Content uploaded by Willem J Kop
Author content
All content in this area was uploaded by Willem J Kop on May 16, 2021
Content may be subject to copyright.
Downloaded from http://journals.lww.com/psychosomaticmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 05/06/2021
Downloadedfromhttp://journals.lww.com/psychosomaticmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 05/06/2021
Biopsychosocial Processes of Health and Disease
During the COVID-19 Pandemic
Willem J. Kop, PhD
ABSTRACT
The biopsychosocial model provides a useful perspective for understanding the development and characteristics of the COVID-19 pandemic
and its anticipated long-term consequences for society as well as individuals. This article provides a biopsychosocial perspective on the
COVID pandemic and an editorial comment on the articles in this Special Issue of Psychosomatic Medicine. Based on analysis of the PubMed
database, it isshown that the attention to psychological and social factors is 74% higher inCOVID-19-related articles compared to all other
health-related scientific articles published during the same time-period (between 1/1/2020 and 4/18/2021). Specifically, 18.6% of the
≈123,500 articles addressing COVID-19-related topics also included psychological or social factors in their content vs. 10.7% of articles
that did not address COVID-19. The biopsychosocial model is relevant to understanding the interrelationships among risk factors and the
multidimensional clinical and psychosocial COVID-19 outcomes. Clinical outcomes directly related to COVID-19 range from severe but
rare events (mortality and intensive care treatment) to less severe common outcomes such as positive screening tests for COVID-19 with or
without symptoms. In addition, psychosocial outcomes range in severity from frequently observed reduced psychological wellbeing to
less common clinical mood and anxiety disorders and, in rare cases, suicidality. The COVID-19 pandemic is characterized by an unusually
strong and short-term link between social factors and biological aspects of the disease, without mediating psychological factors. After a
review of the articles presented in this Special Issue, this editorial concludes with suggestions for biopsychosocial models in research
on COVID-19 and other large-scale health threats.
Key words: biopsychosocial, COVID-19, psychology, social factors, behavior, risk factors, corona virus, review.
The COVID-19 pandemic is characterized by strong interactions
among biological, psychological and social processes. The
biopsychosocial model (1) is therefore critically important to the
understanding of health risks and disease consequences of the
COVID-19 pandemic. Biopsychosocial approaches are also useful
to optimize preventive strategies targeting exposure and vulnerability
to COVID-19 as well as the development and improvement of
immediate and long-term interventions. These contributions can
take place at the population level and also in the treatment of
individuals infected with the virus. In this editorial, a perspective
is presented on: (1) the exponential growth in the published
scientific literature addressing the COVID-19 pandemic and its
social and psychological aspects; (2) the social, psychological,
and biological components of the biopsychosocial model as related
to COVID-19; and (3) a summary of the articles that appear in
this Special Issue of Psychosomatic Medicine on COVID-19.
The scientific literature addressing COVID-19-related issues
has grown exponentially since the emergence of the virus at the
end of 2019. The social and behavioral sciences have added signif-
icantly to this literature, including work from experts in psychoso-
matic medicine, health psychology, and behavioral medicine. To
illustrate the magnitude of the scientific contributions in this area,
the PubMed database was searched on the terms “(corona OR
covid)”, which revealed a total of approximately 123,500 articles
for the period from January 1, 2020, through April 18, 2021, indi-
cating that circa 7% of all ≈1,900,000 biomedical scientific publi-
cations in that period have in some way addressed the COVID-19
pandemic. Limiting this search to articles that also address social
or psychological factors (i.e., adding “AND (psychol* OR social*)”
to the search terms) resulted in a total of 22,944 remaining articles,
suggesting that more than 1 in 6 (18.6%) articles about COVID-19
also included psychological or sociological content. This is substan-
tially higher (i.e., 74%) than the number of papers with a focus on
social or psychological factors included in the PubMed database
that did not address COVID-19-related issues (about 1 in 10) in
the same time period (212,219/(1,900,000–123500) = 10.7%).
