Mental health in biological disasters: From SARS to COVID-19

Abstract

Background:

The outbreak of coronavirus disease 2019 (COVID-19), like severe acute respiratory syndrome (SARS), provokes fear, anxiety and depression in the public, which further affects mental health issues. Taiwan has used their experience of the SARS epidemic for the management of foreseeable problems in COVID-19 endemic.

Aim/Objective:

This review summarizes issues concerning mental health problems related to infectious diseases from current literatures.

Results:

In suspected cases under quarantine, confirmed cases in isolation and their families, health care professionals, and the general population and related effective strategies to reduce these mental health issues, such as helping to identify stressors and normalizing their impact at all levels of response as well as public information and communication messages by electronic devices. The importance of community resilience was also addressed. Psychological first aid, psychological debriefing, mental health intervention and psychoeducation were also discussed. Issues concerning cultures and religions are also emphasized in the management plans.

Conclusion:

Biological disaster like SARS and COVID-19 not only has strong impact on mental health in those being infected and their family, friends, and coworkers, but also affect wellbeing in general public. There are evidenced that clear and timely psychoeducation, psychological first aid and psychological debriefing could amileorate negative impact of disaster, thus might also be helpful amid COVID-19 pandemic.

Keywords

Coronavirus disease 2019 (COVID-19)severe acute respiratory syndrome (SARS)biological disaster mental health religion culture

Background

Natural, man-made or biological disasters, as well as other trauma-causing events, can occur at any time. These disasters induce millions of deaths worldwide, and hundreds of millions of people have suffered varied injuries. Disasters are diverse events as a consequence of a danger that affects social groups and produces material and human losses resulting in insufficient resources of the community and insufficient coping through social mechanisms (Lopez-Ibor, 2006). Therefore, studying mental rehabilitation in the face of disasters has become an important issue.

Coronavirus disease 2019 (COVID-19), a new infectious disease, occurred just before the Lunar New Year in China and is now a global threat. The COVID-19 outbreak was declared a ‘Public Health Emergency of International Concern’ on 30 January 2020 and was scaled up to a ‘pandemic’ on 11 March by the World Health Organization (WHO). As of 13 May 2020, there were 4,235,080 confirmed cases and 286,218 deceased in approximately 186 countries. Given the population and socioeconomic domains affected, COVID-19 has become a biological disaster.

The role of biological disasters in mental health

In biological disasters, fear, uncertainty and stigmatization are common not only in patients and health care professionals but also in the general population. During early March 2020, schools, businesses and factories were closed in several countries, and cities were in lockdown. Incredible economic losses and increasing unemployment rates are predictable. A study in Taiwan reported that the rate of unemployment increased in parallel with the prevalence of depressive and anxiety disorders (Fu et al., 2013). Therefore, the development and implementation of mental health assessment, support, treatment and services are crucial in responding to the COVID-19 outbreak (Xiang et al., 2020). Mental health care should be provided for those in need, including patients with COVID-19, close contacts, suspected cases who are isolated at home, health professionals and the public in the long term.

Epidemic prevention and quarantine in Taiwan

Taiwan, an island only 81 miles from the coast of mainland China, was expected to have a higher number of cases of COVID-19 due to its geographical proximity and its business correspondence given the number of flights and voyages. However, Taiwan surprised the world by successfully preventing a large-scale epidemic outbreak of COVID-19 through big data analytics, new technology and proactive testing (Wang et al., 2020). The Taiwan Centers for Disease Control first implemented onboard quarantine of all direct flights arriving from Wuhan on 31 December 2019, and issued warnings on travel to Wuhan on 6 January 2020.

