MENTAL HEALTH EFFECTS OF A PANDEMIC

Mental health, as defined by the World Health Organization, is a state of well-being in which the individual realizes their own abilities, can cope with the normal stress of life, can work productively, and is able to make a contribution to their community (PAHO/WHO, 2020).

Pandemics disrupt the mental health of individuals and society on many different levels, one of them being widespread panic and increasing anxiety in people subjected to the real or perceived threats of the infectious agent. The mental health effects of a pandemic can impact health for many years, well past the precipitating event. These effects can compound the many challenges facing people who are already prone to mental health problems. For example, the prevalence of depression and posttraumatic stress disorder (PTSD) among populations following such an event is comparable to levels experienced following natural disasters and terrorist attacks (Galea, 2020).

There is very little contemporary epidemiological data on the mental health impacts of a pandemic, as there have been few such events in the last century. The 2002–2004 SARS outbreaks in Asia and Canada provide the most recent epidemiological data on the mental health concerns related to pandemics:

  • Upwards of 40% of the community population experienced increased stress in family and work settings.
  • 16% showed signs of traumatic stress levels.
  • A high percentage felt frightened, apprehensive, and helpless.
  • Only 30% of those surveyed believed they would survive if they contracted the disease, despite an actual survival rate of 80% or more.
  • Residents were diligent about adopting appropriate person-to-person transmission precautions; however, they were adopted differentially based on anxiety levels and perceived risk of contracting the disease.
  • Studies of nurses who treated SARS patients indicated high levels of stress and a rate of approximately 11% traumatic stress reactions, including depression, anxiety, hostility, and somatization symptoms.
    (CSTS, 2021)

The strength and type of personal reaction to a crisis varies depending on a combination of the following:

  • A person’s prior experience with a similar event
  • Intensity of the disruption to the individual’s life (the more disruption, the greater the psychological and physiological reactions may become)
  • The meaning of the situation to the individual (the more catastrophic the event is perceived to be personally, the more intense the person’s stress reaction)
  • The emotional well-being of individuals and their resources for coping
  • Having experienced other recent traumatic events, which can result in failure to cope well with additional stressors
    (FEMA, 2019)

Psychological Effects and Stressors

During a pandemic, it is common for people to feel stressed, anxious, worried, and fearful. Fear of the unknown or fear of uncertainty may be the most debilitating of the psychological effects of a pandemic. As the pandemic begins to spread, people may experience:

  • Fear of contagion and death of self or loved ones
  • Fear of contracting illness while caring for sick loved ones
  • Fear of infecting a loved one
  • Guilt regarding being the source of illness for a loved one
  • Inability to intervene to prevent illness or death of loved ones
  • Witnessing the illness or death of family members
  • Bereavement and grief from loss of loved ones
  • Psychological trauma due to quarantine and social distancing
  • Difficulty maintaining self-care activities
  • Domestic pressures caused by school closures, disruptions in daycare, or family illness
  • Sense of ineffectiveness and powerlessness
  • Loss of faith in health institutions, employers, or government leaders
  • Belief that medical resources are not fairly distributed
  • Restrictions on civil liberties that are perceived to be inequitable
  • Frustration with lack of information and available resources
  • Loss/disruption of job, financial hardship

As the pandemic decelerates, additional stressors begin to arise, which may include:

  • Multiple losses
  • Personal and population-wide bereavement
  • Fear of recurrent waves of the pandemic returning
  • Recuperation from illness
  • Long-term medical complications
  • Continued scarcity of basic necessities
  • Massive economic disruptions
  • Delays in reopening schools, daycare centers
  • Ongoing stress on healthcare infrastructure
  • Dealing with dependent family members who have lost their caretaker
  • Changes in social support due to death and illness

Psychological stressors for health professionals may be related to:

  • Dealing with an overwhelming surge of patients
  • Inability to save lives despite maximal effort
  • Experiencing death on a mass scale
  • Observing population-wide bereavement
  • Dealing with chronic shortages of supplies, vaccines, treatments, facilities
  • Elevated to extreme risk for infection, illness and death
  • Overwork and fatigue
  • Witnessing illness and death of colleagues
  • Constantly working in PPE
  • Enforced separation from family and loved ones
  • Ongoing and seemingly unending duration of work shifts
  • Inability to be home to support ailing, dying, or bereaved loved ones
  • Fear of spreading infection from exposure at work to loved ones at home
  • Witnessing illness on a mass scale
  • Witnessing persons suffering with extreme symptoms
  • Dealing with extreme reactions and possible panic
  • Threats of violence from persons seeking scarce or limited services
  • Lack of communications
    (Shultz, n.d.)

Behavioral Responses to Real or Perceived Threats of a Pandemic

When confronted with a real or perceived threat, responses range widely. For instance, one individual may act in extreme and sometimes irrational ways to avoid the threat. Another may accept that the threat is real but feel the situation is hopeless and begin to withdraw (U.S. DOE/ORAU, n.d.).