However, specific mention of the biopsychosocial perspective
was relatively rare, with only 81 articles mentioning the term in
the title or abstract and 16 in the title (e.g., (2,3)), which can be used
as an overall index of how central the topic was in the article. These
numbers, although not reflecting a formal literature search, indicate
that the behavioral and social sciences have added substantially
From the Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands; Center of Research on Psychology and Somatic
diseases (CoRPS), Tilburg, the Netherlands.
Address correspondence to Willem J. Kop, PhD, Department of Medical and Clinical Psychology P.O. Box 90153 5000 LE Tilburg the Netherlands.
E-mail: w.j.kop@tilburguniversity.edu
Received for publication April 23, 2021; revision received April 27, 2021.
DOI: 10.1097/PSY.0000000000000954
Copyright © 2021 by the American Psychosomatic Society
COVID = corona virus disease, PTSD = post-traumatic stress
disorder
EDITORIAL COMMENT
Psychosomatic Medicine, V 83 •304-308 304 May 2021
Copyright © 2021 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
to the scientific literature on the COVID-19 pandemic and that a
biopsychosocial perspective might add important insights into
the prevention and treatment of the short-term disease complica-
tions and its long-term consequences.
Figure 1 presents a conceptual model based on biopsychosocial
research over the past 50 years since the term was coined by
Dr. George L. Engel in 1977 (1) and incorporating recent work
on the social and psychological factors that play a role in the
COVID-19 pandemic. The biopsychosocial factors displayed in
the left part of the figure result in exposure and vulnerability factors
for adverse COVID-19 outcomes. The clinical COVID-19 outcomes
(middle part) range from relatively rare severe disease manifestations
such as mortality and intensive care treatment, to more common
and less severe outcomes (e.g., a positive screening test for
COVID-19 with or without signs or symptoms of infection). The
psychosocial outcomes also range in severity from relatively rare
events (e.g., suicidality (4)) to clinical psychological outcomes
such as mood and anxiety disorders (5), poor sleep (6), burnout
and exhaustion (particularly among health care workers) (7), to
very common but less severe outcomes (e.g., high levels of
perceived stress and reduced psychological well-being) (see also
articles in this issue of the journal). Psychological outcomes of
COVID-19 can further increase the risk or severity of its clinical
manifestations. The COVID-19 pandemic is not limited to short-term
consequences; it is increasingly clear that adverse long-term effects
can be expected (right part of the figure), which also have biological,
psychological and social aspects. These include adverse economic
consequences at the societal and individual level, including
increased socioeconomic disparities, reduced education (8) and
employment opportunities (9), post stress-related psychological
disorders and symptoms (10) and, importantly, post-viral infection
symptoms (11,12) (e.g., fatigue, poor sleep, respiratory problems,
cognitive problems such as poor concentration, memory, and
sustained attention).
Social factors are associated with adverse COVID-19 outcomes
(13,14). The effects of these social factors on the likelihood of
contracting COVID-19 infection and worse clinical outcomes are
unusually strong and short-term, in contrast to most other contexts
in which the link between social factors and the manifestation of
disease outcomes typically takes years to decades. Large-scale
(macro) social factors (e.g., laws and regulations) have direct
consequences for the biological aspects of the infectious disease,
including virus exposure, individual exposure and access to optimal
medical care. National and local governments play essential roles
in preventive strategies, vaccination programs, and resource
allocations to hospitals and other health care facilities (see
Figu re 1). There is an increasing need for international collaboration
in areas such as travel, trade, production and access to vaccines,
information exchange, and other areas to reduce the threats associated
with the COVID-19 pandemic. In addition, the standard application
of the biopsychosocial model focuses on the “per level”approach
linking the various levels of the model, for example, factors at the
social level are assumed to influence factors at the individual
psychological and behavioral level and these individual factors
in turn influence the individual’s biological processes. However,
the COVID-19 pandemic is characterized by unusually strong
and short-term links between societal factors to biological factors
relevant to disease vulnerability, thereby partly ‘skipping’the
step of mediation via individual psychological factors. The role
of behavioral factors (e.g., physical or social distancing and
FIGURE 1. The biopsychosocial model as related to clinical and psychosocial outcomes of COVID-19. The left part shows the social,
psychological and biological components of the biopsychosocial model, the middle part displays the COVID-19 clinical and
psychological outcomes, with rare events at the top of the triangles and more common events at the base. The right part displays the
long-term outcomes after the acute phase of COVID-19 has passed (see text for additional details).
