"Pandemic fear" and COVID-19: mental health burden and strategies

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ARTICLE
‘‘Pandemic fear’’ and COVID-19: mental health burden and
strategies
Felipe Ornell,
1,2
0000-0001-8638-5842
Jaqueline B. Schuch,
1,2
0000-0001-8638-5842
Anne O. Sordi,
1
0000-0001-8638-5842
Felix Henrique Paim Kessler
1,2
0000-0001-8638-5842
1
Centro de Pesquisa em A
´lcool e Drogas, Hospital de Clı
´nicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS,
Brazil.
2
Programa de Po
´s-Graduac¸a
˜o em Psiquiatria e Cie
ˆncias do Comportamento, Departamento de Psiquiatria e Medicina Legal, Faculdade
de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
In the wake of the September 11 attack in the United
States and the Kiss Nightclub fire in Brazil, psychological
assistance task forces for victims and their families were
quickly organized. However, during pandemics it is com-
mon for health professionals, scientists and managers to
focus predominantly on the pathogen and the biological
risk in an effort to understand the pathophysiological
mechanisms involved and propose measures for prevent-
ing, containing and treating the disease. In such situations,
the psychological and psychiatric implications secondary
to the phenomenon, both on an individual and a collective
level, tend to be underestimated and neglected, generating
gaps in coping strategies and increasing the burden of
associated diseases.
1,2
Although infectious diseases have emerged at various
times in history, in recent years, globalization has facilita-
ted the spread of pathological agents, resulting in world-
wide pandemics. This has added greater complexity to
the containment of infections, which has had an important
political, economic and psychosocial impact, leading to
urgent public health challenges.
2-6
HIV, Ebola, Zika and
H1N1, among other diseases, are recent examples.
1
The coronavirus (COVID-19), identified in China at
the end of 2019, has a high contagion potential, and its
incidence has increased exponentially. Its widespread
transmission was recognized by the World Health Orga-
nization (WHO) as a pandemic. Dubious or even false
information about factors related to virus transmission,
the incubation period, its geographic reach, the number of
infected, and the actual mortality rate has led to insecurity
and fear in the population. The situation has been exacer-
bated due to the insufficient control measures and a lack
of effective therapeutic mechanisms.
5,7,8
These uncer-
tainties have had consequences in a number of sectors,
with direct implications for the population’s daily life and
mental health.
This scenario raises a number of questions: is there a
fear/stress pandemic concomitant with the COVID-19
pandemic? How can we evaluate this phenomenon?
To understand the psychological and psychiatric reper-
cussions of a pandemic, the emotions involved in it, such
as fear and anger, must be considered and observed.
Fear is an adaptive animal defense mechanism that is
fundamental for survival and involves several biological
processes of preparation for a response to potentially
threatening events. However, when it is chronic or dispro-
portionate, it becomes harmful and can be a key component
in the development of various psychiatric disorders.
9,10
In a
pandemic, fear increases anxiety and stress levels in
healthy individuals and intensifies the symptoms of those
with pre-existing psychiatric disorders.
11
During epidemics, the number of people whose mental
health is affected tends to be greater than the number of
people affected by the infection.
12
Past tragedies have
shown that the mental health implications can last longer
and have greater prevalence than the epidemic itself
and that the psychosocial and economic impacts can
be incalculable if we consider their resonance in different
contexts.
11,12
Since the economic costs associated with mental
disorders is high, improving mental health treatment
strategies can lead to gains in both physical health and
the economic sector. In addition to a concrete fear of
death, the COVID-19 pandemic has implications for other
spheres: family organization, closings of schools, compa-
nies and public places, changes in work routines, isolation,
leading to feelings of helplessness and abandonment.
Moreover, it can heighten insecurity due to the economic
and social repercussions of this large-scale tragedy.
During the Ebola outbreak, for example, fear-related
behaviors had an epidemiological impact both individually
and collectively during all phases of the event, increasing
the suffering and psychiatric symptom rates of the popu-
lation, which contributed to increases in indirect mortality
from causes other than Ebola.
13
Currently, ease of access
to communication technologies and the transmission of
sensational, inaccurate or false information can increase
harmful social reactions, such as anger and aggressive
behavior.
14
Diagnostic, tracking, monitoring and containment
measures for COVID-19 have been established in
several countries.