Since the first imported case identified on 21 January 2020, tension has spread nationwide. Through the Central Epidemic Command Center (CECC) led by the Ministry of Health and Welfare, Taiwan took further steps, including making the epidemic news transparent by holding press conferences nearly every day; educating the public on how to prevent virus infection by frequent handwashing, wearing masks all the time in crowded rooms and monitoring their temperature every day; establishing a toll-free Communicable Disease Reporting and Consul-tation Hotline; issuing travel notices; and arranging quarantine for those who were infected or suspected of infection or those who had traveled from the areas of highest alert. Collaboration between public sectors increased. For example, to solve the shortage of masks caused by fear of spread of the coronavirus epidemic, the Executive Yuan announced a surgical mask regulation and rationing policy that included the prohibition of mask exports and establishment of name-based rationing system for purchases of masks.

The Taiwanese government has also prepared medical services nationwide for possible epidemics. The government first asked the Legislative Yuan to pass special regulations for the prevention and rescue of severe special infectious pneumonia. The law specifically states that during the epidemic prevention period, the commander of the CECC may instruct the quarantine, isolated, or patients diagnosed with severe special infectious pneumonia to conduct video recording, photography and release of their personal information or other necessary prevention and control measures or disposal. A history of travel, occupation, contact and cluster (TOCC) is required to be reported upon arrival at hospitals and clinics, and individuals’ travel history is shown on their national health insurance card by synchronizing data sharing with the exit and entry administration. The level of infection control in hospitals and long-term care institutions has also increased with the news of nosocomial infection in other countries. The staff in these services are required to be separated into groups, spaces and time schedules to prevent cross-infection between communities and hospitals. These steps, which resulted from the lessons of the severe acute respiratory syndrome (SARS) epidemic in 2003, have changed constantly and quickly nationwide to respond to the worldwide COVID-19 epidemic.

The comparison of SARS and COVID-19 is as summarized in Table 1. Both infect the respiratory system but the infection area is wider and the number of positive infection rate is more in COVID-19 than SARS. The delayed sequelae of this biological disaster were expected to be in greater severity and much more case numbers. The processing principles are the same between SARS and COVID-19 but need to be implemented more efficiently to combat longer pandemic duration and burnout of health care professionals in current COVID-19 outbreak.

Table 1.

Comparison of SARS and COVID-19.

	SARS	COVID-19
Pathogen	SARS coronavirus (SARS-CoV)	Coronavirus (COVID-19)
Endemic duration	1 November 2002 to 31 July 2003	Since 31 December 2019 and pandemic on 11 March 2020
Case numbers	8,096 confirmed cases, including 774 deaths^a	10,268,839 confirmed cases, including 506,064 deaths^a
Affected countries	China, Hong Kong, Taiwan, Canada and Singapore	All over the world

SARS: severe acute respiratory syndrome; COVID-19: coronavirus disease 2019.

Data come from World Health Organization.

Taiwan’s experience of the SARS epidemic

SARS was the first serious new emerging infectious disease in the 21st century (WHO, 2003), and its medical, social and economic impacts were severe and harsh enough to be imprinted in the collective memory of the Taiwanese. The case–fatality ratio of SARS was estimated to be approximately 15%. Nosocomial infection was a major route of transmission for the SARS epidemic in Taiwan (Lee et al., 2003). The first identified SARS case appeared in April 2003, and an outbreak was reported at Ho Ping Hospital in Taipei on April 24. To prevent further spreading, all patients, visitors and staff members were isolated in that hospital. The epidemic shocked Taiwan, and a hospital in southern Taiwan was isolated for the same reason. Without previous experience with this pathogen, all the people in Taiwan faced unprecedented fears of the biological disaster. People began to store all possible protective equipment and refused contact with people or materials at risk of infection, including infected patients, family members of patients, people in quarantine and even medical professionals (WHO, 2003a).

Fortunately, SARS disappeared mysteriously in the summer of 2003. However, the aftermath of the epidemic remained. Every new outbreak of infectious disease, such as MERS or H1N1 flu, can evoke substantial anxiety in the public. In a positive way, infection prevention and control have become part of life. The people in Taiwan wear masks and obtain flu vaccines more often. Hospitals and long-term care facilities have adopted strict regulations for infection control listed in their accreditation items.

