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April 10, 2020

The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention

Author Affiliations
  • 1Boston University School of Public Health, Boston, Massachusetts
  • 2Emergency Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania
  • 3Coalition for Epidemic Preparedness Innovations. Oslo, Norway
JAMA Intern Med. 2020;180(6):817-818. doi:10.1001/jamainternmed.2020.1562

Since the first case of novel coronavirus disease 2019 (COVID-19) was diagnosed in December 2019, it has swept across the world and galvanized global action. This has brought unprecedented efforts to institute the practice of physical distancing (called in most cases “social distancing”) in countries all over the world, resulting in changes in national behavioral patterns and shutdowns of usual day-to-day functioning.

While these steps may be critical to mitigate the spread of this disease, they will undoubtedly have consequences for mental health and well-being in both the short and long term. These consequences are of sufficient importance that immediate efforts focused on prevention and direct intervention are needed to address the impact of the outbreak on individual and population level mental health.

The sparse literature on the mental health consequences of epidemics relates more to the sequelae of the disease itself (eg, mothers of children with congenital Zika syndrome) than to social distancing. However, large-scale disasters, whether traumatic (eg, the World Trade Center attacks or mass shootings), natural (eg, hurricanes), or environmental (eg, Deepwater Horizon oil spill), are almost always accompanied by increases in depression, posttraumatic stress disorder (PTSD), substance use disorder, a broad range of other mental and behavioral disorders, domestic violence, and child abuse.1 For example, 5% of the population affected by Hurricane Ike in 2008 met the criteria for major depressive disorder in the month after the hurricane; 1 out of 10 adults in New York City showed signs of the disorder in the month following the 9/11 attacks.2,3 And almost 25% of New Yorkers reported increased alcohol use after the attacks.4 Communities affected by the Deepwater Horizon oil spill showed signs of clinically significant depression and anxiety.5 The SARS epidemic was also associated with increases in PTSD, stress, and psychological distress in patients and clinicians.6 For such events, the impact on mental health can occur in the immediate aftermath and then persist over long time periods.

In the context of the COVID-19 pandemic, it appears likely that there will be substantial increases in anxiety and depression, substance use, loneliness, and domestic violence; and with schools closed, there is a very real possibility of an epidemic of child abuse. This concern is so significant that the UK has issued psychological first aid guidance from Mental Health UK.7 While the literature is not clear about the science of population level prevention, it leads us to conclude that 3 steps, taken now, can help us proactively prepare for the inevitable increase in mental health conditions and associated sequelae that are the consequences of this pandemic.

First, it is necessary to plan for the inevitability of loneliness and its sequelae as populations physically and socially isolate and to develop ways to intervene. The use of digital technologies can bridge social distance, even while physical distancing measures are in place.8 Normal structures where people congregate, whether places of worship, or gyms, and yoga studios, can conduct online activities on a schedule similar to what was in place prior to social distancing. Some workplaces are creating virtual workspace where people can work and connect over video connections, so they are not virtually alone. Employers should ensure that each employee receives daily outreach during the work week, through a supervisor or buddy system, just to maintain social contact.

Many observers note that outreach that involves voice and/or video is superior to email and text messaging. Extra efforts should be made to ensure connections with people who are typically marginalized and isolated, including the elderly, undocumented immigrants, homeless persons and those with mental illness. Social media can also be used to encourage groups to connect and direct individuals to trusted resources for mental health support. These platforms can also enhance check-in functions to provide regular contact with individuals as well as to allow people to share with others information about their well-being and resource needs. Even with all of these measures, there will still be segments of the population that are lonely and isolated. This suggests the need for remote approaches for outreach and screening for loneliness and associated mental health conditions so that social support can be provided.

Particularly relevant here is the developing and implementing routines, particularly for children who are out of school, ensuring that they have access to regular programmed work. Online substitutes for daily routines, as mentioned above, can be extremely helpful, but not all children have access to technologies that enable remote connectivity. Needed are approaches for ensuring structure, continuity of learning, and socialization to mitigate the effect of short- and long-term sheltering in place.

Second, it is critical that we have in place mechanisms for surveillance, reporting, and intervention, particularly, when it comes to domestic violence and child abuse. Individuals at risk for abuse may have limited opportunities to report or seek help when shelter-in-place requirements demand prolonged cohabitation at home and limit travel outside of the home. Systems will need to balance the need for social distancing with the availability of safe places to be for people who are at risk, and social services systems will need to be creative in their approaches to following up on reports of problems.

Third, it is time to bolster our mental health system in preparation for the inevitable challenges precipitated by the COVID-19 pandemic. Stepped care, the practice of delivering the most effective, least resource-heavy treatment to patients in need, and then stepping up to more resource-heavy treatment based on patients’ needs, is a useful approach.9 This will require that systems are both well designed and well prepared to deliver this care to patients, from screening to the overflow of mental illness that will inevitably emerge from this pandemic. Scaling up treatment in the midst of crisis will take creative thinking. Communities and organizations could consider training nontraditional groups to provide psychological first aid, helping teach the lay public to check in with one another and provide support. Even small signs that someone cares could make a difference in the early stages of social isolation. Telemedicine mental health visits, group visits, and delivery of care via technology platforms will be important components of stepped care for both acute crisis management and more routine communication and support. Medicare has already expanded coverage of tele–mental health services to include mental health counseling and virtual visits with psychologists and social workers.10 And health systems, both public and private sector, will need to develop mechanisms for refill and delivery of essential medicines, including psychiatric medicines.

