Contribution signée Elke Van Hoof (Vrije Universiteit Brussel), Nele Van den Cruyce (Vrije Universiteit Brussel), Ellen Loix (Vrije Universiteit Brussel) et Evelien Phillips (Vrije Universiteit Brussel).

Abstract

The covid-19 pandemic, including the necessary containment measures taken, creates a plethora of challenges for mental health. These challenges have to be addressed as soon as possible if we don’t want the current crisis to transform into a mental health pandemic. It is not only necessary to assure the continuity of existing psychological care, but it is also pivotal to immediately prepare for the newly emerging needs which are directly and indirectly related to the current crisis. A clear strategy for mental wellbeing and a coordination of existing services should be put into place. This to assure the best possible care within a contagious outbreak, both for the general population at large, and for specific target groups which have been identified as being more at risk, either, for developing new mental health problems or for developing complications of pre-existing mental health problems.

Analysis

The current covid-19 pandemic is not only an epidemiological challenge. The virus itself and the necessary containment measures which have been taken, strongly impede on our daily life as we know it. Fear of infection for ourselves and our loved ones, fear for one’s safety and the lack thereof, for example when being confronted with inadequate protection supplies or confusing and sometimes even contradicting information, the confrontation with death (moreover death without last contact or other cultural end-of-life rituals) and dying in our society, the impact of physical distancing and lack of social–including physical–contact, confinement to the smaller area along the homestead, remote working and technological hassles… are just a few of the preoccupations which people are confronted with in the current pandemic.

It is, therefore, no surprise that research on covid-19 in China has demonstrated that psychological distress in the population rose significantly during the outbreak (Qiu J, Shen B, Zhao M et al; 2020). The fact that psy- chological distress is rising in epidemics, is also validated by research on earlier contagious outbreaks, research which demonstrate that the negative effects on mental health are plentiful (Brooks, 2020). A couple of weeks into the soft lockdown, we are already witnessing this in Belgium, where different helplines report a rise in support calls and several surveys show specific signals of rising distress levels. Ally institute, a nonprofit organization and independent research center specialized in stress, noticed a 10% rise in toxic stress levels in the general population, rising from 15% to 25%, after only 2 weeks of lockdown (VanHoof, 2020). Other examples which already have been reported in the press are: a deterioration of sleep quality and quantity, increase in worrying, lower concentration levels and increase in feeling more down compared to usual.

While these psychological distress signals are already common within our general population, it is clear that certain groups are more at risk for pathological stress levels compared to this general population. The IASC and WHO (2020) indicate that healthcare workers, young people and especially children, the elderly (>60) and people in precarious situations (ex. People suffering from mental illness, disabilities, people living in poverty…) are more at risk and should receive special attention from the start in order for their situation not to decline any further. The impact of quarantine, and even moderate lockdown measures, to which the vast majority of the Belgian population has been exposed, negatively impacts both the levels of experienced psychological distress as the duration of these effects over time (Brooks et al, 2020).

Societal stakes

The majority of our society will, luckily, be able to cope with these mental health challenges without extra support based on their own resilience. Learning from other contagious outbreaks in the past, it can, however, be expected that for a significant part of the general population (up to 30 %), and especially for the target groups identified as being more at risk (up to 70%), the mental health challenges related to covid-19 will be both pathologically problematic as long lasting.

Most commonly reported mental health problems after contagious outbreaks are post-traumatic stress disorder (PTSD), burnout, depression and anxiety disorders, of which problematic symptoms have been reported up to a couple of years after the epidemic (Jalloh MF, Li W, Bunnell RE, et al.; 2017; Brooks, 2020). Specific concerns arise with regards to the effects of the epidemic on people with pre-existing mental health disorders (Yaot H, Chen J & Yi-Feng X, 2020). This both medically, as certain mental health disorders and their treatment increase the risk of infections like pneumonia, as psychologically. For example, people who are being treated in psychiatric hospitals are currently isolated from the rest of society and from their loved ones. Regular outpatient visits are becoming more difficult and impractical by the lockdown regulations on travel and quarantine. Also, certain types of mental illnesses, like for example mysophobia (fear of germs/contamination) and anxiety disorders but also depression; are expected to worsen by the covid-19 pandemic and the necessary measures taken to deal with the virus outbreak. It is clear that the psychological impact of this pandemic can be wide ranging, substantial, and long lasting for the general public and people already experiencing mental health problems. This especially given the fact that the collective confinement which we are encountering only increases the risk and the duration of psychological distress within society (Brooks, 2020).