Issues concerning suspected cases in quarantine or confirmed cases in isolation and their families

As part of the public health response to the COVID-19 outbreak, mandatory contact tracing and 14-day quarantine were applied to suspected or contact cases. However, the impact of quarantine cannot be underestimated. A study using questionnaires to survey patients who received SARS quarantine revealed that these respondents agreed with the quarantine policy, but most of them still suffered negative psychological shock and stigma (Peng et al., 2004). Those who had been quarantined or suspected of being infected had higher depressive levels, poorer neighborhood relationships, poorer self-perceived health and a higher economic impact compared to those not impacted, and the prevalence of depressive symptoms a week before the situation was controlled was higher than 3.7% (Ko et al., 2006). Poorer self-perceived health, economic impacts and neighborhood relationships were negatively associated with depression. A study in Toronto, Canada showed that 28.9% of the 129 quarantined persons had posttraumatic stress disorder (PTSD), and 31.2% had depressive symptoms (Hawryluck et al., 2004) affected by the SARS epidemic. A review of the psychological impact of quarantine identified stressors, such as longer quarantine duration, fear of infection, frustration, boredom, inadequate supplies, inadequate information, financial loss and stigma, which induced negative psychological effects including posttraumatic stress symptoms, confusion and anger (Brooks et al., 2020).

Victims of natural disasters often receive attention, empathy, support and love. In contrast, victims of infectious diseases experience health and economic loss and often are discriminated against and avoided due to fear and anger. Biological disasters have a significant mental health impact on those infected (Bonanno et al., 2008). A previous study of SARS-infected people found that the general stress and negative psychological impact on SARS patients increased, especially among infected health care workers, and the risk of emotional- and stress-related mental illness increased (Chua et al., 2004).

Infected people as well as their families were affected by the consequences of the biological disaster. A study in Hong Kong found that an estimated 50% of family members of SARS patients had psychological problems, including feelings of depression or stigmatization, difficulty sleeping, and excessive mourning for the loss of their loved one (Tsang et al., 2004).

Issues concerning health care workers

The biological disaster resulting from SARS affected not only the general population but also health care staff. Due to its unique pathway of transmission, the SARS virus mostly aggregated in health care settings, and large numbers of health care workers were infected (Koh et al., 2003). A previous study indicated that most SARS cases involved hospital-acquired infections at the peak of the outbreak (Centers for Disease Control and Prevention, 2003), and another study reported that as many as half of the documented SARS cases involved health care workers (Lee et al., 2003). As one of the most seriously affected countries, Taiwan had 664 probable SARS cases in 2003, which included 105 health workers. Observation of the mental health consequences during the 2003 SARS outbreak could guide mental health professionals to provide mental health interventions to those in need.

Changes in routine tasks may be a source of stress. Other negative effects of the SARS outbreak among health care workers included fear of infection, financial loss, changes in lifestyle, caring for colleagues as patients, concern for family and personal safety and masks interfering with social relationships (Straus et al., 2004; Svoboda et al., 2004). Health care workers often have complex feelings about working during an infectious disease outbreak. During the SARS outbreak in Toronto, health workers reported conflicting feelings between their roles as health care providers and parents as well as struggles between professional responsibility and the fear of exposing their families to the risk of infection (Maunder et al., 2003). Emergency department staff in Taiwan during the SARS outbreak were concerned about working overtime if other staff members were quarantined, the stigma of being contacts and the health of their families and themselves (Lin et al., 2007). They lost intimacy and social contact with their families due to living in dormitories or separate rooms and even eating separately, which culminated in physical and psychological isolation.

Studies have shown that the SARS outbreak had predominant psychosocial effects on staff in hospitals, including stigma, fear and frustration when caring for SARS patients (Nickell et al., 2004). Another study investigated stress reactions among staff in a hospital in eastern Taiwan during an outbreak of SARS and found that 20% of staff felt stigmatized and rejected in their neighborhood because of their hospital work, and 9% even reported reluctance to work or considered resignation (Bai et al., 2004). These psychological stressors are hazardous and may lead to undesirable mental health outcomes. Several studies have examined the psychiatric morbidity of medical professionals of the SARS outbreak in Taiwan, such as PTSD (Lin et al., 2007; Su et al., 2007) and decreased utilization of medical services (Chang et al., 2004; Lin et al., 2007).

