Mental health aspects of pandemics with special reference to COVID-19

Abstract

Pandemics are large-scale outbreak of disease that spreads rapidly, afflicting many persons simultaneously across multiple countries.[1] History tells us that as humans spread across the globe so did infections. Infections have been our constant companion since antiquity. Hunters and gatherers formed tribes that turned to farming and formed villages which gradually advanced to metropolis. Urbanization brought residents into denser neighborhoods, which combined with increasing populations are placing increasing pressure on the environment. Catastrophic pandemics have been occurring since antiquity and are frequently mentioned in ancient texts. Pandemics are associated with death, destruction, and devastation. Not surprisingly, pandemics are associated with long-term psychological consequences. A brief estimate of the effects of some of these pandemics is given below. Antonine plague (AD 165) The Antonine plague (the Plague of Galen) began in the far east. Soldiers returning to Rome from the far east brought back the infection which then spread throughout the Roman Empire. The pandemic killed about five million people. Plague of Justinian (541–542) The Justinian Plague (bubonic plague) started in central Africa and spread to Egypt and then hit the Byzantine Empire and many cities around the Mediterranean Sea, spreading with ease via a large number of ships, usually maintained in unhygienic condition, arriving into the ports. The plague killed about half the population of Europe, about 25 million people. Japanese small pox epidemic (735–737) The Japanese small pox epidemic affected most of Japan. As a consequence of this epidemic, approximately 1/3rd of the entire Japanese population (about 1 million) perished.[2] The Black Death (1346–1353) The Black Death or “The Plague” is the first pandemic about which reliable information is available. This pandemic of bubonic plague originated in China in 1334, spread through central Asia and northern India following the Silk Road, and reached Sicily in 1347. Over the next 5 years, it spread throughout Europe, Russia, and the Middle East. The mortality of untreated bubonic plague is close to 70%.[3] Over 50 years, the Black Death caused about 100 million deaths.[4] In subsequent centuries, the plague caused several outbreaks through Europe in causing death and destruction but never with the same ferocity as the initial pandemic.[5] Smallpox (1519–1520) The smallpox epidemic affected the native people of Mexico. It was brought by the European invaders. In this epidemic, about 5 million to 8 million people perished.[6] Cocoliztli epidemic (1545 and 1576) The Cocoliztli (probably indigenous hemorrhagic fevers) epidemics that began in 1545 and 1576 were catastrophic and killed about 7 million to 17 million people in the highlands of Mexico.[6] The 17th-century great plagues The 17th-century “great plagues” included the Great Plague of Seville (1647–1652), the Great Plague of London (1665-1666), and the Great Plague of Vienna (1679). A total of 3 million people died due to these plagues. The Third cholera epidemic (1852) The third cholera epidemic had the highest fatality of the epidemics in the 19th century. The pandemic originated in India and spread across the world. Over a million lives were lost due to this pandemic. The third plague pandemic (1855) The third plague pandemic began with the re-emergence of the disease from its wild rodent reservoir in the Yunnan province of China in 1855. From there, the disease advanced to K'unming in 1866, the Gulf of Tonkin in 1867, and the port of Pakhoi (now Pei-hai) in 1882 and Hong Kong in 1894. From there, it spread to ports in all continents by the infected rats traveling the international trade routes on the new steamships. For the next five decades, the pandemic waxed and waned throughout the world and ended in 1959. The third plague pandemic resulted in 15 million deaths, the majority of which were in India.[7] Yellow fever (the late 1800s) Multiple Yellow fever epidemics ravaged the Americas in the late 1800s, the last ending in 1905. Yellow fever claimed over 100,000 American lives. Though exterminated from America, yellow fever continues to ravage countries in the sub-Saharan Africa and tropical South America. Flu (1889–1890) This flu pandemic occurred due to the H3N8 subtype of the influenza virus. The pandemic originated in Russia and thereafter spread across many countries in the northern hemisphere. The spread of this epidemic was facilitated by the arrival of the modern transport infrastructure. The flu resulted in about one million deaths. Sixth cholera pandemic (1910–1911) The sixth cholera pandemic also originated in India. It spread through ships and other means of transport to the Middle East, North Africa, Eastern Europe, and Russia. The pandemic claimed 8,00,000 lives. The “Spanish Flu” pandemic (1918–1920) ”Spanish Flu” Pandemic was caused by the H1N1 influenza virus. It infected more than 25% of the global population. With a mortality rate of 10%–20%, it caused 50 million, possibly 100 million deaths. The Spanish Flu caused more deaths than the Black Death did in a century.