It is important for healthcare professionals to be aware of the many types of behaviors that may occur in response to the threats of a pandemic:

  • Denial: Members of a community will often experience denial in some form or another (e.g., “it can’t happen to me,” “I’m invincible,” “it’s a hoax,” etc.), which manifests by avoiding taking the recommended precautions necessary to keep oneself and others safe from contagion (U.S. DOE/ORAU, n.d.).
  • Alcohol and other substance use: Stress and addiction often go hand-in-hand; stress can lead to increased alcohol and/or substance abuse and also trigger relapses (Ellis, 2020).
  • Exacerbation of mental health symptoms and behaviors: These may include PTSD, anxiety disorders, depression and somatization, obsessive-compulsive behaviors (OCD), phobic behaviors, or psychotic-like symptoms. It has been found that a substantial portion of those quarantined display symptoms of PTSD and depression. In those with OCD, fear of the disease may worsen negative behaviors, leading to unwanted and intrusive worry as well as cleaning and washing compulsions (Shigemura et al., 2019; Moukaddam & Shah, 2020).
  • Negative reactions of children and teens: Most children and teens respond, in part, to what is happening to the adults around them. Reactions that may occur include:
    • Infants to 2-year-olds may display irritability, excessive crying, and a need to be cuddled more.
    • Preschool and kindergarten children (3–6 years) may return to behaviors they have outgrown (such as bed-wetting), fear of separation from parents/caregivers, tantrums, or difficulty sleeping.
    • Older children (7–10) years may feel sad, mad, or afraid the event will happen again; they may focus on details of the event and want to talk about it all the time or not want to talk about it at all.
    • Pre-teens and teenagers may experience irritability and more “acting out” behaviors, as well as use alcohol, tobacco, or other drugs. Others may become afraid to leave home or may cut back on how much time they spend with their friends. Their emotions may lead to increased arguing and even fighting with siblings, parents/caregivers, or other adults.
    • Older children and teens may experience difficulty with attention and concentration and avoid activities enjoyed in the past.
      (CDC, 2020)
  • Attempts to stock or hoard food and other essentials: People in a pandemic situation may become concerned that supply chains of food and other items (e.g., medications, hand sanitizers, disinfectants, wipes, and toilet paper) will be inefficient during a time of crisis, reducing access to what is needed to maintain health and safety for oneself and others in the community.
  • Scapegoating/xenophobia: Giving a disease the name of a foreign country or particular group results in the desire to wall off those who are viewed as threats of contagion. This fear of the “other” can lead to violence against them. Such incidences of violence toward individuals of a certain race or country can also be directed toward healthcare workers (Parmet & Rothstein, 2018).
  • Mistrust of authority figures, scientists, and healthcare professionals: This has been seen in multiple countries and with multiple infectious agents. During pandemics, mistrust of medical professionals and efficacy of medical-related measures have been linked to conspiracy theories and mixed messages. At its extreme, such mistrust can lead to the lowering of or disregard for adherence to health recommendations (Moukaddam & Shah, 2020).
  • Domestic violence and abuse: Service organizations, healthcare facilities, and law enforcement often report surges of domestic violence, child abuse, and animal abuse during major crises. Pandemics cause feelings of powerless and loss of control, both of which are at the root of domestic violence. A small study comparing data from 2017 through 2019 with data from 2020 during the COVID-19 pandemic found a 1.8-fold increase in incidents of physical intimate partner violence (Gosangi et al., 2020).

Stress and Its Physical and Psychological Health Consequences

When a crisis lasts for an extended period of time, as in a pandemic, stress causes the body to be in a more-or-less constant state of guardedness. This results in long-term activation of the body’s stress response system. Prolonged exposure to cortisol and other stress hormones may increase the risk for or contribute to the development of various problems.

  • Gastrointestinal effects can include bloating and other intestinal discomfort. Changes in gut bacteria may occur, which can influence mood.
  • Cardiovascular effects may include increased risk for hypertension, heart attack, or stroke. Persistent chronic stress contributes to inflammation in the circulatory system, particularly the coronary arteries.
  • Endocrine system effects include an increased production of steroid hormones.
  • Impaired immune system function may affect inflammatory processes, wound healing, and responses to infectious agents and other immune challenges.
  • Reproductive system effects in both men and women may make it harder to conceive.
  • Respiratory effects can present with shortness of breath and rapid breathing and exacerbate pre-existing respiratory disease.
  • Nervous system changes may include long-term impact on the autonomic nervous system, which continues to affect other bodily systems.
  • Psychological effects include an increased risk for depression.
    (AIS, 2020; Seiler et al., 2020)

Psychological Stressors among Healthcare Professionals

Because of their prominent role in responding to a pandemic, healthcare professionals are at high risk for mental health effects. For instance, following the SARS outbreak, a survey found that up to 75% of healthcare workers experienced psychiatric morbidity related to the epidemic (Sadeghi & Wen, 2020).