A Taiwanese study estimated that the prevalence of psychiatric morbidity, including somatic symptoms, sleep problems and anxiety, was 75% in health care workers (Chong et al., 2004). Psychiatric symptoms, including persistent depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium and suicide, were reported in the early phase of the SARS outbreak (Liu et al., 2003). Moreover, it was reported that 93.5% of the medical staff encountered traumatic experiences, and the emergency department staff had more severe PTSD symptoms than the staff in other departments (Lin et al., 2007). The risk factors were quarantine experience, working in high-risk clinical settings such as SARS units or having family or friends who were infected with SARS (Wu et al., 2009). Likewise, health professionals, especially those who work in hospitals caring for people with confirmed or suspected COVID-19, are vulnerable to mental health problems.

During this outbreak of COVID-19, a cross-sectional study in China focusing on health care staff (doctors, nurses, clinical assistants and medical students) showed that the prevalence rates of anxiety, depression and insomnia symptoms were 5.9%, 28% and 34.3%, respectively, and the risk factors were female sex, low social support, contact with confirmed or suspected cases and working on the clinical front-line (Siyu et al., 2020). Concern and support for health workers are advocated.

Overworked and under-resourced health care workers may refuse or be unable to work by facing the real possibility of infection, and reliant on potentially misleading information about a rapidly developing epidemic. Therefore, shortages of health care workers could happen, which may further worsen the overwork problems. Hence, support of health care workers is urgent (Schwartz et al., 2020).

Issues concerning the general population

Biological disasters, unlike most natural disasters, may continue to produce victims over a period of weeks or months. Normal routines and commercial activities are likely to be seriously disrupted, possibly on a citywide or regional basis and for an extended period (Noji, 2001). Several countries implement citywide or even nationwide lockdowns, and people go on panic-buying sprees for facial masks, toilet paper and even food. The fear of SARS increased panic (Lyu et al., 2007) and led to social stigmatization (Bai et al., 2004; S. Lee et al., 2005; Maunder et al., 2003; Person et al., 2004).

Due to the lack of clear and unambiguous media information, the shortage of respirators and gauze masks, the lack of disinfectants in the market and the lack of attention to the huge psychological impact, the people of Taiwan suffered severe fear, uncertainty and insecurity in the first few weeks of the COVID-19 epidemic, which were also reported frequently in the news worldwide. The rate of suicide increased significantly, suggesting that during the SARS epidemic, the population was tempted to attempt suicide due to various psychological stresses (Fan, 2005). The provision of a proper message is useful. Learning from SARS experiences, the Taiwan CECC responded to COVID-19 quickly and has held press conferences to provide infection news transparently and to answer questions thoroughly.

Disasters, regardless of type, are linked to increased use of substances, including tobacco, marijuana and alcohol, as demonstrated by previous studies (Flory et al., 2009; Forman-Hoffman et al., 2005; North et al., 2011; Parslow & Jorm, 2006; Vlahov et al., 2004). The self-medication hypothesis (Bandura, 1989) and social cognitive theory (Khantzian, 1987) are frequently used to explain post-disaster substance use and mental health problems. Alexander et al. proposed a conceptual sequential mediation model and identified perceived coping self-efficacy, psychological distress, and self-medication as pathways to substance use after a disaster (Alexander & Ward, 2018). Vulnerable individuals exposed to disaster have decreased perceived coping self-efficacy, which in turn increases psychological distress and subsequently increases self-medication by substances. Mental health professionals should be aware of disaster-related substance use and mental health problems related to drunk driving and the aftermath of medical costs.

