Suliman Khan Shereen ³ InstituteofVirology, ChineseAcademyofSciencesXiaoHongShanNo.44,Wuhan, Hubei, ofTranslational² HenanMedicalKeyLaboratory Cerebrovascular Diseases,,,China 4 1 www.jogh.org JoGH ©2020ISGH © 2020TheAuthor(s) psychological health psychological Impact of coronavirus outbreak on TheDepartmentofCerebrovascular Diseases,TheSecondAffiliated HospitalofZhengzhouUniversity, Zhengzhou,Henan,China State Key Laboratory ofVirology, StateKeyLaboratory CollegeofLifeSciences,Wuhan University, Wuhan, Hubei,China use ofelectronicdevices. disturbed dailyroutinesandhigher increase thechancesofexposureto restricting peopletotheirhomescan world. Thepracticesofisolationand tined acrossseveralcountries in the large populationsarebeingquaran To curbthespreadofSARS-CoV-2, • doi:10.7189/jogh.10.010331 4 , NadiaBashir sive fatalities, however, their psychological impacts can be serious such as anxiety, insomnia, panic be- of theworldenvironment, viraloutbreaks mayaffect animals orhumans[3,9],withoutcausingexten- accurately, thatwillbe causedbyanewlyemerged pathogenicvirus. Consideringthecurrent situation In abroad aspectof viraloutbreaks, itisimpossibletopredict the extentofmortalityandmorbidity OUTBREAK’S IMPACT ONPEOPLEANDTHEIRRESPONSES chological health. andmedicationsforamelioratingstressinterventions and related psychiatricconditionstoimprove psy- ulations in coping with psychiatric disorders. We further discuss the consequences of being in stress, and lic. Thenwesummarizesomefactsacquired inSARSandMERSoutbreaks toassistthevulnerable pop- effective communicationtobuildpsychologicalresilience amongemergency healthworkersandthepub- paper, wefocusontherisksof psychiatricdisorders associatedwithnovelcoronavirus outbreak, andits poses seriousproblems forpublichealth[8 nating into stress, anxiety, and episodes of depressive reactions. Not only epidemic but also infodemic viral infection,isolation,restricted socialactivities,troubled sleeping,lockdownandforged news;culmi- pneumonic symptoms.Hence,ignoringtheprofound importanceofpsychologicalhealth,ensuedbythe Currently, importanceisgiventothephysicalhealththatincludestherapiesandtreatment primary to lize effective therapies(Figure 1). toidentifymentalhealthabnormalitiesandproperlymental healthaswell,thusitisnecessary uti- 1,2 , RabeeaSiddique 3 , MengzhouXue - 1,2 , HongminLi T demics. Theaftermathofsuchoutbreaks notonlyharmsphysicalbut need toprepare fortheconsequencesofassociatedepidemicsandpan- menace ofimminentendemicshavebrought intoforefront theurgent to othercountriesaswell[7].Theemergence ofSARS-CoV-2 andthe gence not only caused a number of deaths in China but rapidly spread 03), respectively [3-6].TheCOVID-19infection,soonafteritsemer drome (SARS)inMiddleEast(2009)andGuangdong,China(2002- syndrome coronavirus (MERS-CoV)andsevere acuterespiratory syn- continuation ofseriousepidemicscausedbyMiddleEastrespiratory 1,2 monia outbreak inWuhan, China[1,2].Itisthoughttobethe syndrome coronavirus 2 (SARS-CoV-2) caused a deadly pneu- he emergence of novel coronavirus called severe respiratory 1 ] thatmayfurtherincrease theriskofmentalillnesses. Inthis The online version of this article contains supplementary material. The onlineversionofthisarticlecontainssupplementary Electronic material: supplementary 1,2 , AshaqAli 3 , Muhammad Adnan , MuhammadAdnan June 2020 •Vol. 10 No. 1•010331

