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Dr. Mark E. Esterle, MD

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COVID-19 and it's Effect on Mental Health

May is mental health awareness month. I am not sure if this will be a big surprise to many but the psychological effects of the coronavirus pandemic will far outreach the actual virus. We are already seeing this happening and according to Dr. Eike Van Hoof, professor of health psychology and primary care psychology at the University of Brussels, in his recent article from the World Economic Forum April of this year, this will result in a secondary epidemic burnout and stress-related absenteeism in the latter half of 2020. It seems like everybody is on edge and it is bringing out the worst in many.


Everybody reacts to stressful situations in different ways. It can take shape in many forms and expresses itself in every aspect of our lives. Some of the signs are subtle like fatigue, headache, insomnia, increase, or loss of appetite. Others are more obvious such as rapid heartbeat, chest pain, increased muscle tension, and personality changes. Increased levels of stress for prolonged periods can even increase your risk of infection by affecting one's immune system. There are many reasons for stress in lockdown: risk of infection, fear of becoming sick or of losing loved ones, frustration simply from boredom, inadequate supplies, and of course the concern for financial difficulty. We should all heed the warning of these early stress response signs and symptoms, in ourselves and our loved ones, as we work together to get through this pandemic.


The large majority of the planet is on some kind of lockdown due to the coronavirus pandemic. We have created additional field hospitals to handle a potential exponential spike in coronavirus infected patients to handle their medical care but little has been done so far to deal with the psychological effects that can reach farther than the infecting virus.

An individual does not have to get sick from the virus to have psychological effects related to the virus.


Here in Kentucky we have flattened the curve quite successfully and because of that have saved a significant number of lives, but I am not sure that our psychological outcome will be any better off here than any other place in the country that has been hit more heavily from COVID-19.


There is a simple mental toll of quarantine and locked down and unfortunately, we already are seeing the results. In February 2020 the Lancet published a review of 24 studies reviewing the psychological impact of quarantine. I will add a link at the bottom of this blog post to the Lancet review. In short, people quarantined are likely to develop a wide range of symptoms of psychological stress with emotional exhaustion, depression, and post-traumatic stress symptoms. Low mood and irritability specifically stand out as being very common, the study notes. The study noted that in cases where parents were quarantined with children, the mental health toll became even steeper. In one study, 28% of parents warranted a diagnosis of "trauma-related mental health disorder". According to the Lancet review, among quarantine hospital staff, almost 10% reported "high depressive symptoms" up to 3 years after being quarantined. Study reporting on long-term effects of SARS quarantine among healthcare workers noted long-term risk for alcohol abuse, self-medication, and long-lasting avoidance behavior; avoidance referring to hospital workers still avoiding being in close contact with the patients by simply not showing up for work.


Social media certainly does not help reduce the stress and, in some ways, fans the flames. For one, it brings information overload as we are all connected via social media distributing posts and Tweets to each other at all hours of the day or night. It makes it difficult to escape or decompress. It seems that there is constantly a new article or idea being thrown out on social media and often these contradict each other. (Insert harebrained conspiracy theory YouTube video here.) A point of major contention right now is the use and benefit of wearing masks in the general public. I have previously written blog articles regarding concern for recommendations set by the CDC for the general public to use simple cloth masks, which are not the same as the masks that are used in healthcare that have a vapor barrier. Now, however, we are seeing a whole new issue concerning masks in the community; that being the psychological aspect. People are getting into heated arguments and even physical fights with others because they are not wearing a mask or the other way around; arguments and fights over mask shaming. Social media is also charging the stress batteries as we get into debates over of what is the real risk of this pandemic compared to previous pandemics and people's opinions on whether we are taking this too seriously or not seriously enough.


It seems that everyone on Facebook is an expert in epidemiology and virology these days making it difficult to know what to believe. It does not help when certain elected public officials put out charged posts and Tweets that have the effect of causing mistrust in the real experts and encouraging people to ignore the warning bells that are being rung by the epidemiologists and medical community.

