COVID-19 Pandemic: Mental Health and Coping Strategies

The world has been facing a global threat from the past few months from Coronavirus Disease 2019 (COVID-19). There has been a significant increase in morbidity and mortality due to this ongoing pandemic which is creating a global challenge. This pandemic is having a profound effect on all aspects of society especially the physical and mental health of the people. There has been a rising concern about the mental health of normal population, COVID-19 patients, Healthcare Workers (HCW) or doctors, children and the elderly population. Recent research has reported symptoms of anxiety, depression and other symptoms of psychological distress among these populations. The main purpose of this review was to focus on various mental health issues and the coping strategies during the COVID-19 pandemic period.

A major health crisis that has affected around 213 nations across the world is the COVID-19 pandemic. A cluster of pneumonia cases of unknown aetiology that was first reported from Wuhan, Hubei Province, China on 31 December 2019 has spread globally [1]. It has become a pandemic because of its zoonotic nature. Since the past few months a significant increase in the mortality and morbidity rates have occurred due to this pandemic [2]. In the wake of this global health crisis, stringent public health measures have been implemented to curtail the spread of COVID-19 [3]. Widespread outbreak of such diseases are associated with psychological distress and symptoms of mental illness [4,5]. Presently, the World Health Organisation (WHO) laid the major objectives about the prevention of human-to-human transmission in order to limit the spread of this disease to other person and medical HCW. WHO has also given guidelines regarding the isolation and 14-days quarantine period, prevention of complications in infected persons and research to produce vaccine and to minimise the spread of this disease [6]. The main aim of this review was to create awareness about the mental health effects of to COVID-19 and various coping strategies because it has been reported in various studies that due to this pandemic, mental health of a person has been hindered.

The diagnosis of specific diseases needs specific time period, which is the main constraint for measuring and quantifying mental health issues in the population. Long-terms effects may develop in survivors. Brooks SK et al., have written a review which revealed the presence of emotional disturbances including frustration, stress, depression, anger, insomnia, fear, confusion and boredom in quarantined people and healthcare professionals. Specific stressors included greater duration of confinement, having inadequate supplies, difficulty securing medical care and medications, and resulting financial losses [7]. In the current pandemic, the home confinement of large swathes of the population for indefinite periods, differences among the stay-at-home orders issued by various jurisdictions, and conflicting messages from government and public health authorities will most likely intensify distress [8]. It has been noted that there is a need to enhance mental health support because there is an increase in mental health burden. In China, the National Health Commission [9] issued its first comprehensive guidelines for emergency psychological crisis intervention for people affected by COVID-19 on 27 January 2020 which emphasises the need for multidisciplinary mental health teams to deliver mental health support to patients and HCW.

Spreading of COVID-19 rapidly across the globe has resulted in the development of mental health issues like stress and anxiety in the general population [10]. As reported by many studies inadequate knowledge and awareness regarding spread of the virus, routes of transmission, the incubation period of virus and precautionary measures leads to the development of myths, fear and increased level of stress and anxiety [11-13]. During the lockdown period, people became homebound and this is the main source of creating negative mental health issues. They are worried about the insecurity regarding their future [12]. Because of the lockdown, people have reported disappointment, irritability, tension or stress. It was also reported that this event can give rise to new mental disorders or even worsen the symptoms of previous mental disease [11,13]. It was reported that when an outbreak occurs, it produces fear in the normal population. The Kikwit Ebola outbreak already provided beneficial psychological insight into how the general community responds to this biological crisis [14]. Research has shown that misinformation and fictitious reports about the COVID-19 can aggravate anxiety and exacerbate depressive symptoms in the general population [13]. A study found that although more than half of the participants (52.1%) reported that they felt horrified and apprehensive due to the COVID-19 pandemic, they did not feel helpless due to the pandemic when measured on impact of event scale [15].