The role of mental health in biological disasters

Mental health plays an important role in managing new epidemic infectious diseases (EIDs) such as SARS. In particular, effective crisis communication is important to mitigate the fear of new EIDs. The challenge of communication about the risk of EIDs was one of the lessons learned from the experience of SARS (‘WHO Issues Consensus Document on the Epidemiology of SARS’, 2003) The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Taiwanese Society of Psychiatry and Taiwan Association proposed the ‘5 words principle – safety, calming, efficiency, connectedness, instillation of hope (安, 靜, 能, 繫, 望)’ to decrease the impact of anxiety and depression.

Psychological impact and management in the post-disaster period

In a population-based study of 1,278 participants in Taiwan, 9.2% of participants reported that their perceptions of life became more pessimistic after the SARS crisis, and the prevalence of psychiatric morbidity was 11.7% (Peng et al., 2010). Psychological distress was significantly correlated with demographic factors and perceptions regarding SARS. These authors suggested that the marketing of mental health education should be segmented according to age and education level, which should enhance crisis communication for newly emerging biological disasters among the general population.

People in the first few weeks of a biological disaster are particularly overwhelmed. In a study of public perception of media reporting during the SARS outbreak in Taiwan, 21.4% of respondents thought that the positive effects were greater than the negative ones, while 35.7% believed the opposite (Lyu et al., 2007). Reports regarding the closing of Hoping Hospital and the deaths of infected medical staff were the two most frightening news items. Elderly, lower-educated and non-Taipei-area respondents tended to give higher ratings to media reporting.

All potential patients were required to be quarantined at the hospital to prevent further infection during the duration of the SARS epidemic. These individuals were discriminated against because of public fear about SARS. In another study (Ko et al., 2006) that investigated the psychosocial impact and the associated factors of depression of the SARS epidemic in Taiwan when the epidemic had just been controlled, 3.7% of respondents experienced depressive symptoms during the previous week in addition to poorer self-perceived health and economic impact factors. Participants or their friends and family who had been quarantined or suspected of being infected had higher depressive levels, poorer neighborhood relationships, poorer self-perceived health and a higher economic impact than participants who were not. The neighborhood relationship factor was negatively associated with depression among these respondents. The study also suggested that appropriate mental health interventions to improve self-perceived health condition and provide instrumental and psychological support for these respondents as well as decreased stigmatization and discrimination from the public could have buffered the psychological impact of this biological disaster.

Being a family member of a SARS patient presented a greater risk of developing depression, stigmatization and other psychological problems (Tsang et al., 2004). Another study about community psychobehavioral responses during and after the 2003 outbreak of SARS in Hong Kong (Leung et al., 2005) showed that female participants, individuals aged 30–49 years and individuals with only primary education or less were predisposed to greater anxiety. Comparing the public’s psychological responses of SARS in Hong Kong and Singapore, Hong Kong participants had significantly higher anxiety and more frequent somatic symptoms than participants in Singapore (Leung et al., 2004).

Biological disasters have a significant mental health impact on infected individuals (Bonanno et al., 2008; Mak et al., 2009). Previous studies of SARS-infected patients (Chua et al., 2004) found that the general stress and negative psychological impact on SARS patients increased, especially among infected health care workers, as did the risk of emotional- and stress-related mental illness. A study in Toronto, Canada, which was also affected by the SARS epidemic, showed that 28.9% of the 129 quarantined persons had PTSD and 31.2% had depression symptoms (Hawryluck et al., 2004).

During these epidemics, the impact on the psychosocial well-being of high-risk communities is often overlooked. This was especially the case in areas affected by the Ebola infection, where few interventions were taken to address the mental health needs of diagnosed patients, their families, medical professionals or the general public (Bitanihirwe, 2016). In these areas, poor mental health and psychosocial support systems and a lack of trained psychiatrists and psychologists increased the risk of psychological distress and mental illness (Shultz et al., 2015). An ineffective mental health system also made Lion Rock and Liberia poorer due to Ebola virus infections (Shultz & Neria, 2013).

A previous study found that during a biological disaster outbreak, mental health professionals should actively participate in the overall intervention process of the disease to provide timely public health education and psychosocial response (Mohammed et al., 2015).

