Mental Health Stress and Resilience in Times of COVID-19
Original Editor - Andrea Sturm
- 1 Introduction
- 2 Population groups at risk for mental health issues during the COVID-19 pandemic:
- 3 Common responses of people affected by COVID-19
- 4 Stressors particular to COVID-19
- 5 Mental health issues as a result of COVID-19
- 6 The physical and mental health of older adults during the COVID-19 outbreak
- 7 Needs of people with disabilities during the COVID-19 outbreak
- 8 Recommendations for Health Professionals
- 9 Migrants’ and Refugees’ Mental Health
- 10 Children’s Mental Health
- 11 COVID-19 and Suicide
- 12 Additional Resources
- 13 References
The coronavirus disease 2019 (COVID-19) outbreak was declared a public health emergency by the World Health Organization (WHO) on 30 January 2020. This was when all 34 regions of China reported cases of infection, by this time the total caseload was surpassing the 2003 severe acute respiratory syndrome (SARS).
Research studies on the survivors of SARS from 2007 showed that Mental Health problems followed cardio-respiratory difficulties as the second most reported comorbidity. 1 year later, some patients who had SARS, as well as their caregivers, reported a significant lowering in mental health problems. Patients not only experienced the loss of family members and colleagues but also experienced stigmatisation and due to media reporting felt a loss of anonymity. Due to quarantine, isolation or hospitalisation these individuals could not be present at the time of death or attend funerals. Several individuals described they felt the strain on their mental wellbeing because of quarantine and isolation. They also experienced an overwhelming fear for their health or spreading the infection to their family members.
Population groups at risk for mental health issues during the COVID-19 pandemic:
- Children and adolescents;
- Older adults;
- Persons at domestic abuse risk
- Individuals struggling financially or in lower socioeconomic
- Healthcare workers on the frontlines who had heavy workloads, had to make life or death decisions, and were at risk of infection
- Women, in particular, if they have to juggle home-schooling, working from home, and do the household tasks
- Individuals who have had mental health or dependency issues in the past, and made worse by not being able to meet their regular support groups. 
Common responses of people affected by COVID-19
In an epidemic, it is normal for individuals - no matter of children, adolescents, adults and elderly - to feel stressed and worried. Common responses of people affected (both directly and indirectly) could include:
- Fear of getting ill and passing away
- Avoiding going to hospital or health care facilities due to fear of becoming infected when there
- Fear of not being able to work during isolation, being dismissed from work, and losing their income
- Fear of being placed in quarantine due to association with the disease and then being socially excluded/isolated (e.g. racism or xenophobia against persons/ population groups who are from, or perceived to be from, areas affected by COVID-19)
- Feeling powerless to protect the family and the fear of loved ones dying because of the virus
- Fear that quarantine will separate them from loved ones and caregivers
- Parents or caregivers are in isolation/quarantine due to fear of infection and cannot take care of the elderly, unaccompanied or separated minors, or people with disabilities
- Feelings of depression, helplessness, boredom, and loneliness due to isolation
- Fear of reliving the experience of a previous epidemic 
Stressors particular to COVID-19
As emergencies will be always stressful, specific stressors particular to COVID-19 outbreak might affect the population:
- Risk of being infected and infecting others, especially when the mode of virus transmission is not completely clear
- Common symptoms of other illnesses or health problems like fever or coughing, can be mistaken for COVID-19 and lead to fear that the virus was contracted
- Caregivers may feel concerned for their children who are home alone without care and support because of school closures. In many cases this affects women more because they provide most of the informal care within their families, this has a negative effect on their ability to work and get income.
- When caregivers are in quarantine or when there is no support there is a risk of deterioration of the physical and mental health of individuals who are more vulnerable (older adults and people with disabilities). 
Mental health issues as a result of COVID-19
Since anyone of any gender and sociodemographic status can be infected, it is understandable, that increasing mental health issues such as anxiety or depression resulting in erratic behaviour among people amidst infectious outbreaks is a not-uncommon phenomenon.