-

VIEWPOINTS VIEWPOINTS June 2020 •Vol. 10 No. 1•010331 used withpermission). Wuhan, Hubei,China(from thecollectionofSuliman Khan, mental healthcounselingduringtheCOVID-19epidemicin Photo: ChinesepatientswithCOVID-19are provided with spreading hatefulandstressfulnews. media andprintshouldavoid large scale.Socialmedia,electronic psychological stressandanxietyona Infodemic canincreasetheburdenof portray theefforts from healthcare providers, services medicalassociationsandscientificcommunities. associated with the outbreakconventional media to better understand the actual concerns and positively mitigate therisksassociatedwithinfodemicpublichealth communityshouldprovide helptosocialand associatedwithinfodemic canfurtheraddtothepsychologicalstress andanxiety.The majorconcerns To Therefore, peoplewhousesocialnetworksexcessivelyare prone toadverseeffects related toinfodemic. [8 cern details related toCOVID-19afterwasdeclared aPublic HealthEmergency Con- ofInternational mation platformknownasWHOInformationNetworkfor Epidemics.Thisplatformactivelyreported the specific target groups using a series of amplifiers, WHO’s risk communication team launched a new infor may increase theriskofsevere publichealthconsequences.Aimingatsharingtailored informationwith news duringthecurrent outbreak ofCOVID-19.Thissituationisleadingtocausemassiveinfodemic,which novel detailsforCOVID-19andgainingfameoversocialmediahaveacceleratedtherateofspreading forged ing misinformationthrough socialmediaplatformsandotheroutlets[8 serious intheoutbreak ofCOVID-19infection.Thistermisusedtopresent theepidemicofrapidlyspread- The terminfodemiawascoinedduringtheSARSoutbreak, however, itisbecomingcomparativelymore IMPACT OFINFODEMICONPUBLICHEALTH ing duringorafter facingthestressful conditions” (S5).Inthecurrent scenariooftheCOVID-19 outbreak Psychological resilience is generally defined as “the ability to sustain or recuperate, psychological well-be- Resilience ofaffected and/or infectedindividuals MEASUREMENTS AND RESPONSES ]. However, alarge populationiseithernotaware orhasnoaccesstotheinformationprovided.

