my baby with AIDS. Don’t try to kill my baby. We all know that you are dying of AIDS.” – Claire Gasamagera describing her experience with stigma in Rwanda

With outbreaks, stigma and shaming can be directed to a particular race or ethnic group as was observed for Asian Americans during SARS, West Africans during Ebola, Haitians and gay men during early days of HIV/AIDS5. When coronavirus disease (COVID-19) was reported from China, there were initial attacks on Chinese nationals in the USA following profiling statements by Donald Trump identifying the virus as a “Chinese virus” or “Wuhan virus”[14][15]. On the backdrop of this, there is racial profiling of blacks in China as China opens up operations post-gaining control of the outbreak[16][17].

With racial profiling and stigma, the targeted groups are less likely to seek care which compromises response efforts to mitigate the impact of such an outbreak [5]. Other than the impact on response, such kind of mistreatment is directly linked to the psychological well-being of individuals. It breeds division, a feeling of not belonging and causes trauma to the afflicted.

Psychological impact as a consequence of economic downturn, job loss and associated financial hardships with uncertainty about the future

When disease outbreaks occur governments institute restrictive measures to stop spread of the viruses. This has been witnessed all over the world with recommendation of work from home measures following a surge in COVID-19 cases. Lock downs and curfews have been imposed to different extents and with these, economies have suffered a big blow. It’s projected that the world economy will experience a recession of up to 3%[18]. With this economic downturn, companies are expected to downsize with layoffs which will compound to financial hardships.

With work from home, individuals in developing countries where unemployment rates are high and the majority of those employed are in informal employment, this presents an unprecedented threat to their livelihood[19][20]. This is putting to account the fact that majority of these people work on a daily basis to earn their meal at the end of the day. The impact of such measures in worsened where these are the breadwinners even for extended families down in the rural villages. It will compound to neglect of their responsibility to care for their people. Compounded on such, individuals would be more inclined to risk being infected but to look out for and provide for their families. In such situations, this presents a risk to the entire community in case they happen to be infected and spread infection. This negates a critical aspect of good mental health which calls for contribution to society for which in this case there is a trade-off to be made on whether to provide for your people while at the same posing a threat to their well-being on one end.

In efforts to curb such harm, it’s imperative to have national initiatives to cushion such populations from the devastation through social safety nets, alternate market days to ensure access to essentials, structure long-term job-creation interventions and provide business stimulus packages to ensure business continuity[21]. These will look out for the immediate impacts while at the same time secure the future of these people post the outbreak when normalcy sets in.

Psychological impact of social distancing measures, self-isolation, quarantine and treatment to individuals allied with disruption of social support networks

Following declaration of COVID-19 as a pandemic by the WHO, social distancing measures, self-isolation and quarantine were recommended for individuals who were at risk and the general public to different degrees depending on their circumstances. According to research, social networks have been found to serve an important purpose in promoting the mental well-being of individuals[22]. In the midst of such a crisis, these support systems are disrupted with a critical impact on their mental well-being.

It’s recommended that in such circumstances technological and digital solutions be adopted to help in maintaining relationships within individual social networks. In situations where these are not feasible, it would be ideal to have designated national psychotherapy call centers with capacity to offer psychosocial support.

Long-term psychological impact of the outbreak

Painful experiences have been found to lead to trauma which can affect individuals later in life. These are referred to as Post-Traumatic Stress Disorder (PTSD). With disease outbreaks, there are a myriad of stressful events that have taken place ranging from infection and death of loved ones, loss of jobs to stigma and discrimination from peers and communities. These experiences dent human relationships and unless addressed during and after such an experience, they can lead to long-standing psychological impacts. These can compromise on the quality of life the affected individuals live after this occurrence. From the study conducted on immediate and sustained psychological health of health care workers by McAlonan et al. they recommended stress management through the disease outbreak and even offer packs to the most at risk groups to continue accessing care beyond the outbreak14.

There is no health without mental health. Unfortunately, this is a concept that has taken the world some time to realize. Kenya launched its mental health policy paper in 2016 following frantic move by advocacy groups, academicians and some politicians in the space. This was a move in the right direction but from experiences, a policy is just as good as it is implemented. At this point with total knowledge of the importance of mental healthcare, there have been little attention to mental health impacts of the disease in the local context except for isolated zoom meetings to discuss the same. Zoom meetings with experts doesn’t address anything especially when they postulate the probable impacts of the pandemic without clear action plans to mitigate these impacts and improve the quality of human lives.