Outbreaks can have a profound and broad spectrum of psychological impact on people. At an individual level, new psychiatric symptoms in people without mental illness can precipitate, or aggravate the condition of those with pre-existing mental illness and cause distress to the caregivers of affected persons. Individuals may experience fear and anxiety of falling sick or dying, helplessness, or blame of other people who are ill, potentially triggering off a mental breakdown, regardless of their exposure.
Many people have lost their jobs or are working reduced hours. Due to the enormity of this pandemic and the global shut down the sense of normality has been turned upside down. The uncertainty over what even the near future holds will make sustained attention a challenge. A lot of people have to teach or take care of their children at home who used to be at school, kindergarten or childcare. Some people are struggling to figure out how they should pay rent or buy groceries, and are experiencing that the businesses or careers they've spent years building have no meaning anymore. Some individuals have health conditions that make them anxious (and vulnerable) about catching the virus.
Significant psychiatric conditions could be found varying from depression, anxiety, panic attacks, somatic symptoms, and post-traumatic stress disorder symptoms, to delirium, psychosis and even suicidality, which could be associated with younger age and increased self-blame. For persons grieving from the traumatic and sudden loss of loved ones from the outbreak, the inability to gain closure can result in additional stresses, anger and resentment. According to a study on 1210 Chinese citizens in China in the first two weeks following the outbreak conducted by Wang et al, females were reported to experience a higher degree of the psychological impact of the outbreak, such as stress, anxiety, and depression. This finding concurred with previous epidemiological studies that found women to be at an elevated risk of depression, which could possibly be due to their unique biological and socioeconomic factors.
Persons who are sick or quarantined may experience shame, guilt, or stigma. Studies reported a high prevalence of psychological distress with longer duration of quarantine which was associated with an increased prevalence of post-traumatic stress disorder symptoms correlating with symptoms of depression. Foreigners under quarantine or in isolation in hospitals are at increased risk of psychiatric issues, as they are deprived of their social supports and risk uncertainty for repatriation, thereby necessitating practical and emotional support for them.
At the community level, there could be distrust towards other individuals in terms of disease spread and the government and healthcare services in terms of their capability to manage the outbreak. With the closure of community services and the collapse of industries negatively impacting the economy, a lot of people face financial losses and risk unemployment, which will be intensifying the negative emotions experienced by individuals. 
Internationally, stigma and blame targeted at communities affected by the outbreak by other countries due to a fear of infection impede cross-national trade. All these emotions can be amplified by pre-existing depressive and anxiety disorders, contributing to the increased rumination of contracting the disease, and this can profoundly remodel people’s behaviour and social interaction with others. Psychological responses could affect a person’s particular health-seeking behaviour. Feelings of helplessness and anxiety can motivate some people to use unproven methods and remedies that may have detrimental effects.
We may not forget, that even the ability to self-isolate or of quarantine is a privilege. It means someone has a home to shelter in place and could allow themselves to stop or reduce working or to work from home. This means also, they would still have a regular job. But many people around the globe are earning their livings on a daily basis, often in the informal sector, literally living ‘from hand to mouth’. Those individuals simply can’t afford or allow themselves not to work or stay at home (if they even have such). Also, a lack of protective equipment or even not having access to (running) water or soap is a reality which unfortunately is true for many people all over the world. Their fears and risks regarding a possible infection and exposition to the virus may be even higher than in others, who at least could implement self-protective strategies.
What can we do to help patients regain a sense of agency during the pandemic? Watch this video from trauma researcher and psychiatrist Bessel van der Kolk
The physical and mental health of older adults during the COVID-19 outbreak
Older adults may become more anxious, angry, stressed, agitated, with-drawing, overly suspicious during the outbreak/while in quarantine, especially in isolation and those with cognitive decline/dementia. 
Social isolation is associated with increased morbidity from chronic disease and with higher all-cause mortality. Detrimental health behaviours, such as smoking and reduced physical activity may mediate over 30% of this effect. Data from adults aged 50-81 indicated that social isolation is independently associated with reduced physical activity and increased sedentary time, suggesting that this may play a role in the increased risk of disease.
Exercise recommendation for older adults: 150 minutes of moderate-intensity aerobic activity, or 75 minutes of vigorous-intensity activity over the duration of a week above and beyond their weight-bearing activities and other light activity in between their sedentary time. Exercise also contributes to improved functional ability and reduction in falls. 