outbreak. vided withfollow-upinformationduringandaftercontrol ofthe vent thespread ofviralinfections.Furthermore, peoplemustbepro- measurements, publicawareness regarding actionstopre necessary - specific take to advance in risk of time and place identifying iors, possible impact,individualrisk,outcomesofnegativehealthbehav- by theserecommendations; informationaboutviraloutbreak and for the general population must be informed comes, interventions ther stress inthegeneralpopulation.To mitigatethenegativeout- headcovers duringthemassivelockdowninChinamayinducefur scarcity of preventive measurements such as gloves, masks, and burden onfamilymembersduetothefearofgettinginfected.The inside homesratherthanhospitals,whichmayincrease thestress stance, some of the infected individuals were advised to stay isolated recommendations fortheprevention ofviralinfections(S4).Forin- byhealthcareInterventions authoritieshaveconsistedofequivocal brackets). referencesument; other supplementary are indicatedby letter Sin [3,11] (andreferences- Doc S1-S3intheOnlineSupplementary quite severe ascompared totheoutbreaks ofSARSandMERS 2019-nCoV inWuhan, China,thereactions ofthepeoplecouldbe media andsocialnetworks[13- mild, however, thesereactions becomeworsebyrumorsspread by viduals, theresponses ofuninfectedindividualsare expectedtobe consider psychological health [3,1012]. Unlike the infected indi- health care authoritiesshouldhaveaffective plans,whichmust atric disorders. To copewithsuchoutbreaks andepidemics,the people toinduceanxiety, panicbehavior, andotherrelated psychi- spread around theglobe[1,31011],thereby affecting millionsof thousands ofpeople,causehundreds tothousandsoffatalitiesand havior, fear, andhopelessness.Insomecasesviraloutbreaks infect 2 ]. Winning theraceofsharing 15]. Intheoutbreak causedby www.jogh.org • doi:10.7189/jogh.10.010331 - - www.jogh.org Figure 1. Psychological interventions. • doi:10.7189/jogh.10.010331 developing treatment andprevention strategiesandimproving facilities. tists andhealthcare workersshouldcommunicatetheaffected populationabouttheirprogress regarding willbecomenormalandcontrolledbe givenahopethateverything withthepassageoftime.Thescien- that seriousmeasurements willbeimplementedathospitalsandcommunities.Moreover, peopleshould willprotect a longtime,butthegovernment thenation.Inaddition,itshouldfurtherbecommunicated care regulatory authoritiesshouldcommunicatethe people that the riskofbeinginfected may sustainfor increasing resilience (S5-S9).WhilecombatingtheimpactofCOVID-19pneumonia(Figure 1),thehealth whole. Different strategiesincludingbiological,socialandpsychologicalmechanismsare associatedwith (S6). Thus,prevention from thestress and mental impairment requires building resilience inpeople as a absence ofmolecularabnormalitiesthatoccurinsusceptibleindividualsimpairsthecopingability ated bythepresence ofdistinctmolecularadaptationstopromote normalbehavioralfunctionandthe nor stressors thatpeopleduringnormalconditionswouldcopewithreadily (S5-S8).Resilienceismedi- Wuhan mayexperienceunusualstress, anxiety, andevenseriousmentalhealthissuesinresponse tomi- dysfunction whenexposedtotheviralinfectionorat-leastlivinginregions underthreat. Peopleof in Wuhan, China,resilience canbeachievedbyendingthevulnerabilitytopsychopathology andmental practices, therelevant forces should communicatepeople whocanhelpthemidentify suchindividuals. burden ofmentalabnormalitiesintherespective population.To avoidthe negative outcomesofsuch the viral spread in countries with no facilities for combating coronavirus. It will ultimately increase the cause may however, actions fear; such or stress higher the to due be may It flee. to ways find students) (mostly foreigners that China of cities several in observed generally been has It don’tcooperate. people infected peoplemaketheirutmost effort toavoidthespread ofthevirus incommunityhowever, some turbances, disrupted daily biological rhythms, anger, and disappointment (S10,S13-S15). In most cases, The mostcommonimpactsofsuchanoutbreak orepidemic couldbeanxiety, panicbehavior, sleepdis- tiousness andmortality. ities (S10-S12). The overall impact of infectiononmental health will be associatedwith the rate ofinfec- above-mentioned factorswilllikelygeneratemoderateto majorbehavioralandpsychologicalabnormal- threat.regions Intheseregions, undersecondary thestress andfearofinfectionalongwithother The regions and areas other than the originating region of COVID-19 infection will be considered as the Regions undersecondarythreat 3 June 2020 •Vol. 10 No. 1•010331