Perhaps doing something now to help mitigate the toxic psychological effects of COVID-19 lockdown itself is warranted. In the 1990s, France was one of the first countries to adopt a psychological treatment approach for the aftermath of terrorist attacks and disasters.

They set up psychological field units, a cellule d'Urgence Medico-psychologique or CUMPS. We have developed field hospitals for additional medical needs but we have not adequately set up a second tent for psychological needs. People are afraid to catch COVID-19 on the workforce floor and are already avoiding going to work when their employer is requesting a return. This absenteeism and burnout is certainly a concern for employers.


Just before the recent lockdown a benchmark survey in Belgium was performed which showed 32% of the population could be classified as highly resilient as labeled in green.

Only 15% of the population was suggested to have toxic levels of stress indicated below in red. A survey after 2 weeks of current lockdown in that community showed significant change. The green portion shrunk to 25% of the population and the red toxic stress population increased by 10 percentage points to 25% of the total population.



Furthermore, this increased stress significantly affects productivity. In a paper from 2017 referring to productivity losses in quarantine situations in Europe, even if people stay at work, there was a 35% productivity loss.


Insights into the long-term effects of disasters have been understood in the fields of trauma psychology for decades. Listed below is a graph describing adaptation response versus time with an initial disaster impact and then a second hit disaster impact.



These insights are not new but what is different with this coronavirus pandemic is in the scale of the lockdown. Previous evaluation and study of the psychological effects of quarantine have been on a much smaller scale. This is not a "ground zero" situation where a single village or town is quarantined. A third of the global population is dealing with this.

I keep saying to friends and family that this is the time to reinvent the wheel. Every level of industry should be searching for the opportunity in this difficulty. In my field of pulmonary medicine, we are seeing a lot more patients via telemedicine. This was something I was interested in offering patients and have been looking into the options for over the last 2 years, but the coronavirus has forced everyone to get on board. Every industry should take a close look at their workflows and policies to try to find a way of doing business in a meaningful way despite a need for social distancing. The school system certainly has a major opportunity here. For a long time, we have known that kids needed more sleep. Online learning classes could potentially start later so kids can simply get more sleep because they do not have to get up, get ready, and drive to school. Many kids get up extra early to get on the school bus on time. Being able to do education online could limit the number of kids in the classroom physically and staggering classes could have a meaningful effect. It is certainly more complicated than that given not all families have the ability for their kids to stay home to learn online, but again, now is the time to consider reinventing the wheel since the wheel is so broken.

From a psychological perspective, we should be doing things now to mitigate the effects of this pandemic and needed quarantine. We need to make sure that there are interventions in place that can address this need on a large scale. We need to aggressively educate people on the expected psychological impact and stress to them that these reactions are normal. We need to assure that people with acute issues can find the required help. We need to be able to do this in a manner that is consistent with needed social distancing. There are online options. A nonprofit organization called Be Strong was developed initially for empowering youth to prevent bullying in isolation and reduce suicide. This is an excellent online resource for adolescents and parents. Their website is https://bestrong.global. Another online option for mental health and specifically the coronavirus has been developed by the Global Healthy Living Foundation and is a good resource for psychological concerns specifically relating to the coronavirus pandemic. If you are looking for tips or advice in that regard this may be a good place to start. Their website can be found at https://www.ghlf.org/mental-health-coronavirus-support/?gclid=EAIaIQobChMI2uDApqXc6QIVzcDACh2lLw-8EAAYASAAEgLlVvD_BwE


At least that's my take on it,


Mark




https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext



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"Well done is better than well said"

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Dr. Mark Esterle, MD

Louisville Pulmonary Care, PLLC

(502) 899-7377

4003 Kresge Way #312, Louisville, KY 40207, USA

©2018 by Dr. Mark E. Esterle, MD.