Covid-19 confronts our society with a supplementary psychological challenge, i.e. dealing with complicated bereavement. While our western society has been rather shielded from sudden death and dying in recent times, our country is currently being confronted with highly mediatized mortality numbers. This at a time where normal mourning routines are not possible. People are already starting to give a certain expression to this collective loss by burning candles, posting pictures of the victims on social media, etc. Covid-19 is becoming cultural trauma, whereby the high risk for complicated grief should be taken into account in the exit strategy. Symptoms of complicated grief can be compared to PTSD, they are equally problematic and long lasting. Up to 44% of the population could suffer from complicated grief symptoms when being faced with collective or individual emergencies (SHC,2017). This while our current society, including our medical staff and people working on the frontline, is not equipped nor adequately prepared to deal with complicated bereavement, especially at this scale.

Untreated, the combined psychological/psychiatric trauma related to covid-19 and the imposed confinement measures, will result into a significant economic impact, as affected people will not be able to return to work and/or perform at the same standard as was expected of them before the pandemic. This will put a strain on our already struggling economy and also on our healthcare given the fact that healthcare workers are in the frontline of this pandemic.

It is clear that society is being confronted with a plethora of mental health problems. The current care infrastructure is not adequately equipped, nor prepared for this flux of needs and it should not be forgotten that these covid-19 related needs come on top of pre-existing psychological/psychiatric needs which should also continue to be treated. If we want to avoid that the viral pandemic is followed by a mental health pandemic, and given the fact that problematic psychological/psychiatric distress signals are already eminent within our society, it is of pivotal importance to focus on the preservation and the reinforcement of mental health, individual and community resilience, as part of an adequate exit strategy. This is also recommended by the superior health council (2017) and the WHO (2020).

Recommendations

• The prevention, detection and response to mental health conditions should be an important and even vital component of the pandemic response and also of the exit strategy.
• Firstly, the accessibility to mental health resources and the public health service system should be further strengthened and improved, in order to provide both regular care as well as specific covid-19 related care. This particularly after reviewing the initial coping and management of the covid-19 epidemic.
• Secondly, psychological intervention measures should be targeted and adapted as appropriate. A stepped care principle should be worked out in which a triage system can guide people to the appropriate and scientifically proven effective care. A special focus should go to more complicated disorders as PTSD, anxiety, depression and complicated bereavement. Monitoring is pivotal.
• Thirdly,in preparing for a new economic normality, a back to work strategy which takes into account the psychological/psychiatric needs of this pandemic experience should be developed. Ideally, preventive measures including early intervention for acute stress disorder should be implemented in every company that opens-up. An intervention like iedereenok.be is easily implemented as an effective standalone, a-synhronic intervention. It is free and available in 3 languages. Monitoring and triage during the 6 months after relaunch seems necessary.
• Fourthly, it is essential to create a common feeling of trust in the way that our society is dealing with this pandemic, which can only be realized by coherence and transparency within decision making and communication. There is no room for hidden agenda’s or implicit value judgments.
• Lastly, society should prepare for upcoming pandemics. A clear strategy for mental wellbeing and the coordination of existing mental health services should be part of this preparation from the beginning. A solid psychological/psychiatric approach and care plan should be developed, taking into account existing and spontaneously arising support needs and resources.

References

Ally Institute, https://www.ally.institute/

Brooks S et al. The psychological impact of quarantine and how to reduce it: review of the evidence. The lancet 2020, 395, 912-920.

Everyone ok?, https://www.everyoneok.be

IASC. Note d’information Prise en compte des aspects psychosociaux et de santé mentale de l’épidémie de Covid-19, 2020.

Qiu J, Shen B, Zhao M, et al. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. General Psychiatry 2020; 33: e100213. doi: 10.1136/gpsych-2020-100213.

SHC-Superior Health Council. Aanbevelingen inzake de preventie en het beheer van psychosociale restletsels na individuele of collectieve noodsituaties. November 2017.

Van Hoof, E. Lockdown is the world’s biggest psychological experiment – and we will pay the price. World Economic Forum, 9 April 2020.

WHO. Mental Health and Psychosocial Considerations During COVID-19 Outbreak, 2020.

Yaot H, Chen J and Yi-Feng X. Patients with mental health disorders in the covid-19 epidemic. The lancelet psychiatry 2020, 7.