Children are well-attuned to adult’s emotional states; exposure to unexplained and unpredictable behaviour is perceived by children as a threat, resulting in a state of anxiety. For children quarantined at home with their parents or relatives, the stress caused by such a sharp change in their environment might be eased to some extent. However, children separated from their caregivers require special attention, including children infected with or suspected of being infected with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), who are quarantined in local hospitals or collective medical observation centres and children whose caregivers are infected with SARS-CoV-2 [16]. Companionship is essential for a child’s normal psychological development and well-being [17]. Quarantined children are more expected to develop acute stress disorder and unhappiness. Only 30% of the children who were isolated or quarantined met the clinical criteria for Post-Traumatic Stress Disorder (PTSD) [18]. Recently, the National Health Commission of China issued guidelines and listed specific intervention strategies for children who are quarantined in collective medical observation centres [19]. For example, these measures seek to increase children’s communication time with their parents; increase children’s access to disease information via comic books and videos; guide children to establish a regular activity schedule; provide night lights and small gifts; and provide timely referrals to psychiatrists when children feel mental discomfort, such as worry, anxiety, difficulty sleeping, and loss of appetite [19,20].

It has been found that the quarantined people were more likely to feel lonely, anger, depressed, anxious, a feeling of boredom, denial, sleeplessness or even suicidal thoughts [10,11,21]. The suspected or confirmed COVID-19 persons largely experience fear and anxiety regarding the high contagiousness and fatality [11,21]. Survivors of COVID-19 are at a higher risk of developing several mental disorders such as depression, anxiety and PTSD [6]. Li W et al., reported that patients may develop Obsessive Compulsive Disorder (OCD) during their quarantine period [11]. The COVID-19 not only brings in the illness but also the anxiety or panic among the patients [22].

Healthcare workers are facing increased workload and fear of being infected. They too have to undergo quarantine for the specified duration. Ho CS et al., found that increased workload causes physical exhaustion and emotional disturbance such as fear, stress, anxiety and insomnia in their study on 1563 health professionals which reported that more than half (50.7%) of the participants reported depressive symptoms, 44.7% anxiety and 36.1% sleep disturbance [12]. Paramedical staff, ambulance personnel and HCWs have also reported stress and emotional difficulties with increased levels of depression and anxiety. It was reported that rates of anxiety and depression were higher for female HCW. It was found that a considerable proportion of HCWs experienced mood and sleep disturbances during this outbreak [23]. For a healthcare provider, the novel nature of SARS-CoV-2, lack or limited laboratory testing, insufficient treatment options, lack of Personal Protection Equipment (PPE) and the high workload lead to stress. Self-care is very important for healthcare providers (which includes being informed about the illness, looking after and monitoring body’s own reactions and looking for appropriate assistance) and also implementation of mental health intervention if needed [8]. Jones NM et al., found that exposure to social media rumors can also create mental health problems like stress, anxiety, depression, restlessness, denial and fear [24]. Mental health problems also affect attention, decision-making capacity of medical workers that will hinder the fight against COVID-19. It has been observed that there is a long-lasting effect on overall well-being of healthcare professionals [25,26]. The COVID-19 pandemic has put healthcare professionals across the world in an unprecedented situation, who are compelled to take unprecedented decisions and work under extreme pressure. These decisions may include how to allocate scanty resources to equally needy patients, to balance their own physical and mental healthcare needs with those of patients, to align their desire and duty to patients with those to family and friends and to provide care for all severely unwell patients with constrained or inadequate resources [27]. The healthcare workers may suffer from the so-called moral injury. The term “moral injury” is defined as the psychological distress that results from actions which violate someone’s moral or ethical code and those who develop moral injuries are likely to experience negative thoughts about themselves or others as well as intense feelings of shame, guilt, or disgust. These symptoms can contribute to the development of mental health difficulties [28].