This difficult moment in time nonetheless offers the opportunity to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so. The worldwide COVID-19 pandemic, and efforts to contain it, represent a unique threat, and we must recognize the pandemic that will quickly follow it—that of mental and behavioral illness—and implement the steps needed to mitigate it.

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Article Information

Corresponding Author: Sandro Galea, MD, Office of the Dean, Boston University School of Public Health, 715 Albany St, Talbot 301, Boston, MA 02118 (sgalea@bu.edu).

Published Online: April 10, 2020. doi:10.1001/jamainternmed.2020.1562

Conflict of Interest Disclosures: None reported.

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4 Comments for this article
New York is not 100% the U.S.
XIOMARA SPADAFORA, Coomunications-Journalist | Blogger
I believe you forgot one other--rather important--measure to counteract the spiral of the mental health epidemic: To modify lock downs in communities, as soon as possible, depending on their cases and fatality rates so people can return to a level of normalcy. New York is, by many measures, entirely different form the rest of the country. Its density of population, massive public transportation, and proximity of housing are key factors left out often when analyzing data.
Jim Meehan, Mental health nurse | Primary care
Whilst the article identifies places of worship as important socially there is no reference to spirituality per se.

In the excellent tome upon which much my psychiatric training was based (ref), Mental health psychistric nursing - a holistic life cycle approach, a theme running throughout was the five essential domains upon which we could frame human experience, development, and adaptability. These are social, physical, intellectual, emotiona,l and spiritual.
We negate the spiritual at our peril but in the post religious world where faith has for some become a term to be feared or favoured by association as
appropriate, we forget the relevance of spirituality. If through a global collaboration of minds and hearts we as a body of humanity can show true love for and through each other and show genuine care and compassion to offset the suffering and neglect that riddles our communities then we will show the power of love which is the basis of true human spirituality. So let's remember that aspect of humanity and not just refer to mental health without the spiritual heart. One aspect of the crisis is that people are sharing and showing concern for others and this can be mutually therapeutic for the giver and the person receiving the gesture. As is often the case in the aftermath of a disaster we see the best of humanity. At a time when the so called great Faiths have been compelled to stop gathering together in order to protect each other when the gatherings in numbers has been in order to pray for each other, ironically this could unite people of all faiths and none if set times for prayer and or meditation can be agreed and implemented throughout the world. To come together virtually to pray and meditate for the good of all. Perhaps this one will be another step along the way to real learning from history and a means to unifying all countries in a commonwealth of spirituality.

How to combat the emotional impact of COVID-19
Antione Johnson, Master of Arts Special Ed | Trauma Informed Facilitator child and youth residentail treatment center
Yes this pandemic is going to cost many lives, but taking care of our emotional needs will be of the utmost importance. Self-care when properly administered can make the difference between mental wellness and mental illness. There are a host of ways we can practice self-care during this pandemic:

1. Aroma therapy: Aromatherapy is a holistic healing treatment that uses natural plant extracts to promote health and well-being. Sometimes it's called essential oil therapy. Aromatherapy uses aromatic essential oils medicinally to improve the health of the body, mind, and spirit. It enhances both physical and emotional health.

Bibliotherapy: A therapeutic approach that uses literature to support good mental health, is a versatile and cost-effective treatment option often adapted or used to supplement other types of therapy. Proponents of the approach suggest mild to moderate symptoms of several mood-related conditions can be successfully treated with reading activities.

3. Chromtherapy: Color therapy/ color healing is based on the idea that colors create electrical impulses in our brains that stimulate hormonal and biochemical processes in our body; these processes either calm or stimulate us. The types of color therapy sessions on the market are as varied as the colors of the rainbow. Color therapy is an alternative therapy that uses colors and their frequencies to heal physical and emotional problems. Color therapy is also known as chromopathy, chromotherapy,

4. Music Therapy:  The soothing power of music is well-established. It has a unique link to our emotions, so can be an extremely effective stress management tool. Listening to music can have a tremendously relaxing effect on our minds and bodies, especially slow, quiet classical music.

These are just a few I have experienced as a combat veteran with PTSD , but there are other forms of self care interventions.
In the COVID-19 era, Mental and physical health in Japan
takuma hayashi, MBBS, DMSci, GMRC, PhD | National Hospital Organization Kyoto Medical Center
Under the expansion of COVID-19, many people around the world are feeling anxiety and stress. Furthermore, due to refraining from going out, it has been pointed out that people around the world, including the Japanese people, lack basic exercise such as walking. In other words, in the COVID-19 era, how to maintain mental and physical health has become an urgent issue.

Mental stress is thought to be one of the causes of type 2 diabetes. Therefore, coping with stress is important to improve diabetes control. Exercise such as walking, and muscle training reduces anxiety and stress and improves mental
health. In other words, basic exercise such as walking is the most effective means for maintaining mental health.

According to a report from Japan Ministry of Health, Labor and Welfare, the number of consultations regarding COVID-19 to the Psychiatric Social Welfare Center is increasing rapidly. Many consultations such as "I'm worried about getting infected with SARS-CoV-2," "I can't sleep," and "I'm going to get sick because of anxiety." have been sent to the Psychiatric Social Welfare Center.

In order to understand how many people in Japan complain of mental disorders such as depressive symptoms due to refraining from going out and requesting close due to the expansion of COVID-19, Japan Ministry of Health, Labor and Welfare has been conducting a national mental health survey for Japanese peoples since October 2020, four months after the cancellation of the state of emergency (May 25, 2020).