During the COVID-19 pandemic, it is important to mitigate the adverse effects of isolation and maintaining physical activity levels in older adults to protect health when social networks and access to exercise and leisure facilities are reduced.
Social isolation has significant implications for mental health in the elderly. Perceived social isolation and loneliness lead to a wide range of psychological symptoms. These include depression and anxiety, and impact negatively on the quality of life. Social isolation and depression could be mediated through physical activity outside of the home. Enforced social isolation in the context of a pandemic is different from that arising in normal circumstances.
Quarantine during disease outbreaks is linked to anxiety, depression and symptoms of post-traumatic stress, some research evidence even suggests that these symptoms could persist long-term. Quarantine for over 10 days, fears relating to infection, frustration and boredom, and lack of information and supplies were identified as factors associated with negative outcomes. The studies tended to involve relatively short quarantine times of less than three weeks.
Recommendations for Health Professionals to help the elderly with coping with stress during COVID-19
- Emotional support can be provided through informal networks (like families) and mental health professionals.
- Share easily to understand facts about COVID-19 and how to reduce the risk of infection in words older people with/without cognitive impairment can understand. Repeat as often as necessary.
- For community-dwelling older people in residential care (e.g., assisted living, nursing homes), the administrators and staff need to make sure that safety measures are in place to prevent infection and increased worries or panic.
- The support staff who are in lock-down with the residents should also be cared for, because of their added stress not being able to see their families or return to their home.
- The older population are more vulnerable to get infected with COVID-19 because of their limited information sources, and weaker immune systems, as well as the higher COVID-19 death rate. Special care should be taken with the high-risk groups in the elderly population, these include those that live alone/without close relatives; have a low socioeconomic status and/or comorbid health conditions such as cognitive decline/dementia or other mental health conditions.
- Older people who have mild cognitive impairment or early stages of dementia should be informed of what is happening in a way that meets their understanding. Support should be provided to decrease their stress and anxiety.
- It is important that the medical and daily living needs of people with moderate and late stages of dementia, continue to be met during the time of quarantine.
- Telehealth and other online medical services are ideal to provide needed medical services.
- The subjective feelings of loneliness and pain scores of people in nursing homes could be decreased with the use of internet-based solutions, and video calls on smartphones. Keep in mind that older adults might have issues with access and the ease of use of technology (47% of over 75s have never used the internet).
Needs of people with disabilities during the COVID-19 outbreak
Individuals with disabilities and their caregivers have to overcome barriers that could prevent them from accessing care and important information to decrease their risk during the COVID-19 outbreak.
These barriers might include:
Environmental barriers for children and adolescents with mental health needs
- The information and communication of risk for the promotion of health, preventing the spread of infection and reducing the stress in the population, is often not developed and shared with people with communication disabilities.
- Many health care facilities are not accessible to people with physical disabilities.
- Urban barriers and inaccessible public transit systems make it difficult for people with disabilities to access health care facilities.
Institutional barriers 
- The high cost of health care makes it difficult for many people with disabilities to afford essential medical services.
- There is a lack of specific protocols on how to take care of people with disabilities during the quarantine.
Attitudinal barriers 
- There are many prejudices, stigmas and even discrimination against people with disabilities. There also exists a belief that people with disabilities cannot contribute towards the response to outbreak response and cannot make their own decisions. These barriers may cause extra stress for people with disabilities and even their caregivers.
Recommendations for Health Professionals
It is important to create accessible communication messages, which include considerations for people with disabilities (sensory, intellectual, cognitive and psychosocial). This can include:
- Developing websites and factsheets about COVID-19 that are accessible to people with visual disabilities.
- Health care professionals should know sign language or have certified sign language interpreters available for people with hearing impairment.
- Messages about the outbreak should be shared in an understandable way to people with intellectual, cognitive and psychosocial disabilities.
- When creating communication it is important to not only use written information but include interactive websites or face to face communication.
- If/when caretakers have to go into quarantine, plans should be made to make sure there is continued support for people with disabilities who need the care and support.
- Leaders and community organizations can help communicate and provide mental health support to individuals with disabilities that are isolated from their families and caregivers.
