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June 24, 2020

The Coronavirus Disease 2019 (COVID-19) Outbreak and Mental Health: Current Risks and Recommended Actions

Author Affiliations
  • 1New York State Psychiatric Institute, Columbia University Irving Medical Center, New York
  • 2Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
JAMA Psychiatry. Published online June 24, 2020. doi:10.1001/jamapsychiatry.2020.1730

The coronavirus disease 2019 (COVID-19) outbreak has rapidly spread, originating in Wuhan province, China, in late 2019 and making its way around the world in a matter of months. The outbreak is overwhelming intensive care units and health care capacity. According to the World Health Organization, as of May 20, 2020, there are 4 761 559 confirmed cases of COVID-19 and 317 529 COVID-19-related deaths across 216 countries, areas, and territories.1 To cope with the rapid spread of the outbreak, governments have implemented swift, wide-ranging public health emergency measures that include social restrictions and quarantines. Among these are daily updates to travel bans (nationally and internationally), stay-at-home orders for nonessential workers, and the shutdown of all nonessential businesses. These steps to mitigate the spread of the virus influence the lives of billions across the globe. Since the start of the outbreak, there has been widespread stigma and rejection of individuals living in or coming from affected communities, individuals with underlying illnesses, the elderly population, and first responders. While the physical risk (eg, pneumonia, respiratory breakdown) is getting the most scientific and clinical attention, emerging data suggest that this outbreak presents substantial risk for widespread mental health problems and psychological fear-related responses.

Mental Health and Infectious Disease Epidemics

Psychological responses to previous large-scale outbreaks, particularly to the Ebola virus disease (EVD) epidemic from 2014 to 2016, provide insight into the potential impact of rapidly spreading diseases on mental health problems.2 During the EVD outbreak, fear-related behaviors, such as stigmatizing infected survivors and ignoring medical procedures, impeded public health efforts and negatively affected recovery of survivors.3 Anxiety, posttraumatic stress disorder, and depression were found in nearly half of the EVD survivors and their contacts.3

The COVID-19 outbreak presents a similar set of high-risk behaviors: ignoring recommendations for social distancing (eg, young people on spring break or church attendance) and continuing to travel despite restrictions (eg, fleeing high-impact communities). These risky behaviors accelerate the spread of the disease and make it more difficult to isolate confirmed cases. On the other hand, fear-related behaviors, such as extreme avoidance of social contact, will likely result in increased risk of mental health problems. Together, these behaviors may shape the trajectory of the outbreak in the short term and long term.4 Psychoeducation and redirection of fear-related behavioral responses during the outbreak can reduce risks and promote resilience.5

Internet as Major Source of Information During COVID-19 Outbreak

The unprecedent nature and scale of the COVID-19 outbreak coupled with an acute lack of medical capacities (eg, shortages in basic protective equipment and ventilators) have invoked stark public concerns. The increasing number of confirmed cases and deaths have escalated public fear about becoming infected, presenting a novel kind of psychological trauma. The reality of the outbreak and the fear and anxiety that it brings is magnified by myths and fake news (ie, misinformation) driven by erroneous news reports and community panic on social media.

To date, billions of people are being asked to stay at home, which will likely lead to increased exposure to both digital and social media that might be at times unreliable and unverified.6 This widespread use of social media and the extensive array of information can exacerbate confusion and worries and, in turn, increase fear and anxiety and the creation of more fear-driven web and media content. Moreover, indirect exposure to constant news and social media may have a wide range of psychopathological consequences, of which stress-related disorders are the most common.7 Posttraumatic stress disorder symptoms, including nightmares, hyperarousal, sleep difficulties, detachment, and numbing, are particularly disabling and need clinical attention. A 2020 study8 conducted in China examined the prevalence of mental health problems 1 month into the COVID-19 epidemic and found high rates of depression (48.3%), anxiety (22.6%), and a combination of depression and anxiety (19.4%) among 4872 adults. Importantly, people with high social media exposure were almost twice as likely to have depression and anxiety than people with less social media exposure. Social isolation and increased consumption of social media will likely lead to a significant global elevation of mental health problems.

Using the Internet to Ameliorate Risk and as a Platform for Intervention

An effective and timely response is essential to address the immediate, midterm, and long-term psychosocial needs of large populations exposed to the rapidly spreading outbreak, mass trauma, and death. First, in the immediate phase, social media can be used to enhance social support and connectedness.6 Encouraging frequent contact with relatives, friends, and caregivers via telephone, video-based chats, or social media can enhance social support and, in turn, facilitate resilience. Second, in times of quarantine and social isolation, ongoing mental health ambulatory treatments should not be stopped, as online secured platforms (eg, telemedicine) are widely available for use. Considering the expected increase in mental health use, the general public must be advised to seek care in alternative ways. Online platforms can be used to evaluate and diagnose patients, personalize treatments, and monitor their progress. Strategies to provide access to computers and internet across socioeconomic strata are essential. Third, to mitigate anxiety-provoking dissemination of information, large social media platforms (eg, Facebook, Twitter, Google, WhatsApp, YouTube) should direct users to credible websites (eg, World Health Organization, US Centers for Disease Control and Prevention).6 Fourth, limiting media exposure time is advisable.9 Graphic imagery and worrisome messages increase stress and anxiety, elevating the risk of long-term, lingering fear-related disorders.7 Although staying informed is essential, one should minimize exposure to media outlets.

In the midterm, there should be a focus on the development and dissemination of innovative brief online contact-based interventions to encourage healthy lifestyles (eg, physical exercise, balanced diet) and anxiolytic-like activities (eg, meditation, mindfulness). Previous studies10 have shown that social contact-based interventions are effective in changing human perceptions and behaviors. Using empowered presenters with lived experience (eg, “I tested positive for COVID-19”) who attain their goals create a sense of identification for anxious viewers and, in turn, improve functioning and facilitate resilience (eg, “I was able to overcome my anxiety via healthy behaviors”).

Lastly, the large-scale exposure to the outbreak, massive loss of lives, and the financial difficulties may greatly intensify the need for mental health care across exposed communities and among high-risk groups (eg, first responders, medical staff, elderly individuals, bereaved) in the long term. Longitudinal data will be needed to track prevalence of mental health problems, the associated needs for treatment, and how online, cost-effective platforms can be used to address them.

In summary, mass quarantine and social isolation lead to increased use of social media and other information-based websites, which in turn increases fear, stress, and the risk of fear-related disorders. In times of rapidly spreading infectious diseases and mass exposure to trauma, online platforms can be used to guide effective consumption of information, facilitate social support, continue mental health care delivery, and develop and test innovative, personalized contact-based interventions that, if found effective, can be disseminated to address emerging mental health needs.

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Article Information

Corresponding Author: Yuval Neria, PhD, New York State Psychiatric Institute, Columbia University Irving Medical Center, Unit 69, 1051 Riverside Dr, New York, NY 10032 (ny126@cumc.columbia.edu).

Published Online: June 24, 2020. doi:10.1001/jamapsychiatry.2020.1730

Conflict of Interest Disclosures: Dr Neria has received grants from the National Institute of Mental Health and nonfinancial support from New York State Psychiatric Institute. No other disclosures were reported.

References
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World Health Organization. WHO coronavirus disease (COVID-19) dashboard. Accessed May 20, 2020. https://covid19.who.int/
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Gao  J, Zheng  P, Jia  Y,  et al.  Mental health problems and social media exposure during COVID-19 outbreak.   PLoS One. 2020;15(4):e0231924. doi:10.1371/journal.pone.0231924PubMedGoogle Scholar
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