How infectious disease outbreaks affect mental health

Health Research

While the battle with coronavirus continues, we must be prepared for another pandemic – the anxiety, depression, grief and fear among communities as the death toll rises and schools, businesses, public places are closed to prevent COVID-19 infections  

By Denise-Marie Ordway

Government officials and public health leaders worldwide have worked around the clock battling the new coronavirus. Meanwhile, another pandemic requires their attention — the anxiety, depression, grief and fear that spread across communities as the death toll rises and schools, businesses and public places close to prevent COVID-19 infections.

“It is not only the illness that becomes a pandemic, but the same can be inferred about fear, mourning, and despair,” Jacqueline Levin, a psychiatrist at North Shore University Hospital in New York, writes in Psychiatry of Pandemics. “Providing psychiatric care to survivors and healthcare workers in the aftermath of a pandemic outbreak is a complicated, but crucial, imperative in the service of reducing the burden of human suffering.”

Adults respond to crises in a patterned way, notes researcher Ronald W. Manderscheid, an adjunct professor at the Johns Hopkins Bloomberg School of Public Health who is also the executive director of two national mental health organizations, the National Association of County Behavioral Health and Developmental Disability Directors and National Association for Rural Mental Health.

While one-third of adults will be able to function normally, Manderscheid explains that others either will become immobilized or hyperactive and hypervigilant.

“One of the lessons of managing all crises — wars, pandemics, terror attacks, natural disasters — is that our ability to respond will be predicated upon our ability to keep large populations in good mental health and to mitigate panic while we all ride out the storm,” he writes in a paper published in the Archives of Psychiatric Nursing in February 2007.

We’ve gathered academic studies that examine how prior outbreaks of infectious diseases such as Ebola, H1N1 and Severe Acute Respiratory Syndrome (SARS) affected the mental health of the public and hospital staff.

Below, you’ll find research on the psychological consequences of a pandemic, including how people respond to quarantine and isolation, and how the social stigma associated with contagious diseases can harm survivors.

The researchers from the Johns Hopkins Bloomberg School of Public Health examine the mental health consequences of a pandemic. They explain “psychological contagion” and how emotions such as fear, paranoia and anger “may drive behaviors that can include evacuation panic, resistance to public health measures, overburdening of hospitals and clinicians, blaming of the government, and abandoning responsibilities to families and jobs.”

The authors also highlight factors that make some people more likely than others to suffer adverse psychological outcomes — for example, living with someone who has the disease, being female or elderly or having lower levels of education.

They note that personality plays an important role in mental health. For example, people who have an internal locus of control — they believe they have control over events that influence their lives — “cope better with all crises and catastrophes because they view themselves as being in command of their lives and destinies,” they write. “Conversely, those with an external locus of control view themselves as victims of fate with little perceived self-efficacy in being able to influence many life events and outcomes.”

While isolating patients may help contain the risk of infection, those who are isolated experience higher rates of depression and anxiety than those who are not, find researchers from the University of Calgary and Alberta Health Services in Canada. They reviewed all academic articles published on the topic before March 2019 to determine how isolation affects patients’ quality of life and mental health.

The researchers note that isolation “generally involve[s] separate isolation rooms, enhanced environmental cleaning, and the use of additional personal protective equipment.” Among the main takeaways: “All studies except one showed negative impact of isolation precautions on anxiety. All studies suggested negative effect of isolation precautions on depression.”

Another review of the research on how isolation affects infected patients also indicates segregation can have negative consequences for mental health. A group of researchers from City, University of London reviewed studies they found through several research databases up through December 2018. They concluded that “there are a number of apparently negative aspects to contact precautions, in particular with regard to psychological effects and a reduction in the quality of some aspects of [medical] care.”

“The data from the comparative studies suggest that although in many cases infective isolation precautions make little difference to psychological outcomes, where it does make a difference this is primarily negative,” they explain. “There were significant declines in mean scores related to control and self-esteem and in many studies increases in the mean scores for risk of anxiety and depression.”

The researchers note that some studies found that hospital staff spent less time with segregated patients. “Internal medicine interns spent less time with their isolated patients compared with non-isolated patients, the median times being 5.2 and 6.9 [minutes], respectively,” they write.  Healthcare workers saw them fewer times. They saw isolated patients on an average of 2.1 times per hour and other patients 4.2 times per hour. Healthcare workers did spend more time on each visit with isolated patients, though — 4.5 minutes, on average, as opposed to 2.8 minutes with patients who were not isolated.

Although the SARS epidemic of 2003 was traumatic for residents of Hong Kong, many residents had also experienced positive changes as a result of the outbreak, including improvements in social support and family relationships, this study finds.