Biopsychosocial Factors and COVID-19 Outcomes
Psychosomatic Medicine, V 83 •304-308 305 May 2021
Copyright © 2021 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
other COVID-19 protective behaviors) in this context is critically
important and is related to social, cultural, and individual
personality factors (see Hall et al. in this issue of Psychosomatic
Medicine (15).
Psychological factors are part of the individual “person”level
of the biopsychosocial model (1), including experiences (e.g.,
affect and cognitions) and behaviors. The COVID-19 pandemic
is associated with perceived threat, experiences of loss, loneliness/
social isolation and lack of control. These individual psychological
experiences can lead to outcomes ranging from elevated levels of
general psychological distress and reduced well-being to severe
psychopathology and suicidality (4). These psychological outcomes
can be a reaction to having COVID-19 (Figure 1, middle part), but
more often result from the multiple macro-social consequences of
COVID-19 which have had a substantial impact on smaller social
groups (i.e., schools, universities, religious groups, professional and
non-professional associations, etc.), families and groups of close
friends (i.e., the link between biopsychosocial factors with
COVID-19 outcomes in Figure 1). For example, government-based
interventions to curtail the COVID-19 pandemic involve major
changes to societal processes, including restrictions on social
behavior, “lockdowns”, curfews, closing of businesses, reduction
of public transportation and (international) travel. These government-
based interventions can result in psychological distress because
of their direct consequences on daily life and also because they
are sometimes not consistent with the legal rights or usual customs
of individuals and groups and enforced by short-term laws and
regulations that might not have gone through the usual evaluation
processes. Adverse COVID-19-related psychosocial outcomes can
additionally be exacerbated by individual psychological
vulnerability factors such as personality, early life adversity, and
genetic factors. The long-term consequences of social isolation
following government-initiated regulations (e.g., lack of visitors
in nursing homes, restriction to the home in families where
violence is a problem), and job loss are difficult to quantify at
this stage, but are likely to resonate for a long time. The
psychological outcomes of the COVID-19 pandemic also include
non-social factors, such as perceived threat related to fear of becoming
infected, distress associated with actually contracting the disease,
and worries about long-term post-COVID-19 disease-related
factors such as fatigue or other persisting symptoms and cognitive
problems (i.e., post-viral syndromes).
Behavioral factors play an important role in COVID-19, at
the individual “person level”as well as “higher”levels of the
biopsychosocial model (i.e., the behaviors of family members,
friends, and larger groups; for a review see (15)). Two behavioral
domains are particularly relevant to COVID-19. In the first place,
behaviors specific to COVID-19 including social distancing,
minimizing travel, adhering to protective measures such as
wearing masks and hand washing, staying home and/or getting
tested when symptomatic, and getting vaccinated. These behav-
iors are critically important in pandemics as they influence ex-
posure to and spreading of the virus. Individual differences in
these behaviors depend on social, cultural and psychological
factors. A second domain of COVID-19-relevant behaviors in-
cludes health-related behaviors such as smoking, poor dietary
habits and suboptimal weight management, and overuse of al-
cohol and/or other substances. Evidence also suggests that be-
haviors such as physical activity and adequate sleep can
reduce the risk of COVID-19 as they have beneficial effects
on the biology of the disease.
The biological processes involved in COVID-19 are complex
and described in more detail elsewhere (15). In brief, the virus
responsible for the COVID-19 pandemic, the severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), is unusually contagious
and can result in severe and life-threatening conditions, primarily
affecting the respiratory system. However, the occurrence of clinically
severe outcomes is relatively rare compared to other high-risk
viral epidemics, and the main threat is the spread of the disease
and the lack of sufficient hospital capacity to treat the number of
patients that end up developing life-threatening conditions.