6
However, there are still no accurate
Correspondence: Felipe Ornell, Centro de Pesquisa em A
´lcool e
Drogas, HCPA/UFRGS, Rua Prof. A
´lvaro Alvim, 400, Bairro Rio
Branco, Porto Alegre, RS, Brazil.
E-mail: felipeornell@gmail.com
Submitted Mar 17 2020, accepted Mar 19 2020.
How to cite this article: Ornell F, Schuch JB, Sordi AO, Kessler FHP.
‘‘Pandemic fear’’ and COVID-19: mental health burden and strategies.
Braz J Psychiatry. 2020;00:000-000. http://dx.doi.org/10.1590/1516-
4446-2020-0008
Braz J Psychiatry. 2020 xxx-xxx;00(00):000-000
doi:10.1590/1516-4446-2020-0008
Brazilian Psychiatric Association
00000000-0002-7316-1185

epidemiological data on disease-related psychiatric impli-
cations or their impact on public health. A Chinese study
provided some insights in this regard. Approximately half
of the interviewees classified the psychological impact of
the epidemic as moderate to severe, and about a third
reported moderate to severe anxiety.
15
Similar data have
been reported in Japan, where the economic impact has
also been dramatic.
11
Another study reported that patients infected with
COVID-19 (or suspected of being infected) may experi-
ence intense emotional and behavioral reactions, such as
fear, boredom, loneliness, anxiety, insomnia or anger,
11
as
has been reported about similar situations in the past.
16
Such conditions can evolve into disorders, whether depres-
sive, anxiety (including panic attacks and post-traumatic
stress), psychotic or paranoid, and can even lead to
Box 1 Mental health recommendations during pandemics and large-scale disasters
Government actions:
- Encourage the participation of multidisciplinary mental health teams
at national, state and municipal levels
- Provide official channels for updated information to the public
- Training in stress management, trauma, depression and risk
behavior protocols
- Provide alternative service channels (apps, websites, telephone);
- Standardize psychotropic medications and make them available - Monitor and rebut fake news
- Ensure adequate resources and infrastructure for mental health
services
- Continuously encourage scientific research
- Ensure that clinical and mental health care are accessible to the
population
- Consider and respect cultural factors in the implementation of public
policies
- Develop psychoeducational materials that are easily accessible to
the population
- Collect epidemiological data that can support future prevention and
mental health care policies
Individual recommendations:
- Take care of yourself and others, keeping in touch with friends and
family and finding time for leisure activities
- Limit exposure to pandemic-related news, since too much
information can trigger anxiety disorders
- Follow WHO and government health agency recommendations - Tell someone when you experience symptoms of sadness or
anxiety
- Pay attention to your own needs, feelings and thoughts - Assist, as much as possible, people in risk groups
- Limit physical contact with other people while avoiding emotional
distance
- Share contamination prevention information and instructions
- Monitor dysphoric mental states such as irritability and aggression - Understand that stress and fear are normal in unknown situations
- Develop a feeling of belonging to the collective care process - Avoid confusing the solitude of preventive confinement with
abandonment, rejection or helplessness
- Consider the collective impact of your actions - Establish a support network (even if it is a virtual one)
- Consider the impact of social actions on stopping or decelerating the
disease
- Do not discriminate or blame groups or individuals for the
contamination process
- Do not disseminate information from unofficial sources - Maintain adequate sleep, nutrition and exercise patterns
- Practice meditation (mindfulness)
- Maintain normal use of prescription medications - Use positive psychiatry/psychology techniques
Care for special groups:
Children: Maintain family and leisure activities (games). Explain the
phenomenon in clear and accessible language; try to maintain the
routine (insofar as possible), be available to answer any questions
and understand that in such times children may be more irritable,
sensitive, attention-demanding and regressive (e.g. bedwetting). It
is important not to blame them for these behaviors: use a kind and
reassuring approach. Teach them to express disturbing feelings,
such as fear, in a positive way. Control the amount of information
they are exposed to so that they do not become even more
frightened. In case of quarantine, be creative, inventing games
(especially involving physical activity) to avoid tedium.
At-risk populations requiring quarantine (the immunodepressed,
older adults, etc.) and psychiatric patients: Help protect these
populations from contact with the pathogen, especially the most
vulnerable; pay special attention to them through phone/video
calls and social networks. Be available to help with tasks that
must be carried out in places of risk (e.g., shopping at the
supermarket). Maintain greater vigilance regarding symptoms
and guarantee every possible comfort when they are in isolation.
Help them adhere to clinical and psychiatric medication regimens
and provide emotional support.