The psychological impact of these biological disasters on the general public has been studied in the past. Based on the experience of SARS between 2002 and 2003, an epidemiological compartmental model was used to illustrate a possible mechanism for multiple outbreaks or even sustained periodic oscillations of emerging infectious diseases due to the psychological impact of the reported numbers of infectious and hospitalized individuals (Liu et al., 2007).

Community resilience

Community resilience is the continuous ability of the community to use available resources to cope with and recover from adverse situations and is related to the reduction of psychological impact on the general population after a disaster (Ainuddin & Routray, 2012; Coles & Buckle, 2004). Communities with resilience ability can minimize the effect of disasters and make it easier for people to return to normal life. By implementing a community disaster plan, communities can unite to overcome any disaster for physical and economic reconstruction. A previous study focusing on community resilience in disaster recovery in Jialan Village when Typhoon Morakot struck Taiwan in 2008 demonstrated that the village’s recovery was due to the effective use and coordination of community resources and partnership building between the public and private sectors, and was enhanced by values such as a strong sense of mutual help, good physical health, positive attitudes and autonomy (Wang et al., 2013).

Community resilience is not only crucial in natural disasters. A study focusing on Hong Kong during the SARS crisis demonstrated that the functions of civil society can reduce vulnerability, maintain resilience and contribute to organized and spontaneous activities (Sze & Ting, 2004). After the endemic of SARS, Taiwan has worked to strengthen community partnerships that support prevention continually and developed community capacity by promoting individual citizen self-monitoring. To address the impacts of biological disasters on communities, by adhering to the concept of ‘thinking globally, acting locally’, professors have established research regarding community epidemic-prevention procedures and risk-management models (Lo et al., 2020). Therefore, cultivating community resilience is important in disaster rehabilitation.

Special issues: cultures and religions

The COVID-19 outbreak was a global threat, but interventions for its psychosocial impact should be individualized by culture. Asian patients reported a loss of anonymity, stigmatization and racist reactions in the community because the SARS outbreak was thought to have originated in China (Tansey et al., 2007), and they re-experienced these effects during the COVID-19 outbreak. Asians, especially Chinese individuals, who worked overseas were at risk of psychological impacts. In Taiwan, there are several ethnic groups, including Han Chinese, Hakka, aborigine and new residents from other countries, such as mainland China, Indonesia, Thailand and Vietnam. Some of them worked in hospitals as caretakers or household workers. Therefore, they were at risk of infection but may have hidden their symptoms due to fear of losing their jobs.

The symptoms and severity of psychological disorders vary by culture. A study comparing the public’s psychological responses to SARS in Hong Kong and Singapore showed that Hong Kong participants had significantly higher anxiety than participants in Singapore (Leung et al., 2004). Patients suffering from major depression do not complain primarily of sadness but rather note changes in appetite, insomnia, fatigue and other somatic symptoms, such as headaches, backaches and stomachaches (Kleinman, 1996). Chentsova-Dutton and colleagues proposed that cultural norms predict that the impact of depression decreases the ability to react culturally in an appropriate manner to negative emotions (Chentsova-Dutton et al., 2007, 2010). Thus, if Asians suffer from depression, they may be less likely to have the disorder detected, which may result in a worse prognosis.

Refugees experience persecution and forced migration in their original countries and subsequent social exclusion and discrimination in their resettlement countries. Their experiences of persecution, physical and emotional trauma and forced relocation makes them vulnerable to psychological problems (Murray et al., 2010). Considering language barriers and their social, cultural and historical diversity, it is a challenge to deliver mental health services. There is an ongoing need for the development of culturally appropriate mental health services for socially under-included and marginalized populations.

PTSD is a major concern with regard to the psychological impact of disasters. Van Rooyen and Nqweni proposed a framework of culture and PTSD in which culture influences adaptation by interacting with coping strategies and the meaning of symptoms, leading to either a return to normal or a continuation of intrusive memory and other symptoms (van Rooyen & Nqweni, 2012). Therefore, we suggest that mental health providers should have cultural sensitivity in dealing with psychosocial impacts, especially among foreigners, immigrants or refugees.