[89] Asian flu (1957–1958) The Asian flu was caused by new influenza A (H2N2) virus of avian origin. The influenza outbreak originated from Singapore, spread to Hong Kong and the eastern coast of the USA in the late 1950s and later died out after a vaccine was introduced. This influenza pandemic claimed about 1.1 million lives. Hong Kong flu (1968) The Hong Kong flu was caused by influenza A (H3N2) virus which originated from an avian influenza A virus and killed one million people. It continues to cause seasonal influenza A virus associated with severe illness in older people. HIV pandemic HIV/AIDS unlike all previous and subsequent pandemics is a slowly progressing global pandemic that has over decades affected all the continents and different populations. In addition, due to the lengthy survival of patients, it has brought a host of challenges in its wake. HIV has infected about 74.9 million individuals all over the world and about 32 million have died (end 2018) since 1981. Every year, it continues to cause about one million deaths globally.[10] Severe acute respiratory syndrome (2002–2003) The first pandemic of the 21st century was severe acute respiratory syndrome (SARS) caused by the SARS coronavirus (SARS-CoV). The condition manifested with severe respiratory symptoms and had a mortality of 10%. It began in China in November 2002 and affected fewer than 10,000 individuals in 26 countries. As a result of effective public health preventive measures worldwide, the pandemic was contained by the mid-2003.[11] For the first time during and after the SARS pandemic, the psychiatric aspects were studied all over the world. Valuable information on the psychological effects of an acute infectious pandemic on affected individuals, families, communities, health-care workers, quarantine, survivors of severe illness, etc., was gathered.[812] The H1N1 or “Swine Flu” Pandemic (2009-2010) The Swine flu began in Mexico and affected over 10% of the population of the world. It caused an estimated 20,000 to500,000 deaths.[1314] Because the disease disproportionately affected healthy young adults, often quickly resulting in severe respiratory failure, it was perceived as extremely threatening. However, the final death rate was lower than the death rates of influenza. The initial announcements and warnings by the WHO caused alarm in the general public, but this changed to distrust and disgruntlement as the predicted dire consequences of the pandemic did not materialize.[15] Governments and health agencies were blamed for panic (”panicdemic”) and pushing vaccines without adequate study to enhance the profits of pharmaceutical firms at the cost of the general public (H1N1 vaccines worth 1.5 billion dollars were administered in 2009 in the USA alone).[816] The COVID-19 pandemic The pandemic caused by novel CoV (COVID-19) began in Wuhan in China and has spread to 215 countries. It has already affected 7,000,000 individuals and killed 313,636. The virus is more transmissible than SARS-CoV and has a case fatality rate of 2.3%.[17] A unique feature of this pandemic is the accompanying “infodemic”– an excess of (mis) information on social media and elsewhere – which is a major hazard to mental well-being during this health crisis.[18] PSYCHOLOGICAL FACTORS IN PANDEMICS Despite their periodic occurrence and devastating consequences, surprisingly, pandemics have evoked minimal interest in mental health professionals, though the situation has vastly improved in the past decade. Psychosocial stressors in pandemics Pandemics are almost invariably characterized by ambiguity, misunderstanding, and a feeling of urgency.[19] As the causative agent is usually new, in the early stages of a pandemic, there is widespread ambiguity about the chances and effects of becoming infected, along with lack of information and understanding about the most effective mode of prevention and treatment.[20] Other psychosocial stressors related to pandemics include threats to the health of self and loved ones, lockdowns, social distancing, separation from family and friends, death of loved ones, social isolation due to quarantine, shortages of food and medicines, loss of earnings, closure of educational institutions and industries, and cancellation of functions and festivals.[2122] Importance of psychological factors during pandemics The current methods for combating pandemics are largely behavioral or educational interventions comprising of risk communication, vaccination adherence programs, personal protective measures, and social distancing. Extreme psychological distress related to actual or threatened infection is a significant issue. Psychological factors are also essential for understanding and combating the collective disorderly behavioral patterns displayed by people facing widespread, serious infection. Effects of stressful life events and negative emotions on the immune system Stressful life events and negative emotions suppress the immune system to some degree, resulting in enhanced susceptibility to infection.[23] Although the mechanisms of these effects are not exactly known, research has shown that stressors and negative emotions influence the production of lymphocytes and pro-inflammatory cytokines.[23] On the other hand, psychotherapeutic interventions such as cognitive behavioral therapy by decreasing a person's stress proneness and negative emotions, may reduce stress-related immunosuppression.[24] The frantic chase for quack remedies and traditional therapies A serious threat to the health of self or loved ones can impair the person's ability to make rational decisions.