VIEWPOINTS VIEWPOINTS June 2020 •Vol. 10 No. 1•010331 in Wuhan after the COVID-19 outbreak [1 world’s the in time first the For history, havoc and fear peak with quarantine, medical on is city whole a THERAPEUTIC ORRECOVERYSTRATEGIES mission rate in those cases was significantly lower as compared to 2019-nCoV of Wuhan [3 in past caused by the coronavirusesserved namely, SARS-coronavirus andMERS-CoV, howeverthetrans- infecting thousandsofpeopleandkillinghundreds ofthem[11](S2,S4,S7).Similaroutbreaks were- ob threat. Theoutbreak ofCOVID-19pneumoniaimposedaseriousthreat totheresidents ofthecityby The area of novel coronavirus origination (Wuhan) will be considered as the region under the primary Regions underprimarythreat on rumorsandforged newsfrom unauthenticsources. play acriticalrole bybroadcasting instructionregarding relaxation, meditation,andadvicetonotfocus can media Nevertheless, education. from spiritual benefited be should beliefs certain with communities and communicate through media to encourage individuals for life and healthy activities. In addition, toms followedbytheoutbreak. Professional clinicalpsychologistsorpsychiatristsshouldcomeforward must beeducatedormadeaware ofthedevelopmentclinicaldepression, andsuicidalityrelated symp - ation andcognitivebehavioraltechniques,and/ormedicationifneeded(S11,S16).Furthermore, people have moderatepsychologicaldisturbancescanbehandledbymentalhealthprofessionals through relax- It may be possible through facilitating the community by electronic andsocial media. Individuals who apy canalsobe selected,whichfocuseson interpersonal relationships (S27). functional beliefs about symptoms and to challenge these beliefs logically (S25-S26). Interpersonal ther cognitive therapymayalsobe helpfulinwhichtheaffected personistaught toidentifyirrationalordys- including relaxation training,guided self-dialogueandcognitiverestructuring (S24-S26).Inaddition, related disorders, educationaboutthesedisorders related symptomsandtechniquestomanageanxiety some goodmemoriesandevents ismade.Moreover, stress inoculationtrainingfordepression, stress, and sure based therapymayalsobeusefulinthescenarioofcurrent situation.Inthistherapyexposure to ical andpsychiatricsymptomsfollowedbythe2019-nCoV outbreak inWuhan, China(S24,S25).Expo- outbreaks (S23).Inaddition,cognitivebehaviortherapymayalsoeffective incombatingthepsycholog- tors provide psychoeducationbyteachingthatsuchpsychologicalproblems are normalresponses tosuch ticipants are askedtodescribetheirfeelingsandbehavioral reactions duringtheepidemic.Theinstruc- also be dealt with psychological debriefing by administering briefing sessions (S22,S23) in which the par irrespective oftheirseverity. Furthermore, peoplewith acutestress disorder ordepressive disorders will resilience willbeimportantinthepopulationwhoare likelytodeveloppsychoticortraumaticsymptoms among peopleandhealthcare ofviralinfection.Psychological workersindirectly exposedtothecarnage The alleviationofacutedistress andpreventing chronic depression, anxietyandposttraumaticstress Psychological counselingbasedtherapies logical therapiesandpsychiatricassistancewhere needed. educate peoplethrough psychologicalcounseling.Moreover, theyshouldbeprovided withpharmaco- of thepeopleandleavingothersunderburden ofstress. Thus,aproper systemmustbedevelopedto tronic devices.Forforeigners, theconditionsare more severe ascountrieshavestarted evacuatingsome even familymembers,thus,theyprefer toremain isolatedandlockeddown,whileoverusingtheelec - ical conditionsthatmayincrease panicbehavior. Peopleare scared ofbeinginfectedbytheirfellowsand and highermorbidityare increasing hysteriaandanxietyamongpeople.PeopleinWuhan are undercrit- trists. psychia- and psychologists, with equipped centers, public specified at guidance and counseling with of regionsrisksshouldbeimplementedhere. atsecondary Furthermore, thepeopleshouldbeprovided ous problems inthefuture, alloftherecommendations thatwehavediscussedintheprevious section well, becauseitismore intenseintermsofinfectingandkillingtheindividuals[11].To overcome seri- workers (S22),however, theCOVID-19infectionmaycausesuchabnormalitiesin generalpublicas chronic depression. MERSandSARSinducedseriouspsychologicalproblems majorlyinhealthcare on healthandcancauseseriousmentalproblems includingacutestress, insomnia,severe anxiety, and were longtermandsevere (S18-S22).Comparatively, theCOVID-19mayhavestrong negativeeffects MERS negativelyimpactedmentalhealthuptoahigherextentandinsomecases,theimpactsimposed