High-risk groups for adverse COVID-19 progression include
individuals with low socioeconomic resources, minority groups,
individuals with chronic medical conditions, including diabetes
mellitus, individuals with obesity, among others. In addition to
these general risk factors, psychoneuroimmunology research has
shown that high levels of psychological distress are associated
with impaired functioning of the immune system (16) and autonomic
nervous system dysregulation (5). Systematic laboratory research
by Cohen and colleagues found that, when young adults are
exposed to a cold or influenza virus that typically causes respiratory
complaints, those with high levels of psychological distress, current
smokers, and individuals with suboptimal intake of vitamin C,
experienced more respiratory problems when monitored in
quarantine (in groups of participants) for up to 6 days (17). In
contrast, usual physical activity levels, adequate and efficient
sleep, moderate alcohol intake, social integration, and perceived
social support were associated with a lower risk of respiratory
problems (17). Of particular relevance to COVID-19 is the
reduced anti-viral response among individuals with depression
or other psychological conditions associated with high levels of
distress (18). Furthermore, evidence has shown that psychological
distress may adversely affect the response to vaccines (19,20), but
current evidence supporting benefits of psychological interventions
to enhance the antibody response to vaccination is limited (21).
The role of genetic factors and gene-environment interactions in
this context still needs systematic investigation.
In this special issue of Psychosomatic Medicine, a series of ar-
ticles is presented in which biopsychosocial risk factors and out-
comes of COVID-19 play a central role. Hall and colleagues (15)
provide a comprehensive review of the biological characteristics of
COVID-19 and discuss critical behavioral aspects of exposure and
vulnerability to adverse clinical outcomes. The authors summarize
critical evidence supporting the association of affective, cognitive,
behavioral, and socioeconomic factors with the spread of infection,
response precautions, and outcomes of government-based
“mitigation measures.”Individuals living with severe mental
illness and/or chronic medical diseases are at high risk of adverse
outcomes, and the authors show that technological innovations
might prove useful in improving outcomes and reducing COVID-
19-related risks. In a cross-sectional study by Wang and colleagues
(22) the affective consequences of COVID-19 are documented in
Wuhan, China, where the first major adverse consequences of
the COVID-19 pandemic occurred. This team, being at the core
of the early phases of the pandemic, documented that participants
from Wuhan had a higher prevalence of mental health problems
compared to participants from other parts of China (46.6% vs.
32.2%; covariate-adjusted odds ratio (OR) = 1.89, 95% confidence
EDITORIAL COMMENT
Psychosomatic Medicine, V 83 •304-308 306 May 2021
Copyright © 2021 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
interval (CI) = 1.65–2.17), with the highest risk for anxiety (15.2% vs.
6.2%; OR = 2.65, 95%CI = 2.14–3.29) and depression (18.3% vs.
9.7%; OR = 2.11, 95%CI = 1.74–2.54). The prevalence of suicidal
ideation during the COVID-19 epidemic in Wuhan was 10.5%.
Only 7.1% of participants reported seeking help for mental
health issues and 3.5% received treatment. Results from the UK
revealed consistent findings, as shown by Pieh and colleagues
(23), with more mental health problems in individuals younger
than 35 years, women, people with no work, and people with
low income. During COVID-19, several groups are at high risk
of mental health problems, and Bo and colleagues (24) showed
that pregnancy was associated with high levels of depression,
particularly among women who experienced delays in prenatal
care as a consequence of COVID-19-related limitations in prenatal
care resources. Jowett et al. (25) found that of the post-traumatic
symptom clusters that develop in response to COVID-19, a
sense of threat was most strongly related to somatic complaints.
The association between post-traumatic stress disorder (PTSD)
and psychophysiological risk factors is addressed in a study by
Ginty and colleagues (26). This intriguing study found that heart
rate reactivity to a mental challenge task predicted subsequent
PTSD symptoms of intrusion and hyperarousal, but not avoidance,
whereas no associations with blood pressure reactivity were found.
