The NEW ENGLA ND JOURNAL of MEDICINE

Perspective 

Mental Health and the Covid-19 Pandemic

Betty Pfefferbaum, M.D., J.D., and Carol S. North, M.D., M.P.E.​​

U
Mental Health and the Covid-19 Pandemic
ncertain prognoses, looming severe shortages struction, a primary concern is
of resources for testing and treatment and post-traumatic stress disorder
(PTSD) arising from exposure to
for protecting responders and health care trauma. Medical conditions from
providers from infection, imposition of unfamiliar natural causes such as life-threat-
ening viral infection do not meet
public health measures that in- effects may translate into a range the current criteria for trauma re-
fringe on personal freedoms, large of emotional reactions (such as quired for a diagnosis of PTSD,1
and growing financial losses, and distress or psychiatric conditions), but other psychopathology, such
conflicting messages from author- unhealthy behaviors (such as ex- as depressive and anxiety disor-
ities are among the major stress- cessive substance use), and non- ders, may ensue.
ors that undoubtedly will con- compliance with public health Some groups may be more vul-
tribute to widespread emotional directives (such as home confine- nerable than others to the psy-
distress and increased risk for ment and vaccination) in people chosocial effects of pandemics. In
psychiatric illness associated with who contract the disease and in particular, people who contract the
Covid-19. Health care providers the general population. Extensive disease, those at heightened risk
have an important role in address- research in disaster mental health for it (including the elderly, people
ing these emotional outcomes as has established that emotional dis- with compromised immune func-
part of the pandemic response. tress is ubiquitous in affected pop- tion, and those living or receiving
Public health emergencies may ulations — a finding certain to care in congregate settings), and
affect the health, safety, and well- be echoed in populations affect- people with preexisting medical,
being of both individuals (caus- ed by the Covid-19 pandemic. psychiatric, or substance use prob-
ing, for example, insecurity, con- After disasters, most people lems are at increased risk for
fusion, emotional isolation, and are resilient and do not succumb adverse psychosocial outcomes.
stigma) and communities (owing to psychopathology. Indeed, some Health care providers are also par-
to economic loss, work and school people find new strengths. Never- ticularly vulnerable to emotional
closures, inadequate resources for theless, in “conventional” natural distress in the current pandemic,
medical response, and deficient disasters, technological accidents, given their risk of exposure to
distribution of necessities). These and intentional acts of mass de- the virus, concern about infecting

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PERS PE C T IV E Mental Health and the Covid-19 Pandemic

and caring for their loved ones, with quarantine to reduce the risk appropriately normalized by pro-
shortages of personal protective of infecting others and to protect viding information about usual
equipment (PPE), longer work the community’s health, emotion- reactions to this kind of stress
hours, and involvement in emo- al distress tempted some to con- and by pointing out that people
tionally and ethically fraught re- sider violating their orders.3 can and do manage even in the
source-allocation decisions. Pre- Opportunities to monitor psy- midst of dire circumstances.
vention efforts such as screening chosocial needs and deliver sup- Health care providers can offer
for mental health problems, psy- port during direct patient en- suggestions for stress manage-
choeducation, and psychosocial counters in clinical practice are ment and coping (such as structur-
support should focus on these greatly curtailed in this crisis by ing activities and maintaining rou-
and other groups at risk for ad- large-scale home confinement. tines), link patients to social and
verse psychosocial outcomes. Psychosocial services, which are mental health services, and coun-
Beyond stresses inherent in increasingly delivered in primary sel patients to seek professional
the illness itself, mass home-con- care settings, are being offered mental health assistance when
finement directives (including stay- by means of telemedicine. In the needed. Since media reports can
at-home orders, quarantine, and context of Covid-19, psychosocial be emotionally disturbing, contact
isolation) are new to Americans assessment and monitoring should with pandemic-related news
and raise concern about how include queries about Covid-19– should be monitored and limit-
people will react individually and related stressors (such as expo- ed. Because parents commonly
collectively. A recent review of psy- sures to infected sources, infected underestimate their children’s dis-
chological sequelae in samples of family members, loss of loved tress, open discussions should be
quarantined people and of health ones, and physical distancing), encouraged to address children’s
care providers may be instructive; secondary adversities (economic reactions and concerns.
it revealed numerous emotional loss, for example), psychosocial ef- As for health care providers
outcomes, including stress, de- fects (such as depression, anxiety, themselves, the novel nature of
pression, irritability, insomnia, psychosomatic preoccupations, in- SARS-CoV-2, inadequate testing,
fear, confusion, anger, frustration, somnia, increased substance use, limited treatment options, in-
boredom, and stigma associated and domestic violence), and indi- sufficient PPE and other medical
with quarantine, some of which cators of vulnerability (such as supplies, extended workloads,
persisted after the quarantine was preexisting physical or psycholog- and other emerging concerns are
lifted. Specific stressors included ical conditions). Some patients sources of stress and have the
greater duration of confinement, will need referral for formal men- potential to overwhelm systems.
having inadequate supplies, dif- tal health evaluation and care, Self-care for providers, including
ficulty securing medical care and while others may benefit from mental health care providers, in-
medications, and resulting finan- supportive interventions designed volves being informed about the
cial losses.2 In the current pan- to promote wellness and enhance illness and risks, monitoring one’s
demic, the home confinement of coping (such as psychoeducation own stress reactions, and seeking
large swaths of the population or cognitive behavioral tech- appropriate assistance with per-
for indefinite periods, differences niques). In light of the widening sonal and professional responsi-
among the stay-at-home orders is- economic crisis and numerous bilities and concerns — including
sued by various jurisdictions, and uncertainties surrounding this professional mental health inter-
conflicting messages from gov- pandemic, suicidal ideation may vention if indicated. Health care
ernment and public health au- emerge and necessitate immedi- systems will need to address the
thorities will most likely intensi- ate consultation with a mental stress on individual providers and
fy distress. A study conducted in health professional or referral for on general operations by monitor-
communities affected by severe possible emergency psychiatric ing reactions and performance,
acute respiratory syndrome (SARS) hospitalization. altering assignments and sched-
in the early 2000s revealed that al- On the milder end of the psy- ules, modifying expectations, and
though community members, af- chosocial spectrum, many of the creating mechanisms to offer psy-
fected individuals, and health care experiences of patients, family chosocial support as needed.
workers were motivated to comply members, and the public can be Given that most Covid-19 cas-

