Psychiatric Annals

CME Article 

The Long-Term Mental Health Effects of COVID-19

Syed Z. Iqbal, MD; Benjamin Li, MD; Edore Onigu-Otito, MD; Mohammad Faraz Naqvi, MD; Asim A. Shah, MD

Abstract

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

The novel coronavirus 2019 (COVID-19) has affected the mental health of health care professionals and the general population. Most of the research has focused on the immediate and short-term implications of the COVID-19 pandemic, with a paucity of research available exploring the long-term mental health effects. Experience with previous disasters has shown that survivors suffer from various mental health problems including posttraumatic stress disorder, major depressive disorder, anxiety disorders, phobias, fears with avoidant behaviors, and various neuropsychiatric disorders. There has been an increased incidence of substance use and internet addiction along with increased rates of domestic violence and child abuse. Social distancing is helpful in limiting the spread of the disease, but the impact of social distancing and quarantine has resulted in increased anxiety among the general population. The long-term mental health effects are anticipated to be intensified due to the pandemic affecting people worldwide. Mitigation strategies need to be implemented as there will be no vaccine available to limit the long-term mental health effects of this pandemic. [Psychiatr Ann. 2020;50(12):522–525.]

Abstract

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

The novel coronavirus 2019 (COVID-19) has affected the mental health of health care professionals and the general population. Most of the research has focused on the immediate and short-term implications of the COVID-19 pandemic, with a paucity of research available exploring the long-term mental health effects. Experience with previous disasters has shown that survivors suffer from various mental health problems including posttraumatic stress disorder, major depressive disorder, anxiety disorders, phobias, fears with avoidant behaviors, and various neuropsychiatric disorders. There has been an increased incidence of substance use and internet addiction along with increased rates of domestic violence and child abuse. Social distancing is helpful in limiting the spread of the disease, but the impact of social distancing and quarantine has resulted in increased anxiety among the general population. The long-term mental health effects are anticipated to be intensified due to the pandemic affecting people worldwide. Mitigation strategies need to be implemented as there will be no vaccine available to limit the long-term mental health effects of this pandemic. [Psychiatr Ann. 2020;50(12):522–525.]

The world has suffered from various deadly viruses including the 1918–1919 influenza pandemic, the 1957–1958 influenza pandemic, the severe acute respiratory syndrome (SARS) pandemic (2003), the Swine flu pandemic (2009–2010), the Middle East respiratory syndrome (MERS) outbreak (2012–2015), and the Ebola virus outbreak (2014–2016). 1 The novel coronavirus 2019 (COVID-19) was first identified in Wuhan, China, in December 2019,2 and as November 5, 2020, there are 9,463,782 confirmed cases in the United States with 233,129 deaths.3

The exposure to a disaster or traumatic event is associated with a variety of mental health disorders including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), substance use, anxiety disorders, panic disorder, phobias, and neuropsychiatric disorders.4 Prolonged isolation has been shown to increase the risk of domestic violence and child abuse.5 It can also result in prolonged grief due to loss of loved ones and psychological distress presenting with somatic symptoms.4 Survivors of disasters such as Hurricane Ike in 2008, the World Trade Center attack in 2001, the Deepwater Horizon oil spill in the Gulf of Mexico, and the SARS pandemic showed persistent symptoms of depression and anxiety.5 Impact from previous disasters and pandemics can help forecast the possible long-term mental health outcome of COVID-19. The economic downturn due to the COVID-19 pandemic has likely amplified the metal health burden. The long-term mental health effects of COVID-19 are anticipated to be more severe than from the SARS and similar outbreaks.6 Further research is needed to focus on those long-term mental health implications and to formulate effective strategies to minimize the outcomes.

Common Long-Term Psychiatric Effects

PTSD is a disorder that can be easily predicted in person who has experienced a traumatic life event.4 PTSD has a higher prevalence in emergency department (ED) professionals as compared to the general population.7 Health care workers have suffered a major toll from COVID-19, from witnessing multiple patient deaths to anxiety about contracting the virus and passing it to their loved ones with uncertainty around employment stability. One review estimates that PTSD is prevalent in 30% to 40% of people directly affected by a traumatic event, 10% to 20% of rescue workers, and 5% to 10% in the general population.4 The prevalence of PTSD is higher in children as compared to adults who are exposed to disaster or traumatic events. Studies have reported a prevalence rate of 100% in children exposed to mass violence.4 A Taiwanese study about SARS showed that 22% of the ED staff who worked in high-risk exposure areas had symptoms of PTSD versus 13% of the staff who worked in medium- to low-risk areas with less exposure.6 Symptoms can extend from 1 to 3 years after the traumatic event or pandemic has ended.2 A study conducted in Canada during the SARS outbreak included 1,550 health care workers in which 36% of respondents showed significant long-term PTSD symptoms.6 Another study found that 10% of the health care workers were still having a high level of PTSD symptoms since the SARS outbreak.6 After the SARS and MERS outbreak, PTSD, emotional lability, impaired concentration, fatigue, and impaired memory were reported in more than 15% of patients in follow-up of SARS and MERS postinfection for a duration of 6 weeks extending to 39 months.8