Bourassa et al. (27) used novel technologies (large-scale GPS
tracking) to determine the effects of government-issued stay-at-
home orders on physical movement (i.e., remaining within 1 mile
of home and overall vehicle miles driven per day). It was found
that these orders resulted in corresponding changes in mobility,
but the magnitude of these changes was relatively minor. Willroth
et al. (28) showed that the personality factor agreeableness was
associated with compliance to government-issued behavioral
guidelines.
The studies in this Special Issue mentioned so far focused on
individuals in the general population. When examining patients
admitted for clinically severe COVID-19 in Wuhan, Li et al. (29)
found high levels of anxiety (56.3%) and depression (39.3%),
with female sex, widowhood, and COVID-19 disease duration as
potential risk factor for both conditions. In addition to patients
with COVID-19, health care workers who take care of severely
ill patients also experience reduced psychological well-being and
a higher prevalence of psychological disorders, possibly resulting
from high levels of psychological strain. Wang et al. (30) found
that acute stress disorder is common (38.3%) among health
professionals in Wuhan. Acute stress disorder was also associated
with physical symptoms (30). High levels of psychological
distress were also reported in primary care physicians during the
peak of the COVID-19 epidemic in Chengdu city, province of
Sichuan, China as shown by Zeng et al. (31). High levels of
distress were related to perceived low preparedness and high
levels of work and personal life impact. A systematic review of
35 articles by Yan et al. (32) covering data from 25,343 health
care professionals indicated that fear-related symptoms (67%)
and high levels of perceived stress (56%) were the most commonly
reported psychological problems, followed by anxiety symptoms
(41%), insomnia (41%), post-traumatic stress disorder symptoms
(38%), depressive symptoms (27%), and somatic symptoms (16%).
In aggregate, the findings reported in this Special Issue of
Psychosomatic Medicine indicate a high prevalence of mental
health and other psychosocial problems during the COVID-19
pandemic, particularly among young adults and individuals with
low socioeconomic resources in the general population, patients
hospitalized with COVID-19 symptoms, and (frontline) health
care professionals. Anxiety and a sense of COVID-19 related
threat may increase the risk of developing somatic symptoms in
general, and possibly corona virus infection-related symptoms.
Elevated autonomic nervous system responsiveness to mental
stressors may further increase the risk of developing mental health
problems. Individuals who experience mental health problems
during the COVID-19 pandemic may also have an increased risk
of developing long-term post-COVID-19 adverse mental and
physical health outcomes and future studies are needed to evaluate
whether these high-risk groups could benefit from early intervention
programs.
This selective review highlights the importance of the
biopsychosocial model in optimizing the response to the COVID-19
pandemic. Although this model has been criticized as being too
vague, insufficiently specific on how the three main factors of
the model interact, and inadequately considering an individual’s
subjective/personal experiences (e.g., (33)), the biopsychosocial
model remains a valuable alternative to the biomedical model it
intended to expand upon (34). In addition, models focusing on
social and structural determinants of health (e.g., as proposed by
the World Health Organization) could be considered as additional
perspectives on the COVID-19 pandemic because they are more
explicit about macro-social factors. However, the biopsychosocial
model also specifically addresses these “higher order”
socioeconomic and cultural levels in addition to the biological,
psychological and social factors mentioned in this article. For
example, it is possible that collectivistic cultures and also countries
with a relative totalitarian government structure are better equipped
than individualistic cultures and democratically organized countries
to efficiently respond to the social challenges related to a large-scale
infectious epidemic such as COVID-19. At the biosphere level—i.e.,