Religion and spirituality have been reported to be embedded in the posttraumatic recovery process for understanding traumatic events, the selection of methods to cope with adversity and the coping methods themselves; these factors, therefore, influence the short- and long-term outcomes of trauma (Harper & Pargament, 2015). South Korea stopped all large activities for religious reasons due to notable cases of COVID-19 infections centered on a religious organization in Daegu and a neighboring hospital. The Vatican also closed St. Peter’s Basilica to tourists due to COVID-19. In Taiwan, Dajia Mazu Pilgrimage was also suspended for infection control of COVID-19. Therefore, devotees are unable to gain comfort from these activities, which may worsen their mental health.

Lessons learned and recommendations

Recommendations were summarized in Table 2. Female sex, prior trauma, prior psychiatric history including anxiety and depression, family psychiatric history, peritraumatic dissociation, acute stress symptoms, less education, Black race, higher trauma severity, lack of social support and additional life stress have been reported to be risk factors for PTSD (Breslau et al., 1995; Brewin et al., 2000; Goldenberg & Matheson, 2005; McFarlane, 2000). By identifying those at risk, mental health professionals can provide early intervention and prevent PTSD.

Table 2.

Recommendations for mental health in COVID-19.

Recommendations	Content
Identify risk factors of PTSD	1. Less education 2. Black race 3. Prior psychiatric history including anxiety and depression 4. Family psychiatric history 5. Acute stress symptoms 6. Peritraumatic dissociation 7. Higher trauma severity 8. Lack of social support 9. Additional life stress
Be aware of patients’ disease fluctuation	Psychiatric doctors should be aware of patients’ disease fluctuation during COVID-19 period
Disaster-related mental health education	Training staff in advance of first-line care on common psychosocial impacts and supportive psychotherapy skills
Use electrical devices	1. Electrical devices can be used for patients in institutions such as nursing homes, hospitals and prisons to maintain contact with their families 2. Using electronic devices and applications instead of side-by-side interviews for psychological counseling for affected patients, their families and the general population to reduce infection risks

PTSD: posttraumatic stress disorder; COVID-19: coronavirus disease 2019.

Patients with a history of psychiatric disorders, such as anxiety and depression, are vulnerable to traumatic events (Breslau et al., 1995). Infection risk from visiting the hospital for regular follow-up, free-floating anxiety and rumination on the outbreak may deteriorate their pre-existing disease. Psychiatric doctors should be aware of patients’ disease fluctuation during this period, which does not usually receive attention during traumatic events.

Most health professionals working in isolation units and hospitals do not receive enough training in disaster-related mental health care. Timely mental health care must be developed. We suggest training the staff in advance, regarding first-line care on common psychosocial impacts and supportive psychotherapy skills. Early detection of patients’ psychological needs is the main goal. Electrical devices can be used for patients in institutions such as nursing homes, hospitals and prisons to maintain contact with their families.

The content of mental health promotion in disasters

Psychological first aid

Psychological first aid (PFA) is a set of early interventions and principles provided by clinicians and nonclinicians for people in emotional distress (Reyes, 2004), especially for those with acute stress from recent trauma (Bisson & Lewis, 2009). The goals of PFA are to stabilize psychological functioning, mitigate psychological distress and dysfunction, facilitate the return to adaptive psychological and behavioral functioning and promote access to further care (Everly & Flynn, 2006). The WHO provides a toolkit in different languages on PFA that presents a set of basic principles and techniques (WHO, War Trauma Foundation, & World Vision International, 2011). Surprisingly, PFA was developed from expert consensus but has not been empirically tested (Bisson & Lewis, 2009; Watson et al., 2011). Nevertheless, people who are infected or in quarantine might benefit from PFA given the stress of biological disasters.