During the COVID-19 pandemic, several studies have demonstrated an increased risk of psychological implications to healthcare workers. Such effects include increased risk of acquiring trauma or stress-related disorders, depression, and anxiety. Fear of the unknown or becoming infected were at the forefront of mental challenges healthcare workers face. In addition, being a nurse and being female appeared to confer greater risk (Cabarkapa et al., 2020).

Along with facing all the stressors being experienced by the general public during a pandemic, healthcare workers on the frontline (i.e., those who provide direct care and services to the sick or injured) experience additional stressors. These may include:

  • Stigmatization and ostracization due to caring for infected patients and their remains
  • Shaming oneself about voicing one’s own fears and concerns
  • Fear of passing the infectious agent on to family and friends and the need to isolate oneself from them
  • Tension between public health priorities and the wishes of patients and their families regarding quarantine
  • Strain of strict bio-security measures:
    • Physical strain of having to constantly use protective equipment (e.g. dehydration, heat, exhaustion)
    • Physical isolation, which makes it difficult to use touch to provide comfort to a sick or distressed patient or to give/receive comfort after working hours
    • Need to be constantly aware and vigilant regarding infection control procedures
    • Strict procedures that prevent spontaneity and autonomy
  • Psychological effects when the system fails to provide adequate personal protective equipment (PPE):
    • Fear of increased risk of infection
    • Extreme stress around disregarding usual practices for caring for oneself in order to remain uninfected and to continue to provide safe patient care
  • Higher demands both professionally and personally:
    • Long hours
    • Increased patient numbers
    • Working in unfamiliar areas
    • Keeping up-to-date with best practices and developing information
    • Possible separation from and concern about family members
    • Inner conflict about competing needs and demands (e.g., “I want to take care of my patients; it’s my calling and I am expected to; but I know I am taking great risks by doing so.”)
  • Witnessing human suffering and dealing with life-and-death decisions
  • Reduced capacity to use social support due to intense work schedules and stigma within the community toward frontline workers and the need for social distancing
  • Insufficient ability to carry out adequate self-care because of work demands and time constraints
  • Lack of information about long-term exposure to infected individuals related to insufficient scientific knowledge about the infectious agent
  • Burnout and compassion fatigue (see below)
    (IASC, 2020)

LACK OF PPE

Months after the start of the COVID-19 pandemic, the shortage of personal protective equipment persists, leading frontline workers to ration their use of disposable gloves, gowns, and N95 respirator masks meant to reduce their chances of becoming infected. Healthcare workers continue to be required to reuse their tight-fitting respirator masks up to six times before disposing of them. Although they are sterilized each day with ultraviolet light, the masks invariably sag after two or three shifts, leaving gaps that can allow the virus to seep through. Hospitals, nursing homes, and medical practices routinely have to spend time and heighten their disease exposure by decontaminating disposable masks and gloves for reuse (Finkenstadt et al., 2020).

BURNOUT AND COMPASSION FATIGUE

Burnout is a gradual process by which people detach from meaningful relationships in response to protracted stress and physical, mental, and emotional strain. This results in a feeling of being drained, being unproductive, and having nothing more to give. Compassion fatigue is a state of chronic physical and mental distress and exhaustion following the strain of feeling others’ pain.

In a 2021 survey, 76% of healthcare workers reported being exhausted and experiencing burnout, while 52% experienced compassion fatigue (MHA, 2021). Another survey found that while nursing staff have had low morale in the past, “this time they’re broken,” and their trauma is continuous, with no time to recover. Some nurses have reported that both the demands of the job and a lack of support due to shortages have had a negative impact on their career and that they were thinking of leaving the profession (Ford, 2021).

MORAL DISTRESS

Moral distress is the result of having to act in a manner that is in opposition to one’s own values and beliefs. Members of the healthcare professions have ethical values that focus on the well-being of each individual patient and in which decisions are made based on:

  • Autonomy: The right of patients to retain control over their own bodies according to their personal values and beliefs
  • Beneficence: The obligation of healthcare providers to do all they can to benefit the patient in each situation
  • Nonmaleficence: The exhortation “to do no harm”
  • Justice: An element of fairness in all medical decisions as well as equal distribution of scarce resources

Moral distress, the result of an ethical dilemma, occurs when there is a disparity between what healthcare providers can do and what they believe they should do. For example:

  • When healthcare professionals feel they are abandoning their patients because they believe they can no longer provide the quality of care they know is correct
  • When triage protocols force difficult decisions that may determine who lives and who dies. For example, between who will and who will not receive care or in the rationing of limited resources (SJU, 2020; Pearce, 2020)
  • When requirements for one’s own safety interfere with the needs of a patient. For example, when a COVID-19-infected patient who is unable to get out of bed without assistance unexpectedly falls while the nurse is taking the time to properly don PPE.