Conclusion

Mental health is an important aspect of human health and well-being. Disease outbreaks may not have a direct impact on the brain but their far-arching and wide-reaching effects on social, economic and political systems influence mental wellness. It’s therefore imperative to discern emergency response and preparedness strategies with consideration of the mental health impacts of such outbreaks. With such a plan, psychotherapy support can be assured to those who need them, social support systems are established, health workers welfare is put to consideration, and the long term recuperation measures are in line. This is what guarantees a mentally healthy society and this is what we should all aspire to achieve.

References [1] Mental health: strengthening our response: https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response [2] Notice on the Guiding Principles of Emergency Psychological Crisis Intervention for Pneumonia with New Coronavirus Infection: http://www.nhc.gov.cn/jkj/s3577/202001/6adc08b966594253b2b791be5c3b9467 [3] Mental health and psychosocial considerations during the COVID-19 outbreak: https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf [4] Mental healthcare in Kenya: Exploring optimal conditions for capacity building: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337996/ [5] An “Epidemic Within An Outbreak:” The Mental Health Consequences of Infectious Disease Epidemics: https://oneill.law.georgetown.edu/epidemic-within-outbreak-mental-health-consequences-infectious-disease-epidemics/ [6] Stockpiling is in full effect, but it’s not the answer to surviving a coronavirus outbreak: https://nationalpost.com/news/world/covid-19-stockpiling-surviving-coronavirus-outbreak [7] Excessive stockpiling during COVID-19 outbreak puts others at risk: https://www.hpj.com/ag_news/excessive-stockpiling-during-covid-19-outbreak-puts-others-at-risk/article_14e2f26e-74f1-11ea-9e9c-87197452858d.html [8] Outbreaks as precipitating risk factors for mental illness: https://www.psychiatrictimes.com/anxiety/fears-outbreaks-and-pandemics-lessons-learned/ [9] SPJ Code of Ethics: https://www.spj.org/ethicscode.asp [10] The impact of disease on family members: a critical aspect of medical care: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3791092/ [11] ‘Exhume our son’s body for decent burial,’ family of Siaya Covid-19 victim asks State: https://www.standardmedia.co.ke/article/2001367884/exhume-our-son-s-body-for-decent-burial-family-of-siaya-covid-19-victim-asks-state [12] Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers: https://www.ncbi.nlm.nih.gov/pubmed/17500305 [13] Fears, Outbreaks, and Pandemics: Lessons Learned: https://www.psychiatrictimes.com/anxiety/fears-outbreaks-and-pandemics-lessons-learned/ [14] Growing Xenophobia Against China in the Midst of Corona Shock: https://www.counterpunch.org/2020/03/31/growing-xenophobia-against-china-in-the-midst-of-coronashock/ [15] Spit On, Yelled At, Attacked: Chinese-Americans Fear for Their Safety: https://www.nytimes.com/2020/03/23/us/chinese-coronavirus-racist-attacks.html [16] Chinese official: claims of racial targeting are ‘reasonable concerns’: https://www.theguardian.com/world/2020/apr/13/chinese-official-claims-racial-targeting-reasonable-concerns [17] China’s Racism Is Wrecking Its Success in Africa: https://foreignpolicy.com/2020/04/15/chinas-racism-is-wrecking-its-success-in-africa/ [18] World Economic Outlook, April 2020: Chapter 1: https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020 [19] COVID-19 LOCKDOWNS THREATEN AFRICA’S VITAL INFORMAL URBAN FOOD TRADE: https://pim.cgiar.org/2020/04/02/covid-19-lockdowns-threaten-africas-vital-informal-urban-food-trade/ [20] COVID-19: African governments must support the informal sector: https://africanbusinessmagazine.com/opinion/covid-19-african-governments-must-support-the-informal-sector/ [21] Informal worker demands during COVID-19 crisis: https://www.wiego.org/informal-worker-demands-during-covid-19-crisis [22] The correlation of social support with mental health: A meta-analysis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5633215/ Authors: Phn. Theogene Uwizeyimana and Dr. Odhiambo David