4 , 11] (S3). In addition to serious mortality, rapid transmission www.jogh.org • doi:10.7189/jogh.10.010331 , 10, ] (S17). 11] (S17). - - www.jogh.org • doi:10.7189/jogh.10.010331 (S27). disorders depressive and anxiety chronic of case the in effective and beneficial more is therapy) bined approaches are notworking.Nevertheless,theuseofbothpharmacotherapyandpsychotherapy(com- All these drugs could be effective; however, their use should be only recommended when psychological idone orquetiapine(atypicalantipsychotics)shouldbegivenasanadjuncttoSSRIsSNRIs(S27,S31-S33). ulate GABA signaling), including, gabapentin and pregabalin can be used. In case of severe anxiety, risper cluding dizziness,drowsiness, drugs(thatmod- andincreased riskoffalls.Insuchcasesthealternative benzodiazepines havebeenfoundwithgoodresults. However, theyhavesomeserious adverseeffects in- recommended indepression (S27,S31).Amongsecond-lineagentsforanxietyanddepressive disorders onist) and Vilazodone (a serotonin reuptake inhibitor and partial agonist of serotonin receptors) are also of mental disorders specifically depression and anxiety (S28-S30). Agomelatine (a melatonin receptor ag- (SNRIs) and selectiveserotonin reuptake inhibitors(SSRIs). Thesedrugsare effective againstseveraltypes are the first-line pharmacological treatment options such as serotonin-noradrenaline reuptake inhibitors cannabinoid systemsandvariousneuropeptide are generallypreferred. Insuchtherapiesantidepressants serotonergic, endo- adrenergic, glutamatergic, influence that Drugs treatment. psychological to adjunct Pharmacological treatment ofdepression, anxiety, andrelated disorders orinsomecases isanalternate therapies Pharmacological workers needseriousattentionandpsychologicalcounseling. be addressed properly. Inaddition to thegeneralpopulation exposed to the viraloutbreak, health care through thestress andprone todevelopserioussymptomsofpsychiatricdisorders inlaterstagesmust ways, thus,theadministrationofmedicationisrecommended. Overall,theindividualswhoare going sibilities thatalarge populationdevelopssevere psychiatricsymptomsbydisruptionofmolecularpath- these approaches, otherpsychologicaltreatments shouldalsobeevaluatedandemployed.There are pos- experiencing high levels of stress and are vulnerable to develop serious mental abnormalities. Besides i.e,theresidentsventive measurements ofWuhan. imposedbythegovernment, Theseindividualsare egy shouldbepreferred fortheindividualsdirectly exposedtotheepidemicanddirectly faced thepre- ommended forpeoplewithsevere stress symptomsfewweeksaftertheincident.Thistherapeuticstrat - is recommended forthepeoplewhogainstress immediatelywhile briefcognitive-behaviortherapyisrec- cognition-based therapy will be effective after the epidemic is ended. Generally, psychological debriefing chological resilience canbeaneffective strategyduringthedaysofepidemicoroutbreak. However, vidual-based therapiesshouldbegivenpriority. Based onitsexperienceatawidescaleinthepast,psy- tion. Generally targeting the entire population or large communities is not beneficial thus targeting indi- from againstcoronavirus theactionstakenbygovernment epidemic,viralinfection,andfearofinfec- get thecommunitiesorentire populationsaswelltheindividualswithpsychiatricsymptomsresulting atric aberrations caused by direct or indirect exposure to the situation. These strategies are specific to tar of people, it is imperative to evaluate and develop strategies to address psychological health and psychi- outbreaksviral affectscontinued that aroundof China view in the specifically In and millions world the SUMMARY ANDCONCLUSION Online Supplementary Document Online Supplementary Additional material request from thecorresponding author)anddeclare noconflictsofinterest. Competing interests: The authors have completed the ICMJE Unified Competing Interest form (available upon proved thefinalmanuscriptassubmitted. thestudy.revised andeditedthemanuscript andMXsupervised Allauthorshavecriticallyreviewed andap manuscript. SKandRSconductedtheliterature searches andprepared thedata.SK,RS,HL,AA,MAD, andNB Authorship contribution:SKistheleadingauthorwhoconceptualizedanddesigned studyandwrote the Projects ofHenanProvince ofChina(forMX). gram of China (grant no: 2018YFC1312200), and Innovation Scientists and Technicians Troop Constructions of China(grantsno:81870942,81471174and81520108011), NationalKeyResearch andDevelopmentPro Zhengzhou University(forS.K)andtheoperatinggrantsupport from theNationalNaturalScienceFoundation of Hospital Affiliated Second The from grant research Postdoctoral the acknowledge authors The Funding: 5 June 2020 •Vol. 10 No. 1•010331 - - - -

VIEWPOINTS VIEWPOINTS June 2020 •Vol. 10 No. 1•010331 REFERENCES 12  11  6 9 8 7 10  5 13  4 3 2 1 15  14          Zaki Public Health. related coronavirus ofbatorigin. Zhou Zarocostas 2020. World HealthOrganization. Coronavirus disease2019(COVID-19)situationreport. 28,2020.Geneva:WHO; February man withpneumoniainSaudiArabia. Bawazir Medline:14585636 ydoe SR) n undn, epes eulc f hn, n eray 2003. February in China, of Republic People’s Guangdong, in (SARS) syndrome Zhong doi:10.1038/s41579-018-0118-9 Khan 2020; coronaviruses toglobalhealth—Thelatest2019novelcoronavirus outbreak inWuhan, China. Hui 2016; east respiratorysyndrome andsevere acuterespiratory syndrome coronaviruses amonghealthcare personnel. Cui 3 Khan Wuhan, China.Lancet.2020;395:497-506.Medline:31986264 Huang C,Wang Y, LiX,RenL,ZhaoJ,HuY, etal.Clinicalfeatures ofpatientsinfectedwith2019novelcoronavirus in Liu Escobar-Viera doi:10.1128/JCM.00187-20 biology and therapeutic options. Jones mHealth. Ruzek 2018; review of the evidence on social media use and depression among lesbian, gay, and bisexual minorities. lockdown. . Medline:32032614 J S DSI, , AM, ,