After PTSD, depressive disorders have been the second most studied postdisaster mental health disorder.4 It is estimated that 5% of the population affected by Hurricane Ike and 10% of adults in New York City post-9/11 met criteria for MDD 1 month after the disaster.5 In addition, after the Deepwater Horizon oil spill in the Gulf of Mexico, the general population showed clinically significant signs of depressive disorders.5 The SARS outbreak was associated with increased incidence of depression in patients and clinicians.5

The psychological reaction to pandemics has resulted in emotional distress manifested as anxiety disorders, fear, frustration, panic disorders, phobias, and avoidance behaviors.1 The loss of loved ones results in prolonged grief in populations affected by a traumatic life event or disaster.4 Excessive inflow of information via news and social media can generate a high level of anxiety and stress, resulting in symptoms of palpitation, restlessness, and insomnia.1 A few epidemiological studies have focused on these mental health consequences as they relate to COVID-19; one study rates job stress as a significant factor along with personal factors, including fear of infecting family members and excessive worries about one's own risk of becoming infected with COVID-19.6 The SARS outbreak was also associated with increased incidence of anxiety symptoms in patients and clinicians.5 The fear of acquiring infection at work and transmitting it to family members has resulted in avoidance behaviors like social isolation (ie, spending less time with family to limit transmission).6 Long-term quarantine can lead to symptoms of PTSD along with behavioral changes like vigilant hand washing and avoidance of crowded places, which delays return to normal activities.9

Comorbidities and Psychosomatic Disorders

The above-mentioned disorders rarely present in isolation, as disaster-related PTSD is mostly comorbid with other conditions including anxiety disorders, MDD, and substance use disorder.4 More than one-half of all the survivors of the Oklahoma City bombing in 1995 and the World Trade Center attack in 2001 who met PTSD criteria also had MDD.4 With the start of COVID-19, health care workers have presented with symptoms of anxiety, depression, irritability, insomnia, distress, and PTSD symptoms.6 With the start of COVID-19, health care workers have presented with anxiety and depression along with PTSD.6 At Mount Sinai Hospital in New York City, it is estimated that 25% to 45% of frontline workers suffer from PTSD.6 A survey conducted in China measured the symptoms of anxiety, depression, and insomnia using the Generalized Anxiety Disorder scale, the Center of Epidemiology Scale for Depression, and the Pittsburg Sleep Quality Index in 7,236 people of whom 2,250 were health care workers.6 This survey showed that 34.7% of those health care workers had anxiety disorder, 19.8% had depressive disorder, and 23.6% presented with symptoms of insomnia..6 Another study in China with 1,257 health care workers in 34 hospitals showed that 71.5% had symptoms of stress, 50% had depression, 44.6% had anxiety, and 34% had insomnia.6 Similarly, 51.6% of the staff working in high-risk areas and 38.5% working in medium- to low-risk environments had a Chinese health questionnaire-12 score consistent with psychiatric morbidity.6

A prospective study of mothers with low income who were affected by Hurricane Katrina showed bereavement, fear of well-being of loved ones, and a lack of access to medical care as predictors of adverse mental and physical health at 1 year postdisaster, which persisted for 12 years.10 As in the influenza pandemic, late-onset neuropsychiatric manifestation can also be attributed to the direct and indirect effect of COVID-19 on the brain.8 This could be related to direct viral infection of the brain (encephalitis), cerebrovascular disease in context of procoagulant state, the degree of hypoxia, and the immunological response.8 Similarly, the majority of patients with acute respiratory distress syndrome, a hallmark of severe COVID-19 that requires mechanical ventilation, have demonstrated impairment in memory, attention, and concentration at 1 year postinfection with reduced quality of life.8 The disaster-affected population has presented with psychosomatic symptoms in the form of sleep deprivation, headache, fatigue, abdominal pain, and shortness of breath.4 In one review, the prevalence of psychosomatic symptoms ranged from 3% to 78% in the disaster-affected population, with most of these symptoms subsiding with the passage of time but persisted in some.4 Studies have shown that survivors of critical illness are at risk for persisting psychiatric impairment, including depression, anxiety, and PTSD.8

Substance Use Disorder

Research has shown that after a major traumatic event the rate of substance use disorders increases, especially the use of alcohol.11 This increase was more prominent in people with a previous substance use challenge prior to the disaster.11 The incidence of alcohol use increased in survivors of Hurricane Ike, Hurricane Katrina, and the World Trade Center attack.11 The period post-9/11 saw New York residents report a 10% increase in tobacco use, a 25% increase in alcohol use, and a 3% increase in marijuana use.4 The aftermath of Hurricane Sandy in 2012 saw a rise in opioid use.11