Aging is the main cause of increasing psychological, social and environmental vulnerabilities in the elderly population. It increases the risk of various infectious diseases and leads to a decrease in their body immunity. Additionally, they also have co-morbidities (like diabetes mellitus, hypertension, Parkinson’s disease, dementia, etc.,) which also increase the risk of getting infection during a pandemic [29]. Because of their increased risk of health problems, the “social isolation” is a serious health concern among the elderly population [30]. A recent study by Santini ZI et al., demonstrated that social isolation or disconnection puts older adults at a greater risk of stress, anxiety and depression [31]. It was found that the elderly individuals, whose only social contact is like places of worship and community centers, are affected more due to social isolation. People who do not have close family or friends, could be placed at additional risk, along with those who are already lonely and isolated [32]. Besides, older people might have cognitive and sensory deficits which makes it difficult for them to comprehend and follow precautions. Mental health is the cornerstone of public health, more so in the elderly. As the need for a ‘viral cure’ eclipses importance of mental health, the global panic only aids in increasing the spread. Lessons learnt from earlier pandemics like SARS have proved that regular telephonic counseling sessions, healthy contact with family, relevant and updated information, caring for the general medical and psychological needs and respecting their personal space and dignity are important components of mental healthcare in the elderly [33]. This warrants sensitisation at all levels for early detection of mental healthcare needs and plan appropriate interventions, especially for the vulnerable old-age population [29].

Early identification of community and healthcare groups which are at a high risk of developing psychological morbidities is needed by health authorities for targeted early psychological interventions. Furthermore, there is increased risk of psychiatric issues among people in quarantine or in isolation in hospitals because they are deprived of their social supports, thereby practical and emotional support is necessary for them. In this pandemic, online psychotherapy has been adopted by many hospitals for psychiatric patients through video conferencing platforms (like Zoom) [12]. It also minimises virus transmission from face-to-face therapy. The online and smartphone-based psychoeducation about the viral outbreak, promote mental wellness and initiate psychological intervention like Cognitive Behavioural Therapy (CBT) and Mindfulness-Based Therapy (MBT) [12]. All HCW need to be prepared for the moral dilemmas they are going to face during the COVID-19 pandemic. It is known that properly preparing staff for the job and the associated challenges reduces the risk of mental health problems [34]. Routine support processes (such as peer support programmes) available to healthcare staff should include a briefing on moral injuries, as well as an awareness of other causes of mental illness and what to look out for. Once the crisis is over, supervisors should ensure that time is made to reflect on and learn from the extraordinarily difficult experiences to create a meaningful rather than traumatic narrative [27]. Mental health support and follow-up should be provided even six months after the release from isolation for those individuals with prior vulnerable mental health status. Appropriate supplies of food, clothes and accommodation to the individual, if needed should be provided [35]. For children to ensure that they have access to regular programmed work, require access to online and advanced technologies, that would enable remote connectivity. Relevant steps are needed for ensuring better infrastructure for continuity of learning and socialisation to mitigate the short and long-term effects of COVID-19 [36]. A new form of intervention can be implemented to cope up with mental stress. Psychological First Aid (PFA) is a form of psychological support that teaches individuals how to care for themselves and to provide basic psychological support for family, friends, and neighbours. It is a community-based intervention which is a low-cost, sustainable model and appropriate for populations with special needs, and can be present wherever and whenever it is needed. In this intervention, mental health professionals don’t “heal” clients in therapy; they merely give them the tools to make repairs to their psyche and their coping skills [37]. Raphael B in her pioneering book on disaster mental health, described PFA in the context of services provided in the first hours after a disaster which included 11 components [38]:

Walker G wrote about PFA in a more general manner for understanding the event and significant stressors [39].

This model of PFA is intended for the general population to be educated about stress and responses to stress (including traumatic stress), active listening, resilience and coping skills, and when and how to make referrals to mental health professionals. PFA is an intervention that focuses on mental health of the individual [37,40]. Ornell F et al., has suggested some individual recommendations for coping with stress. Maintenance of adequate sleep, nutrition and exercises are the best way to cope with stress. Adequate awareness about the COVID-19, avoid fake news of social media and establish a support network like involving in leisure activities, share your thoughts with someone will be helpful in reducing the stress and anxiety related to COVID-19 [41].

The COVID-19 pandemic has led to significant mental health issues and has drawn attention to these issues. Because of this pandemic, financial crisis has ensued, along with decreased recreational activities, as a result of which mental health issues are likely to grow exponentially. That is why, it is important to understand the mental health implications of the COVID-19 pandemic including measures to cope with this unprecedented situation for effective management of these mental disorders.

More studies are needed to investigate the long-term psychiatric sequelae arising from the COVID-19 pandemic such as impact of the global economic recession on mental health. More research should be done on psychotherapeutic interventions.

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