What are the major ways that the novel coronavirus and COVID-19, the disease that it causes, affect mental health? To approach that question, we must break this issue down into several component parts. First, a review of some of the things we know about this virus and the pandemic. Statistics and other basic information for this column are obtained from Wolters Kluwer UpToDate, which updated this topic last on July 14, 2020 at the time of this writing.
Knowledge and information about the coronavirus 2 (SARS-CoV-2) is evolving rapidly, and we must be vigilant to be as on top of this as we can. COVID-19 has been associated with multiple psychiatric problems in various groups, including the patients who get the disease, their families, and those who care for them. Psychiatric symptoms and disorders may occur in clinicians who are exposed to COVID-19. For health care workers in China and Italy, sites of the early phases of the pandemic, anxiety was seen in 12-20% of workers, depression in 15-25%, insomnia in 8% and evidence of traumatic distress in 35-49%. Interestingly, a survey of clinicians in Singapore revealed 5-10% of workers were at similar risk, possibly in part because of their previous experience with SARS in 2003. If anything has become more clear to me as I work with patients as well as speak with friends and family members, the uncertainty that this pandemic has caused has been one of the most difficult aspects to deal with. What you do not know can indeed hurt you, emotionally speaking.
Has the coronavirus itself, or COVID-19 the disease, caused mental health or emotional problems directly? Few data are available on this subject. Of course, biological and psychosocial factors are surely in play here. Coronavirus can affect central nervous system function. We have all seen the recent reports of sudden cerebrovascular accidents in persons with no such history previously. Alterations in behavior, cognition and personality have also been seen. Retrospective studies have also shown that the virus can affect the brain directly, as encephalopathies, inflammatory responses and physical impairments may lead to neurobehavioral problems. One study cited by UpToDate showed that past viral epidemics had lead to neuromuscular dysfunction as well as the above symptoms. The fact that many people who are infected and develop COVID-19 are admitted to intensive care units may in and of itself lead to symptoms that are related to that extreme physical and emotional stress.
Studies of previous coronavirus epidemics do suggest that those who suffer from COVID-19 may develop mental health sequelae. Previous looks at groups of patients with acute SARS or MERS infections showed that they did indeed suffer from delirium, with insomnia, trouble concentrating, memory impairment, confusion and depressed mood being seen. It appears that in a sample of self report surveys from January to April of this year, anxiety, depression, distress and traumatic stress were present in up to 36 per cent of adults. While no consistent predictors of mental health illness in adults have been identified yet, the presence of these symptoms has been unmistakable. In children, a Chinese sample of second through sixth graders who were quarantined at home for an average of thirty four days showed reported anxiety and depression in twenty per cent of the kids and worry about becoming infected in fully two thirds!
How has the pandemic changed our daily lifestyle? Mental health illness may result from various stressors, including just being exposed to others who are potentially infected with the virus, fear of infecting family members, lack of access to testing, increased workload (think parents who are holding down jobs and educating their children at home), economic hardship due to layoffs or furloughs or loss of jobs, and the ever present feeling that our personal freedoms are being diminished.
How has it changed our ability to work and to go to school on a daily basis? All of us have been affected in some way by this pandemic and how it has impacted the economy and our ability to support ourselves and our families. Some of us have even been quarantined for fourteen days or perhaps longer. What mental health symptoms might be precipitated by these conditions? Anger, anxiety, depression, boredom, confusion, fear, exhaustion.
How has the pandemic affected those who had pre-existing mental health problems? On a very basic level, according to this UpToDate article, some patients with pre-existing mental health illness may be more at risk for infection due to difficulties with simple handwashing, physical distancing, and poor insight around these basic areas. Many of these patients might live in close proximity to others and not be able to physically distance. Some might already be delusional, and this prolonged focus on physical illness and infection might become embedded into their delusional systems. The availability of routine appointments, injections, groups, and other support systems may vastly strain the ability of the mental health system to provide needed services to those with existing mental health problems. Lack of socially based interventions such as AA, NA and Alanon due to social distancing requirements may be detrimental to those trying to maintain sobriety and clean time. Patients who have a hard time getting refills of their medications may cut back on the doses or stop them all together, usually disastrous. Also, inability to get necessary lab studies and other testing done can derail treatment.
Exacerbation of the use of alcohol and other substances is a very real possibility with this kind of increase in stress without a corresponding increase in support. A survey of Chinese adults in March 2020 found that during the pandemic, use of alcohol increased 32% among regular drinkers. Recurrence of alcohol use happened in 19% of ex-drinkers. Regular smokers used 20% more tobacco, and 25% of ex-smokers fired up again. Eating disorders are another area that might be impacted negatively as levels of anxiety and uncertainty rise.
The risk of suicide is very real during this pandemic. Why? Folks are stuck at home, they have lost their jobs, income has shrunk, childcare is unavailable, there is social isolation and decreased access to church and other social support systems. The sale of guns has risen sharply during this pandemic, a huge risk for increased suicide attempts on its own. We have all read of the completed suicides of overwhelmed healthcare workers who simply could not give as much as they felt called to and could give no more.
Treatment and management of these mental health issues has been a major challenge for the health care system. Hospitals and emergency departments are stressed, some outpatient clinics and services may be physically closed, and availability of medicines may be severely limited. Novel ways to deliver services have sprung up literally overnight in many areas, and bolstered in areas where they already existed. Reminders about healthy routines (limit exposure to news, eat and sleep regularly, exercise moderately, participate in positive activities, etc) are a good place to start for all of us. For many, telemedicine services have been lifesaving during this time. As many of you know, I have been doing telepsychiatry for ten years, but never have I been as busy with the provision of telemedicine services as I have these past four months. No show rates have decreased, patient satisfaction levels have increased, and we have been able to provide many services that are just as high quality as they would have been if delivered face to face. There are some minor inconveniences and limitations to these services, but the ability to connect far outweighs most of them. The ability to electronically prescribe medications as well as deliver psychotherapy and various types of support has been nothing short of amazing.
These are just some of the issues that we are facing with the need to screen for, diagnose, treat and manage mental health symptoms, syndromes and illnesses during the COVID-19 pandemic. There are many more and the list will grow as we move through this time. Remember to educate yourself about COVID-19, wear a mask, wash your hands, and practice responsible physical distancing. Together, we will get through this.