In a survey of 6,416 people in relationship to COVID-19 and substance use and addictive behaviors, the prevalence of severe internet addiction increased from 4.3% to 23%, whereas the relapse to alcohol abuse and smoking abstinence was found to be 19% and 25%, respectively.12 Regular alcohol users reported a 32% increase in usage, and 20% of smokers reported an increase in usage during the COVID-19 pandemic.12 Increased use of substances in health care workers has also been documented along with the general population as a maladaptive coping mechanism to mitigate the effects of stress.5 Efforts are under way to address the need for treatment, including relaxed federal requirements for treatment with methadone and buprenorphine for opioid use as well as the development of virtual treatment programs and the adoption of 12-step groups and SMART recovery online platforms.10

Child Abuse and Domestic Violence

Adverse childhood experiences, which include different forms of abuse, neglect, and household dysfunction occurring before age 18 years, are a public health problem that can worsen during a pandemic.13 Unemployment and financial constraints in families can result in increasing distress leading to mental health problems and violence.14 Virtual learning during the COVID-19 pandemic has added stress on parents who are also working from home.14 Parental stress can be displaced to children in the form of strict parenting resulting in child maltreatment and traumatic events.14 The economic burden in families can result in severe mental illness, substance use disorder, and suicidal behaviors in parents, which all affect the parent-child relationship with increased risk of domestic violence and child abuse in the families.14 In China, the prevalence of domestic violence has increased 3-fold during the lock down.15 Increased rates of child abuse, neglect, and exploitation was reported during the Ebola virus outbreak in West Africa from 2014 to 2016.15 Importantly, children with mental health disorders and developmental disabilities are particularly vulnerable to the effects of pandemics due to their greater health care needs, mental health concerns, and dependence on community-based services.16

Resilience and Mitigation Strategies During the COVID-19 Pandemic

Postdisaster research can help in understanding the mental health symptom trajectories of COVID-19 longitudinally. The symptom trajectories have the following stages of resolution: resistance (experiencing no symptoms or mild symptoms), resilience (rapid decline in symptoms after a short-time period), recovery (decline after long-time period), and chronic dysfunction (persistent symptoms).4 The COVID-19 pandemic has provided mental health professionals with an opportunity to study resilience. In a study of 3,042 participants in the United States, 48.5% reported distress about having family members contracting COVID-19, 36% expressed concern of infecting others, and 19.9% expressed concern of getting the virus themselves.17

Interventions promoting resilience should be further researched and provided to people with risk factors for poor mental health.18 Targeted psychological intervention can be delivered online and through smartphone technologies to populations who have high risk for mental health challenges.19 The Centers for Disease Control and Prevention has provided effective guidelines for frontline health care workers to minimize work-related stress including increased awareness of symptoms, taking breaks from work, engaging in self-care activities, and seeking help at the time of need.19

Conclusion

COVID-19 has a significant impact on the mental health of the community including the health care professional and the general population. Due to the rapidly evolving nature of the pandemic, there is limited research about the long-term mental health effects of COVID-19. The long-term consequence of this current pandemic can be inferred from the experiences of past pandemic and disasters. Health care workers have suffered from anxiety disorders, depressive disorders, and PTSD, whereas the general population is also susceptible to mental health consequences due to the practice of social distancing, quarantine restrictions, and bearing the financial burdens due to high unemployment rates. It is important to implement strategies to limit the effect of this pandemic on the mental health of the population globally in the form of support groups and counseling as these interventions can be provided online with the use of technology. Future research is required to further explore the long-term mental health consequences.Due to the high global morbidity and mortality rates, the anticipated mental health impact of COVID-19 could be larger as compared to previous pandemics like SARS and MERS.

References

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Authors

Syed Z. Iqbal, MD, is an Assistant Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Benjamin Li, MD, is an Assistant Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Edore Onigu-Otite, MD, is an Associate Professor Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Mohammad Faraz Naqvi, MD, is the Clinical Studies Coordinator, Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center. Asim A. Shah, MD, is the Barbara & Corbin J. Robertson Jr. Chair in Psychiatry, the Executive Vice Chair, and the Professor of Psychiatry, Family and Community Medicine, Baylor College of Medicine; the Chief of Psychiatry, Ben Taub Hospital/Harris Health System; and the Chief, Division of Community Psychiatry & Director of Mood Disorder Research Program, Ben Taub Hospital.

Address correspondence to Syed Z. Iqbal, MD, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza - BCM350, Houston, TX 77030; email: Syed.Iqbal@bcm.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20201103-01

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