During the COVID-19 epidemic, PFA providers could also be infected through face-to-face counseling. Xiang et al. suggested using electronic devices and applications instead of side-by-side interviews to provide psychological counseling for affected patients, their families and the general population (Xiang et al., 2020). In Taiwan, a 24-hour hotline service (‘安心專線’) provided by psychologists has been operated after the outbreak of COVID-19 to help citizens, patients or those in quarantine understand their reactions, improve their coping, and connect with other services. Telemedicine is also used in Taiwan for patients who are in quarantine but need medical advice.

Psychological debriefing

Psychological debriefing, in the form of individual or group sessions provided hours or days after a traumatic event, includes emotional ventilation, trauma processing and psychoeducation (Bisson et al., 2009). It was designed to provide opportunities for processing trauma, facilitating recovery, providing education and linking with resources (Regel, 2007). However, in biological disasters, staff are unable to attend group sessions either for work in shifts or infection control consideration.

Mental health intervention and psychoeducation

Multidisciplinary mental health teams (including psychiatrists, psychiatric nurses, clinical psychologists and other mental health workers) established by health authorities to deliver mental health support to patients and health workers were suggested by Xiang et al. during the COVID-19 outbreak (Xiang et al., 2020). Mental health professionals should actively participate in the overall intervention process of the disease to provide timely public health education and psychosocial response (Mohammed et al., 2015).

Furthermore, suspicions and resistance to public health response measures during a crisis could be due to communication failures among different communities and between government and citizens (Noji, 2001). Xiang et al. suggested that clear and regular updates about the COVID-19 outbreak should be provided to health workers and patients to reduce their sense of uncertainty and fear (Xiang et al., 2020). Effective crisis communication was important to mitigate the fear of SARS (WHO, 2003). Officials should quarantine individuals for no longer than required, provide a clear rationale for quarantine and information about protocols and ensure sufficient supplies. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favorable (Brooks et al., 2020). The Taiwanese government aggressively arranged press conferences every day and frequently advertised health education, but mental health was not included. The marketing of mental health education should be segmented according to age and education level, especially for mentally ill patients. Appropriate mental health intervention to improve the self-perceived health condition, provide instrumental and psychological support for the ‘impacted group’ and decrease stigmatization and discrimination from the public could have buffered the psychological impact of this biological disaster (Ko et al., 2006).

Patients who are suspected or diagnosed with COVID-19, as well as health professionals caring for infected patients, should receive regular clinical screening for mental health, especially depression, anxiety and suicidality, by mental health workers (Xiang et al., 2020). We agree with the need for mental health evaluation in these vulnerable groups as well as in the general population, who are also influenced by COVID-19. Considering the large case numbers, the method of evaluation requires further discussion. Self-reported questionnaires are efficient, but their reliability is questionable. Side-by-side interviews by psychiatrists are reliable but costly. Websites and platforms providing educational materials on anxiety, depression and PTSD could be useful for patients who surf the internet instead of going to clinics during this period.

The limitation of our review article was that the causality cannot be well defined and further prospective study is need.

Conclusion

COVID-19 is not only an infectious disease but also a biological disaster that has severe mental health impacts in suspected cases under quarantine, confirmed cases in isolation and their families, health care workers and the general population. Studies have shown that PFA, psychological debriefing and building community resilience are effective for maintaining mental health during disasters. Because the duration and scope of COVID-19 is still increasing and uncertain, these strategies should be implemented to address challenges and to improve early recovery and rehabilitation after disasters.

Footnotes

Acknowledgements

The authors appreciate the assistance of the staff at the Kaohsiung Municipal Kai-Syuan Psychiatric Hospital.

Author contributions

K.-Y.H. conducted literature review and wrote most part of this article. W.-T.K., D.-J.L., W.-C.L., K.-Y.T., W.-J.C., J.-J.H., and L.-S.C. conducted literature review and participated in the article writing and revision. S.-T.H. coordinated the whole team to review and discuss perspectives, and revised the article. F.H.-C.C. organized the whole team to review past studies, and edited and revised the article. All authors read and approved the final manuscript.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed in this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Frank Huang-Chih Chou

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