Hospitals and health care referral centers:
- Establish a contingency plan and strategies for dealing with more serious psychiatric symptoms
- Establish a relationship of transparency and trust with employees that prioritizes equity and well-being
- Ensure adequate training for teams and provide support or supervision, which can be done in group settings
- Provide quality clinical and psychological assistance for teams exposed to risk situations
- Maintain an empathetic and flexible posture when facing the fears, stress and changes in routine common to such situations
- Ensure mental health care for the family members of people who may be affected by the pathogen
- Inform everyone that feelings such as fear, anxiety and sadness are normal at times like this and guide those who are seeking help
whenever necessary
- Ensure a healthy climate of communication and collaboration between professionals and teams, in addition to providing expert
intervention in interpersonal problems that may arise
- Constantly value the work of those who are exposing themselves to risk for the social good
Braz J Psychiatry. 2020;00(00)
2F Ornell et al.

suicide.
17,18
These conditions can be especially prevalent
in quarantined patients, whose psychological distress
tends to be higher.
16
In some cases, uncertainty about
infection and death or about infecting family and friends
can potentiate dysphoric mental states.
11,18
Even among patients with common flu symptoms,
stress and fear due to the similarity of the conditions can
generate mental distress and worsen psychiatric symp-
toms.
15,19
Despite the fact that the rate of confirmed vs.
suspected cases of COVID-19 is relatively low and that
the majority of cases are considered asymptomatic or
mild, as well as that the disease has a relatively low
mortality rate,
20,21
the psychiatric implications can be
significantly high, overloading emergency services and
the health system as a whole.
In conjunction with actions to help infected and qua-
rantined patients, strategies targeting the general popula-
tion and specific groups must be developed, including
health professionals who are directly exposed to the
pathogen and have high stress rates.
22
Although some
protocols for clinicians have been established, most
health professionals who work in isolation units and
hospitals are neither trained to provide mental health
assistance during pandemics
1,17
nor receive specialized
care. Previous studies have reported high rates of
anxiety and stress symptoms, as well as mental dis-
orders, such as post-traumatic stress, in this population
(especially among nurses and doctors), which reinforces
the need for care.
22,23
Other specific groups are especially vulnerable in
pandemics: older adults, the immunocompromised, patients
with previous clinical and psychiatric conditions, family
members of infected patients and residents of high-
incidence areas. In these groups, social rejection, discri-
mination, and even xenophobia are frequent.
17
Providing psychological first aid is an essential care
component for populations that have been victims of
emergencies and disasters, but there are no universal
protocols or guidelines for the most effective psychoso-
cial support practices.
24
Although some reports on local
mental health care strategies have been published, more
comprehensive emergency guidelines for such scenarios
are unknown,
1,17,19
since previous evidence refers only to
specific situations.
24
In Brazil, a large developing country
with pronounced social disparity, low education levels and
humanitarian-cooperative culture, there are no para-
meters for estimating the impact of this phenomenon on
the population’s mental health or behavior. Will it be
possible to implement effective preventive and emer-
gency actions aimed at the psychiatric implications of this
biological pandemic in broad spheres of society?
Specifically for this new COVID-19 scenario, Xiang
et al., suggest that three main factors should be
considered when developing mental health strategies:
1) multidisciplinary mental health teams (including
psychiatrists, psychiatric nurses, clinical psychologists
and other mental health professionals); 2) clear com-
munication involving regular, accurate updates on the
COVID-19 outbreak; and 3) establishing safe psycholo-
gical counseling services (for example, via electronic
devices or apps).
17
Finally, it is extremely necessary to implement public
mental health policies in conjunction with epidemic and
pandemic response strategies before, during and after the
event.
13
Mental health professionals, such as psycholo-
gists, psychiatrists and social workers, must be on the
front line and play a leading role in emergency planning
and management teams.
1
Assistance protocols, such as
those used in disaster situations, should cover areas
relevant to the individual and collective mental health of
the population. Recently, the WHO
25
and the U.S. Center
for Disease Control and Prevention
26
published a series
of psychosocial and mental health recommendations,
several of which are included in Box 1. This is in line with
longitudinal data from the WHO demonstrating that psy-
chological factors are directly related to the main causes
of morbidity and mortality in the world.
25
Thus, increased
investment in research and strategic actions for mental
health in parallel with infectious outbreaks is urgently
needed worldwide.
1
Disclosure
The authors report no conflicts of interest.
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