[25] At the beginning of a pandemic, reliable vaccines and medical treatment are often not available. In this scenario, to protect themselves and their loved ones, people in desperation turn to quack remedies and dubious traditional therapies. Traditional remedies for influenza include inhalation of vapors of carbolic acid, wearing necklaces of garlic, and drinking pine tar. Folk remedies for SARS included diets of turnips, vinegar, kimchee, or spicy foods, and even smoking cigarettes, all of which were ineffective. We may add cow's urine to this list. During the SARS pandemic, some people in China hired sorcerers, lit firecrackers, and burned fake money. People take large doses of vitamins or herbal supplements in the hope that this will boost their immunity.[2226] Civil unrest, rioting, and violence Widespread sickness, debility, and death during pandemics evoke prosocial, affiliative, supportive, behaviors in the form of mutual aid such as running community kitchens, ambulance services, or disposal of dead bodies.[27] However, civil unrest or riots have sometimes erupted during pandemics.[28] There are numerous examples of groups of citizens clashing violently with health workers, due to fears that the health workers were harming rather than helping them.[22] During the Ebola outbreak in September 2014, eight health-care workers and journalists reached the Guinean village of Worme to teach the villagers how to protect themselves against Ebola. But, the villagers, believing that the workers were spreaders of the disease, attacked and killed them.[29] Villagers in Zhejiang province of China protesting the local government's SARS policy attacked officials and broke windows and furniture of the local offices.[26] The recent attack on health-care workers in Indore and other parts of India can be added to the list. Psychological reactions to stress, harm, and loss in pandemics The majority of people are resilient to stress, and this may be more true for people from developing countries. Many persons who survive major stressful events do not suffer adverse psychological effects. Experience of the recent past however tells us that the psychological effects of pandemics are often larger than the medical effects. For instance, during the West African Ebola outbreak (2014–2015), the “epidemic of fear” affected more people than the epidemic itself.[2230] Similarly, during the 2003 SARS pandemic, the psychological morbidity greatly exceeded the medical morbidity in terms of both the number and duration of impact.[3132] Reactions of people to the stress of pandemic vary from fear to indifference to fatalism.[33] At one end of the spectrum are people who blatantly disregard the risks and refuse to follow the recommended health behaviors including hygiene practices, social distancing, and vaccination. At the opposite end of the spectrum are people who develop intense anxiety or fear. Psychologically, a moderate level of anxiety motivates people to address health threats, but severe anxiety is incapacitating.[22] Studies conducted during the early stages of the Swine flu pandemic that of a community had significant of American some of anxiety about becoming of residents of that were about the health of their family to were not about the infection measures, and on a People had of fear even at of social media was associated with anxiety and behaviors in people had more fear for the of their in by the included more frequently and to health-care out in and stress symptoms were in in perceived stress in anxiety in in and in of the the were associated with recent stressful life a and of and syndrome were associated with quarantine, more than was associated with perceived stress, and Death of a loved one due to COVID-19 was associated with perceived stress, and During from the infected individuals, health-care workers are also This has manifested in their who are health-care workers, to their psychosocial stressors may or psychiatric including anxiety and stress or loss of loved ones in the pandemic may be by or a to widespread including the deaths of loved ones in the pandemic, may result in As a pandemic the general public to the threat and anxiety is However, in individuals, the adverse psychological effects can be severe and of pandemics The of a pandemic is by an for and from the the of developing a new vaccine is and the vaccine will not be it is the This be by Similarly, the of new is also and without is with against the to stressful as At the media that reliable information about the pandemic is for the general At the beginning of an epidemic, measures to that be time for the medical and pharmaceutical are the The of interventions for rates individuals and the virus are quarantine, social distancing, and the The public health during a pandemic is to the outbreak at the with minimal risk is for this of information by the general public to about to themselves from the infection. 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Although the majority of the population are resilient to the stress of many health anxiety and and some develop psychiatric including anxiety and As a pandemic the general public to the threat and anxiety is However, in individuals, the adverse psychological effects can be severe and as a so that the treatment not than the

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