the “top level”of the biopsychosocial model—it has been found
that air pollution was reduced at the peak of lockdown and travel
restriction (35). The COVID-19 pandemic has created enormous
suffering worldwide, causing high levels of distress, substantial
societal, and individual disease burden, and already over
3 million deaths in the 15 months after the report of the first
cases in December 2019. Despite the clearly devastating effects,
there have also been a few positive points related to the COVID-19
pandemic (36), including the increased use of the internet for social
communication and connectedness (37) and major advances in the
application and progress of telecommunication, telemedicine, and
telemonitoring (for example, (38)). These positive aspects also
have biopsychosocial underpinnings and are essential in promoting
resilience at the societal and individual level. Research methods
other than cross-sectional designs are needed to unravel the role of
biopsychosocial processes in large-scale public health threats. The
behavioral subcomponent of the biopsychosocial model is of
particular importance in infectious disease pandemics (see Figure 1),
The negative consequences of the COVID-19 pandemic far
outweigh the positive ones and the major effects of psychosocial
factors, such as social isolation, on health make it clear that the
biomedical model is not sufficient to fully understand patterns of
health and well-being, illness and disease risks. Social and
psychological determinants of health are increasingly incorporated
in the diagnosis and treatment of diseases in clinical care settings,
Biopsychosocial Factors and COVID-19 Outcomes
Psychosomatic Medicine, V 83 •304-308 307 May 2021
Copyright © 2021 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
and the COVID-19 pandemic will likely accelerate the attention
paid to biopsychosocial factors in routine health care. It is likely
that the COVID-19 pandemic will have long-term adverse outcomes
and not be the last infectious large-scale health challenge that
requires an integrated global response. The present experiences and
scientific findings emphasizing the importance of biopsychosocial
factors in COVID-19 should help preparedness and effective
responsiveness to future large-scale health threats.
Dr. Deborah N. Ader provided very helpful suggestions on an
earlier version of this paper.
Source of Funding and Conflicts of Interest: The present re-
search was supported by the Dutch Research Council, The Hague,
the Netherlands (project NWO # 440.20.039). The author reports
no conflicts of interest.
REFERENCES
1. Engel GL. The need for a new medical model: A challenge for biomedicine. Sci-
ence 1977;196:129–36.
2. Chigangaidze RK. Risk factors and effects of the morbus:COVID-19 through the
biopsychosocial model and ecological systems approach to social work practice.
Soc Work Public Health 2021;36:98–117.
3. Leonardi M, Lee H, van der Veen S, Maribo T, Cuenot M, Simon L, Paltamaa J,
Maart S, Tucker C, Besstrashnova Y, Shosmin A, Cid D,Almborg AH, AnttilaH,
Yamada S, Frattura L, Zavaroni C, Zhuoying Q, Martinuzzi A, Martinuzzi
M, Magnani FG, Snyman S, El Oumri AA, Sylvain N, Layton N, Sykes C,
Saleeby PW, Winkler AS, de Cam argo OK. Avoiding the ban ality of evil in times
of COVID-19: Thinking differently with a biopsychosocial perspective for future
health and social policies development. SN Compr Clin Med 2020;1–3.
4. Banerjee D, Kosagishara f JR, Sathyanarayana Rao TS. ‘The dual pandemic’of sui-
cide and COVID-19: A biopsychosocial narrative of risks and prevention. Psychia-
try Res 2021;295:113577.
5. Dedoncker J,Vanderhasselt MA, Ottaviani C, Slavich GM. Mental health during
the COVID-19 pandemic and beyond: The importance of the vagus nerve for
biopsychosocial resilience. Neurosci Biobehav Rev 2021;125:1–10.
6. Dzierzewski JM, Dautovich ND, Ravyts SG, Perez E, Soto P, Donovan EK. Insom-
nia symptoms during the COVID-19 pandemic: An examination of biopsyc hosocial
moderators. Sleep Med 2021. doi: 10.1016/j.sleep.2021.02.018.
7. Sanghera J, Pattani N, Hashmi Y, Varley KF, Cheruvu MS, Bradley A, Burke JR.
The impact of sars-cov-2 on the mental health of healthcare workers in a hospital
setting-a systematic review. J Occup Health 2020;62:e12175.