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PE R S PE C T IV E Mental Health and the Covid-19 Pandemic

es will be identified and treated needs of special populations, and Disclosure forms provided by the au-
thors are available at NEJM.org.
in health care settings by workers death notification and bereave-
with little to no mental health ment care. Risk-communication From the Department of Psychiatry and Be-
training, it is imperative that as- efforts should anticipate the com- havioral Sciences, College of Medicine, Uni-
sessment and intervention for plexities of emerging issues such versity of Oklahoma Health Sciences Cen-
ter, Oklahoma City (B.P.); and the Altshuler
psychosocial concerns be admin- as prevention directives, vaccine Center for Education and Research, Metro-
istered in those settings. Ideally, availability and acceptability, and care Services, and the Division of Trauma
the integration of mental health needed evidence-based interven- and Disaster, Department of Psychiatry,
University of Texas Southwestern Medical
considerations into Covid-19 care tions relevant to pandemics and Center — both in Dallas (C.S.N.).
will be addressed at the organi- should address a range of psycho-
zational level through state and social concerns. Mental health This article was published on April 13, 2020,
at NEJM.org.
local planning; mechanisms for professionals can help craft mes-
identifying, referring, and treating sages to be delivered by trusted 1. Trauma- and stressor-related disorders.
severe psychosocial consequences; leaders.4 In:​Diagnostic and statistical manual of men-
tal disorders. 5th ed. Arlington, VA:​Ameri-
and ensuring the capacity for con- The Covid-19 pandemic has can Psychiatric Association, 2013:​265-90.
sulting with specialists.4 alarming implications for indi- 2. Brooks SK, Webster RK, Smith LE, et al.
Education and training regard- vidual and collective health and The psychological impact of quarantine and
how to reduce it: rapid review of the evi-
ing psychosocial issues should be emotional and social functioning. dence. Lancet 2020;​395:​912-20.
provided to health system leaders, In addition to providing medical 3. DiGiovanni C, Conley J, Chiu D, Zabor-
first responders, and health care care, already stretched health care ski J. Factors influencing compliance with
quarantine in Toronto during the 2003 SARS
professionals. The mental health providers have an important role outbreak. Biosecur Bioterror 2004;​2:​265-72.
and emergency management com- in monitoring psychosocial needs 4. Pfefferbaum B, Schonfeld D, Flynn BW,
munities should work together to and delivering psychosocial sup- et al. The H1N1 crisis: a case study of the
integration of mental and behavioral health
identify, develop, and dissemi- port to their patients, health care in public health crises. Disaster Med Public
nate evidence-based resources re- providers, and the public — ac- Health Prep 2012;​6:​67-71.
lated to disaster mental health, tivities that should be integrated DOI: 10.1056/NEJMp2008017
mental health triage and referral, into general pandemic health care. Copyright © 2020 Massachusetts Medical Society.
Mental Health and the Covid-19 Pandemic

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The New England Journal of Medicine
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Copyright © 2020 Massachusetts Medical Society. All rights reserved.