Over the last month the human race has gradually woken up to a new world. Across the globe the novel coronavirus affected most populations, spreading fear and panic in all regions. However, the only way to combat such a healthcare crisis and to reduce the possible losses is through cooperation and collaboration of us all.
While following advice by different governments is key to contain the spread of the virus, the real battle against this pandemic is fought by the front-line medical teams. Therefore, in this stage it is paramount to follow governmental and scientific advice, in order to support these front-line medical defenders as well as our health systems to contain the spread and eventually save lives.
Past human experience
It is true that this is not the first time the human race faces a pandemic. Actually, in the last 100 years the world witnessed four pandemics: the Asian flu (1957 – 1958) and the Hong Kong flu (1968 – 1969), where up to 4 million people died during each pandemic[i] and 2009 flu pandemic (2009 – 2010), where it is estimated that less than half a million people died.[ii] However, parallels have been drawn particularly between the novel coronavirus pandemic and the first pandemic that occurred in the 20th Century, the Spanish flu pandemic. This pandemic hit the world in 1918 and it is estimated that it has claimed up to 40 million lives.i
Experts in different fields have studied how the Spanish flu pandemic had an impact on different aspects of people’s lives, such as, economic, political and even military. Nevertheless, as a psychiatrist, I believe that the psychological impact of the Spanish flu has been underestimated, or to a large extent overlooked. This could be attributed to the fact that the start of this pandemic in 1918 coincided with the last year of World War I (1914 – 1918). Thus, it might have been overshadowed by events of the war and people were more desensitised to hearing about big number of casualties.
At the same time, mental health disciplines were not developed to a degree that would have allowed us to detect and deal with signs of psychological distress or mental health disorders secondary to the Spanish flu pandemic. Yet, over the last 100 years the disciplines of psychiatry and psychology have made huge advances especially after World War II. Therefore, I believe that the way different countries will deal with the psychological impact of Covid-19 and the psychological aftermath of this pandemic will play a pivotal role in determining the legacy of this pandemic in different country.
Exaggerated sense of entitlement
Modern, capitalist and materialistic life has been designed to give us an exaggerated sense of control, certainty and entitlement. All of this has been shattered in only few weeks by the novel coronavirus. It is important to acknowledge that this fragile eco-psychological system has contributed to the increased levels of psychological distress we are witnessing, which can lead in certain cases to mental health disorders, if left unattended. In order for a person or a group of people to deal in a helpful way with highly stressful situations that are emotionally charged, they need to acquire a healthy level of psychological resilience. This psychological resilience should have been acquired before the onset of the situation; however, this does not deny the importance of other psychological measures that can be implemented to deal with the acute stage and aftermath of the pandemic.
To give an example, lets imagine what a footballer needs to do in order to perform well during a critical match and to protect himself from injury. He will have to train well before the match in order to have the muscular strength that would allow him to perform well and avoid injury during the match. During the match itself he will need to take certain precautions and wear protective gear to avoid injury, and after the match he will need to take measures that would allow his muscles to recover from the strenuous effort he did. The same applies to highly intense psychological situations and how a person can survive these situations while carrying on their duties and without sustaining psychological injuries.
It is estimated that more than a third of the global population is now on lockdown because of Covid-19 pandemic. This means that people are staying at home with no clear sign when this might end, and the vast majority of people would not have imagined that this could happen if it was suggested only a couple of months back. This significant amount of uncertainty and lack of control is clearly associated with psychological problems. This will affect people who either have an established mental health diagnosis, or those who have never been diagnosed with a mental health disorder before. Psychiatrists and mental health professionals are already seeing deterioration in people suffering from different mental health disorders such as, depression, anxiety, Post Traumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder (OCD), addiction, sleep disorders, Attention Deficit Hyperactivity Disorder (ADHD), hypochondriasis … etc. On the other hand, people who have never been diagnosed with a mental health disorder are also experiencing psychological distress and in some cases symptoms that they have never experienced before. People should be reassured that it is not unusual to experience psychological distress in such situation, however, they should also be advised on when and how they should seek help from mental health specialists if needed.
The impact on medical frontlines and the public
Medical staff working in the frontlines are already under enormous psychological pressure. It is expected that as the coronavirus pandemic overwhelms health systems, doctors will have to take life-death decisions more frequently and based on available resources, rather than medical knowledge. For example, if there are two patients who need to be placed on a ventilator and there is only one ventilator available, doctors will need to decide which patient will be placed on the ventilator (a potentially lifesaving treatment) and which patient will not. Different health systems already started publishing guidelines to aid doctors in taking such decisions, but these guidelines will never be able to simulate every scenario doctors will face. This means that doctors and medical teams will have to live with the results of decisions they take that will deny some patients treatments that would have potentially saved their lives. While under different circumstances, only a month ago, the same medical team would have taken a different decision.
Simultaneously, while these ethical dilemmas are taking place, nurses and medical teams will see patients dying on their own without their families. They will have to calm patients down in their last moments and deal with their fears that they might have passed the virus onto other people, including their loved ones. People will soon learn that they cannot grief in the usual way. Children won’t be able to attend their parent’s funerals and parents won’t be able to say their final goodbyes to their kids who will die. People who will manage to survive covid-19, actually this is the majority of people who will be infected, could develop survivor guilt especially if they passed the infection to a family member or a friend, who lost their life fighting this illness. Also, people contracting the infection might be confronted with significant stigma even from their family members and they will need to psychologically process this.
All of this will happen on a background of social distancing, self-isolation and extreme loneliness. Therefore, our usual psychological coping mechanisms with loss, grief and our strive of having closure to painful events will face huge challenges. This could lead to suppression of emotions that can manifest as psychological maladjustment and mental illness in the future. It is worth paying attention that many people, who will contract the virus and survive will be declared medically fit, but the hidden psychological scars will stay there for years to come.
The aim of this article is to highlight the psychological challenges that we are facing and to shed light on the psychological aftermath of this pandemic. This comes from a sense of responsibility that the first step in solving a problem is to acknowledge its existence and then to understand the different elements forming the problem and working on eliminating or mitigating them. I believe that understanding what we are psychologically going through and what we are expected to face over the next few months will help us to decide the best plan of action. In turn this will have a direct impact on other outcomes of this crisis and will underpin the legacy this pandemic will leave on every country and nation.
We did not choose to have this pandemic; however, we can choose the strategy by which we can deal with it and psychological aspects should be at the heart of this strategy.
[i] Stefano Lazzari & Klaus Stöhr. 2004 Apr. Avian influenza and influenza pandemics. 82(4): 242. Bulletin of the World Health Organization.
[ii] Fatimah S Dawood, A Danielle Iuliano, Carrie Reed, Martin I Meltzer, David K Shay, Po-Yung Cheng, Don Bandaranayake, Robert F Breiman, W Abdullah Brooks, Philippe Buchy, Daniel R Feikin, Karen B Fowler, Aubree Gordon, Nguyen Tran Hien, Peter Horby, Q Sue Huang, Mark A Katz, Anand Krishnan, Renu Lal, Joel M Montgomery, Kåre Mølbak, Richard Pebody, Anne M Presanis, Hugo Razuri, Anneke Steens, Yeny O Tinoco, Jacco Wallinga, Hongjie Yu, Sirenda Vong, Joseph Bresee, Marc-Alain Widdowson. 2012 Sep. Estimated Global Mortality Associated With the First 12 Months of 2009 Pandemic Influenza A H1N1 Virus Circulation: A Modelling Study. 12 (9), 687-95. Lancet Infect Dis.