8. The Lancet. COVID-19: The intersection of education and health. Lancet 2021;
397:253.
9. Rosén M, Stenbeck M. Interventions to suppress the coronavirus pandemic will
increase unemployment and lead to many premature deaths. Scand J Public Health
2021;49:64–8.
10. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, Chen-Li D, Iacobucci M,
Ho R, Majeed A, McIntyre RS. Impact of COVID-19 pandemic on mental health
in the general population: A systematic review. J Affect Disord 2020;277:55–64.
11. Writing Committee for the COMEBAC Study Group, Morin L, Savale L, Pham T,
Colle R, Figueiredo S, Harrois A, Gasnier M, Lecoq AL , Meyrignac O, Noel N,
Baudry E, Bellin MF, Beurnier A, Choucha W, Corruble E, Dortet L, Hardy-Leger
I, Radiguer F, Sportouch S, Verny C, Wyplosz B, Zaidan M, Becquemont L,
Montani D, Monnet X. Four-month clinical status of a cohort of patients after hos-
pitalization for COVID-19. JAMA 2021;325:1525–34.
12. Huang C, HuangL, Wang Y, Li X, Ren L, Gu X, Kang L, GuoL, Liu M, Zhou X,
Luo J, Huang Z, Tu S, Zhao Y, Chen L, Xu D, Li Y, Li C, Peng L, Li Y, Xie W,
Cui D, Shang L, Fan G, Xu J, Wang G, Wang Y, Zhong J, Wang C, Wang
J, Zhang D, Cao B. 6-month consequences of COVID-19 in patients
discharged from hospital: A cohort study. Lancet 2021;397:220–32.
13. Mishra V, Seyedzenouzi G, Almohtadi A, Chowdhury T, Khashkhusha A, Axiaq
A, Wong WYE, Harky A. Health inequalities during COVID-19 and their effects
on morbidity and mortality. J Healthc Leadersh 2021;13:19–26.
14. Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lock-
downs: A review and meta-analysisof longitudinal studies and natural experiments.
Psychol Med 2021;51:201–11.
15. Hall PA, Sheeran P, Fong GT, Cheah CSL, Oremus M, Liu-Ambrose T, Sakib
MN, Butt Z, Ayaz H, Jandu N, Morita PP. Biobehavioral aspects of the
COVID-19 pandemic: A review. Psychosom Med 2021;83:309–21.
16. Miller G, Chen E, Cole SW. Health psychology: Developing biologically plausi-
ble modelslinking the social world and physicalhealth. Annu Rev Psychol 2009;
60:501–24.
17. Cohen S. Psychosocial vulnerabilities to upper respiratory infectious illness: Im-
plications for susceptibility to coronavirus disease 2019 (COVID-19). Perspect
Psychol Sci 2021;16:161–74.
18. Slavich GM, Irwin MR. From stress to inflammation and major depressive disor-
der: A soc ial signal t ransduct ion theor y of depression. Psych ol Bull 2014;140:
774–815.
19. Glaser R,Sheridan J, MalarkeyWB, MacCallum RC, Kiecolt-GlaserJK. Chronic
stress modulates the immune response to a pneumococcal pneumonia vaccine.
Psychosom Med 2000;62:804–7.
20. Madison AA, Shrout MR, Renna ME, Kiecolt-Glaser JK. Psychological and be-
havioral predictors of vaccine efficacy: Considerations for COVID-19. Perspect
Psychol Sci 2021;16:191–203.
21. Vedhara K, Ayling K, Sunger K, Caldwell DM, Halliday V, Fairclough L, Avery
A, RoblesL, Garibaldi J, Welton NJ, RoyalS. Psychologicalinterventions asvac-
cine adjuvants: A systematic review. Vaccine 2019;37:3255–66.
22. Wang Q, Feng H, Wang M, Xie Y, Hou B, Lu X, LiuZ, Ouyang K, Zhang R, Cai
Q, Xu Z, Li H, Chao H, Yang X, Hong Y, Hu X, Liu Z, Liu Y. Mental health and
psychological responses during the coronavirus disease 2019 (COVID-19) epi-
demic: A comparison between wuhan and other areas in China. Psychosom Med
2021;83:322–7.
