OPINION | Covid-19: May be prudent to over-estimate the mental health consequences of the virus

The Covid-19 pandemic has affected millions around the world and damaged the mental well-being of many.

This damage may be hard to reverse without prompt action. Coupled with the social isolation linked to the prolonged lockdown, the pandemic is expected to lead to new episodes of mental illness for many South Africans and exacerbate pre-existing mental illness.

Thirty months after the SARS outbreak in 2003 (the first massive infectious disease outbreak of the 21st century), a third of survivors  met criteria for any psychiatric disorder; a quarter met criteria for post-traumatic stress disorder (PTSD); and approximately 16% had depressive disorders. These statistics underscore the importance of detecting and treating psychiatric illness in people with Covid-19, and in their contacts.

We cannot ignore the profound negative effects of stress, fear, profound loss and grief. If evidence from other countries is anything to go by, the physical and mental health, and social and economic impacts of the disease, will be inordinately borne by poor South Africans (more than 50% of South Africans live below the poverty line). Billions of people around the world have either been or currently are in full or partial lockdown. This may be a mammoth "experiment" but the consequent physical distancing has undoubtedly slowed the transmission chain.

Stressors during the pandemic

That said, the pandemic and the lockdown, independently and in combination, have unintended consequences by severing family ties and inhibiting  social norms, values and rituals, and will arguably exert a severe toll on the mental health of people  – not only in the immediate and short-term but for many years to come. 

Quarantines can lead to PTSD symptoms, depression, and alcohol abuse and dependence, with some evidence that quarantines of longer duration are associated with poorer mental health, specifically PTSD, over time. During previous infectious disease epidemics, common stressors endorsed during quarantine were a long period of quarantine, fears of being infected, frustration, boredom, shortage of supplies, inadequate information from public health authorities, financial loss, and stigma. These are all stressors that are being endorsed during the current pandemic.

Research on the mental health consequences of economic crises has taught us about the significant relationship between severe economic recession and population-level psychological distress, including the emergence, and worsening, of mood, anxiety and substance-related disorders and suicide. Physical isolation, economic worries, heightened anxiety and guilt (about exposing others to the virus or not doing enough to help others) are all risk factors for suicidal behaviours (this includes suicidal thoughts, attempts, and completed suicide). 

In a recent article, Danny Horesh and Adam Brown contend that like other mass traumatic events, the Covid-19 pandemic is expected to result in PTSD, with typical features of hypervigilance (centred on protective measures to avoid infection), intrusive thoughts (related to infection, health, fears of dying), avoidance, and negative mood and cognitions (around fears of the world changing and the future being bleak) that will be subjectively distressing and persistently impact on day-to-day functioning over time.  

Unique challenges

In the face of the restrictions and accompanying economic hardship, South Africa’s youth and  persons with pre-existing mental illness may be especially hard hit by the potentially severe and long-term mental health consequences of the Covid-19 crisis. The stress, fear and emotional pain induced by the rapid and aggressive spread of infection, as well as the scale of prolonged grief from the sudden and massive loss of life, will be felt for a long time, and by successive generations. Like other pandemics, this one is also characterised  by unpredictability, widespread community impact, mass fatalities, and persistence as American scholars Ginny Sprang and Miriam Silman have pointed out

The COVID-19 pandemic also poses unique challenges for the management of hospital inpatients and outpatients with psychiatric illnesses. Prior to the pandemic, psychiatric services in our public sector, especially at district and community levels, were already overstretched and under-resourced in terms of bed capacity and shortages of mental health personnel.

The deployment of these staff within hospitals to assist with the screening and management of suspected and confirmed Covid-19 cases in general medical settings, and the closure of psychiatric wards because of Covid-19 infection, further add to the challenge of providing adequate psychiatric care. Psychiatric units in public hospitals are typically characterised by bed shortages, overcrowding and sharing of dining, bathroom and daily activity spaces (e.g. for group activities such as occupational therapy and group psychotherapy). 

Given their compromised and disordered mental states, disorganised behaviour, impulsivity, sub-optimal self-care and impaired insight, patients with mental illness may not be in a position to adhere to infection prevention and control measures and protect themselves in the face of Covid-19. Those who cannot access outpatient care may be left to self-manage their mental and physical health, as Benjamin Druss from Emory University argued recently.

Mental health system needs urgent strengthening

Existing social isolation, loneliness, homelessness, poorer physical health in patients with serious mental illness (e.g. schizophrenia, bipolar illness), overweight/obesity, lack of exercise and other unhealthy lifestyle factors associated with psychiatric illness, and the side effects of psychotropic medication, are added risks. As a result of the high rates of co-occurring physical illness (e.g. diabetes, cardiovascular disease) – at least two-fold higher than the general population – patients with mental illness have a heightened vulnerability to developing Covid-19 pneumonia and other complications. 

Our mental health system needs urgent strengthening through multi-sectoral interventions targeting mental health, well-being and resilience, for both the general population and for vulnerable groups. This includes, but is not limited to, health care workers, women, youth, the elderly, and the mentally ill. These interventions should be embedded in the general medical Covid-19 pandemic care that is already being provided. 

More than ever, given the scale of the pandemic, we need sound research to learn more about the psychiatric and neurological manifestations and their impact in our general population and in vulnerable groups. There are already several research studies currently underway at Stellenbosch University, and a number of these are collaborative multi-country initiatives (e.g., As this is a novel, ravaging virus, it may be prudent to over-estimate the mental health sequelae and the resources that will be required. We can harness the interconnectedness and the tremendous co-ordinated response from the health sector that Covid-19 has necessitated to achieve this. 

*Prof Soraya Seedat is the Executive Head of the Department of Psychiatry at Stellenbosch University.

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