Researchers from the Chinese University of Hong Kong asked 818 Hong Kong residents aged 18 and 60 years to compare their lives during the two months leading up to the outbreak with their lives during the two months afterward. The researchers learned that “some positive changes due to SARS had also been fostered in the midst of the negative impacts on mental health.”

Another study focuses on the experiences of 34 survivors of the 1995 Ebola epidemic in the Democratic Republic of Congo. Most had cared for sick family members before becoming infected them.

While many survivors watched friends and loved ones die of the disease and reported feeling rejected by society, all said they experienced an increase in religious faith. “All survivors felt they were strengthened through their belief in god,” the authors write. “And although most had lost family members, their religious belief was even greater after the epidemic.”

More than half of the 300-plus public health workers surveyed for another study said they likely would not report for duty during a pandemic. The paper, from researchers at Ben-Gurion University of the Negev and Johns Hopkins Bloomberg School of Public Health, examines the reasons employees at three county health departments in Maryland said they would be unlikely to show up for work during a pandemic influenza-related emergency.

Nearly 70% of all employees who completed the anonymous survey in 2005 said they believed they’d be taking a personal risk by working during such an event. Most also said they did not think they would be asked to report to work. The researchers found that employees who were most willing to report to work tended to perceive themselves as being better able to address questions from concerned members of the public. They also were more likely to perceive their jobs as important to the health department’s response to the crisis.

“Lack of knowledge, ambiguity regarding one’s exact tasks, and questionable ability in performing one’s role as risk communicator were all significantly associated with a higher perceived personal risk and a two- to ten-fold decrease in willingness to report to duty,” the researchers write.

Yet another study looks at the psychological and occupational impact of a SARS outbreak on a large hospital in Canada during the first month of the outbreak in 2003.

“Prominent among the varied responses of individual staff members were themes of fear, anxiety, anger and frustration,” write the authors, who, at the time of the study’s publication, worked at Mount Sinai Hospital in Toronto, a teaching hospital affiliated with the University of Toronto. “Many expressed conflict between their roles as health care provider and parent, feeling on one hand altruism and professional responsibility and, on the other hand, fear and guilt about potentially exposing their families to infection. Some nurses on units that had no patients with SARS felt that their needs became secondary. Collaboration and collegiality were observed in units that volunteered to send staff to other units to assist with care.”

Supervisors and other leaders felt compelled to be at work. “Throughout the hospital,” the authors explain, “it was found that many staff required ‘permission’ from peers or supervisors to refrain from doing too much … There were wide discrepancies in workload between those subjected by circumstances or personal attitudes to over-work and those prevented from working by quarantine or a ‘nonessential’ designation.”

This study looks at how the stigma associated with H1N1, also known as swine flu, compares with the stigma associated with infectious diseases such as AIDS and cancer. Researchers examine the role stigma plays in people’s desire to separate themselves from someone who has been infected with a harmful, contagious illness.

“Understanding the relationship between stigma and people’s desire for physical distance from others with infectious disease is critical to the extent that it can inform strategies to protect public health during future influenza pandemics,” write the researchers, from Yale University and the University of Connecticut.

The scholars wanted to know whether healthy individuals would continue to avoid people with an infectious disease if the stigma did not exist. To find out, they conducted an online survey in November 2009, at the height of the H1N1 pandemic in the U.S. They sought feedback from college students — 219 students at the University of Connecticut — because they were among the subgroups with an elevated risk of H1N1 infection, the authors note.

What they learned: University students felt more prejudice toward people infected with H1N1 than those living with cancer or HIV/AIDS. Their survey responses also indicate that “reductions in influenza stigma may not entirely undermine public health officials’ goals to increase physical distancing.”

“Although prejudice contributes to the relationship between H1N1 threat and physical distance, the relationship between H1N1 threat and physical distance would remain without prejudice,” the authors explain. “Consequently, it may be possible to reduce people’s feelings of prejudice toward others with influenza while maintaining their desire for distance from others with influenza.”

“People may hold prejudices and perpetuate discriminatory behavior based on such stigma,” write researchers from the U.S. Centers for Disease Control and Prevention. “Stigma may be internalized by people who currently have a disease or who have survived a disease. Stigmatized individuals may see themselves as inferior to others and worthy of self-hate due to their disease status.”

The stigma associated with a disease can discourage people from getting tested and seeking treatment.

“Health-related stigma and the perception that one might be HIV-infected were also associated with never receiving an HIV test among black/ African American and Hispanic/Latino young adults, lower medication adherence, and higher levels of depression, anxiety, excessive worry, avoidant coping strategies, and suicidal ideation,” the authors write. “HIV stigma has been associated with substance abuse and sexual risk-taking.” (This article was circulated by Journalist’s Resource, an international organization)

Leave a Reply

Your email address will not be published. Required fields are marked *