- It is important to include people with disabilities, their families and their caregivers in all the phases of the outbreak response.
Migrants’ and Refugees’ Mental Health
Refugees and migrants are vulnerable to mental health disorders, as events before departure, during travel and transit, and after arrival can be complex and stressful. Access to healthcare facilities and other social infrastructure could be reduced, and made worse by a lack of knowledge, and cultural and language barriers. Research in Austria showed a high share of refugees (32%) having moderate or severe mental health problems. Younger refugees (15-34 years) show higher risk levels, and a positive association with e.g. experienced discrimination and the fear for partners and children left behind were found.
Many of these persons live, travel, and work under conditions where physical distancing and recommended hygiene measures are impossible due to poor living conditions and great economic precarity. As these persons are already marginalized, the following considerations should be taken into account, to ethically ensure social justice: 
- Improved access to healthcare and economic support strategies should be made accessible to migrant and refugee populations (regardless of their age, gender, or migration status)
- Instant actions should be taken to move refugees from people overcrowded facilities to safer living conditions. Deportations should be suspended to uphold the principle of nonrefoulement and urgent family reunification for minors should be promoted.
- Racism and prejudice should be discouraged on a social level.
Children’s Mental Health
In difficult times it is normal for children and other family members may have strong reactions like sadness, being irritable or confused. Sleeping disorders, physical reactions and fear of the unknown could take place. Everyone reacts differently. Some parents perhaps immediately develop a new home routine, some others may struggle in balancing their work and home duties. As a reaction to these new situations children can experience intense sadness or anger, others may be withdrawn or behave as if nothing has happened.
Research among children in the Hubei province showed increased levels of depression and anxiety in students aged 6-12. In 188 countries schools have been suspended nationwide, which means over 90% of enrolled learners worldwide were out of education. The closure of businesses, loss of employment, restriction of movement and social distancing as wider effects of the national lockdowns are highly stressful ‘life events’ for families. School closures are isolating children, fellow pupils and their teachers from each other. 
When schools close it means that children and adolescents who have mental health needs, do not have access to the resources they usually have through schools. For young people with mental health problems, the routine of school helps them have an anchor in life the closure means that their symptoms could relapse. Adolescents in racial and ethnic minority groups, having a low family income, or with public health insurance already have less access to mental health services without school closures.
Children who have special education needs like those in the autism spectrum or other disabilities are also at risk. When their daily routines are disrupted they can become frustrated and short-tempered. Parents could create a schedule for their children to reduce anxiety induced by uncertainty. Furthermore suspended therapy sessions of children with special needs could decrease their chance to develop essential skills.
Social distancing measures may result in further isolation in an abusive home. Abuse is likely aggravated during this time of economic uncertainty and distress. Domestic violence and increased rates of child abuse, neglect, and exploitation have been reported in this epidemic and during previous public health emergencies, such as the Ebola outbreak in West Africa from 2014 to 2016. Overall family stresses can increase due to parental unemployment or loss of household income.
Recommendations for Health Professionals
- Encourage children to actively listen and to have an understanding attitude
- It helps children to relieve their stress when they are able to express and communicate their disturbing feelings in an environment that is safe and supportive
- Encourage the family and caregivers to create a sensitive and caring environment around the child.
- If it is possible, create opportunities for children to play, to be physically active and to relax
- Promote regular routines and schedules or help them create new ones in their new environment
- Provide up to date information in a reassuring, honest and age-appropriate way
COVID-19 and Suicide
It is reported that yearly around 800 000 people die by suicide. Furthermore, for each suicide are more than 20 suicide attempts. This as a ripple effect that impacts families, friends, colleagues, communities and societies.
Strong restrictive measures were implemented as a response to the COVID-19 pandemic. These are having a substantial impact on the global economy, including increasing unemployment rates worldwide. Mental health providers need to be aware that rising unemployment is associated with increased rates of suicides. The national lockdowns to avoid overburdened or crashing health care systems due to COVID-19 were resulting downsizing of the economy can lead to other unintended long-term problems. Suicides are preventable. Please make sure to know the phone numbers and addresses of relevant mental health services in your country of work.
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