23. PiehC,BudimirS,DelgadilloJ,BarkhamM,FontaineJRJ,ProbstT.Mental
health during COVID-19 lockdown in the united kingdom. Psychosom Med
2021;83:328–37.
24. BoHX,YangY,ChenJ,ZhangM,ZhangDY,LiY,LiR,CheungT,NgCH,Wu
XJ, Xiang YT. Prevalence of depressive symptoms among pregnant and postpar-
tum womenin China during the COVID-19 pandemic. PsychosomMed 2021;83:
345–50.
25. JowettS, Shevlin M, Hyland P, Karatzias T. Posttraumatic stressdisorder and per-
sistent somatic symptoms during the COVID-19 epidemic: The role of sense of
threat. Psych osom Med 2021; 83:338–44.
26. Ginty AT, Young DA, Tyra AT, Hurley PE, Brindle RC, Williams SE. Heart rate
reactivity to acute psychological stress predicts higher levels of ptsd symptoms
during the COVID-19 pandemic. Psychosom Med 2021;83:351–7.
27. Bourassa KJ. State-level stay-at-home orders and objectively measured move-
ment in the united states during the COVID-19 pandemic. Psychosom Med
2021;83:358–62.
28. Willroth EC, SmithAM, Shallcross AJ, Graham EK, MroczekDK, Ford BQ. The
health behavior model of personality in the context of a public health crisis.
Psychosom Med 2021;83:363–7.
29. Li T, Sun S, Liu B,Wang J, ZhangY, GongC, Duan J. Prevalenceand risk factors
for anxiety and depression in patients with COVID-19 in Wuhan, China.
Psychosom Med 2021;83:368–72.
30. WangY,DuanZ,PengK,LiD,OuJ,WilsonA,WangN,SiL,ChenR.Acute
stress disorder among frontline health professionals during the COVID-19 outbreak:
A structural equation modelling investigation. Psychosom Med 2021;83:373–9.
31. Zeng X, PengT, Hao X, ZouC, Lin K, Liao X, Chen S,Hayhoe B. Psychological
distress reported by primary-care physicians in China during the COVID-19 pan-
demic. Psychosom Med 2021;83:380–6.
32. Yan H, Ding Y, Guo W. Mental health of medical staff during the coronavirus
disease 2019 (COVID-19) pandemic: A systematic review and meta-analysis.
Psychosom Med 2021;83:387–96.
33. Haslam SA, Haslam C, Jetten J,Cruwys T, Bentley SV. Rethinking the nature of
the person at the heart of the biopsychosocial model: Exploring social changeways
not just per sonal pathw ays. Soc Sci Med 2 021;272:113566.
34. Kar unamuni N, Ima yama I, Goonetilleke D. P athways to well -being: Unt angling
the causal relationships among biopsychosocial variables. Soc Sci Med 2021;
272:112846.
35. Lu D, ZhangJ, Xue C, Zuo P,Chen Z, Zhang L, Ling W, Liu Q, Jiang G. COVID-
19-inducedlockdowns indicate the short-term control effect of air pollutant emis-
sion in 174 cities in China. Environ Sci Technol 2021;55:4094–102.
36. Ha KM. The reliance on positive impacts of COVID-19 outbreak for psycholog-
ical mitiga tion. Psychosom Med 2 021;83:398–9.
37. Dezecache G, Frith CD, Deroy O. Pandemics and the great evolutionary mis-
match. Curr Biol 2020;30:R417–9.
38. Tretter F, Wolkenhauer O, Meyer-Hermann M, Dietrich JW, Green S, Marcum J,
Weckwerth W. The quest for system-theoretical medicine in the COVID-19 era.
Front Med (Lausanne) 2021;8:640974.
EDITORIAL COMMENT
Psychosomatic Medicine, V 83 •304-308 308 May 2021
Copyright © 2021 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