Li 91: 11: 5 S S P NM Chan JI, , , : , NS, e10496. F Fan Ali Siddique A , 264- e0149988. Eric Kuhn Shi Azhar 2016; Van Boheemen , , J Proc NatlAcadSciUSA. . Al-Mazroo Zheng A Thompson How to fight an infodemic. TC, H ZL. , 6 CG, Siddique , 2018; . Medline:31953166 2 Lan Medline:30037786 E Origin andevolutionofpathogeniccoronaviruses. Chu : 37. , R BJ, Whitfield Madani , E doi:10.1016/S0140-6736(03)14630-2 Medline:26930074 T 11: Shereen Medline:28293610 , , YT Li Jaworski doi:10.1016/j.jhin.2020.01.019

E Yang

RR 89- R , , YM, , Jradi Wu S Nabi , , 93. TA Schetter Bestebroer X-L, DL,

MA, Poon JTS, , Medline:28647126 H BK, Ntoumi G , Nature. Wessel Shi . J Clin Microbiol. Ahmed Ali Geng Novel coronavirus isputtingthewholeworldonalert. Owen LLM, doi:10.1016/j.ijid.2020.01.009

doi:10.2196/10496 N EnglJMed. CD W-F 2017; A Lancet. TM, , doi:10.1371/journal.pone.0149988 F , CB, X Liu , , 2018; doi:10.21037/mhealth.2016.08.06 Xie JE, Silver , A Zhang Kock 114: [email protected] China Henan Zhengzhou The SecondAffiliated Hospital ofZhengzhouUniversity Suliman KhanPhD [email protected] China Henan Zhengzhou The SecondAffiliated HospitalofZhengzhouUniversity Mengzhou XueMD,PhD Correspondence to: Zhao , Osterhaus J Shensa Ramsey Badri ZH, , 2020; Bai 556:

11663- R RC N

W ,

2012; Chan 6 Q doi:10.1016/j.jiph.2017.05.003 , Dar M , . 255- 395: 2020; et al. A , et al. KM. Distress and rumor exposure on social media during a campus . et al. ,

MERS-CoV infection:Mindthepublicknowledgegap. 8 Sidani ADME, 367: O KH, . 8 676. Medline:29042513 , . Mobile mental health interventions following waranddisaster.Mobile mentalhealthinterventions Comparative epidemiology of human infections with middle Comparative epidemiologyofhumaninfectionswithmiddle Medline:29618817 Fatal swineacutediarrhoea syndrome causedbyanHKU2- JCM.00187-20 [Epub ahead of print]. Medline:32161092 et al. The emergence ofanovelcoronavirus (SARS-CoV-2), their 1814- Medline:32113495 et al. JE,

Fouchier doi:10.1016/S0140-6736(20)30183-5 Nat RevMicrobiol. The continuing2019-nCoVepidemicthreat ofnovel Brown 20. Epidemiology andcauseofsevere acuterespiratory

Medline:23075143

AL, RAM. et al. doi:10.1073/pnas.1708518114 doi:10.1038/s41586-018-0010-9 Isolation ofanovelcoronavirus from a doi:10.1016/S0140-6736(20)30461-X For better or for worse? A systematic For betterorforworse?Asystematic 2019; www.jogh.org 17: doi:10.1056/NEJMoa1211721 J HospInfect. Lancet. 181- • doi:10.7189/jogh.10.010331 92. 2003;

Medline:30531947

JMIR Ment Health Int JInfectDis. 2020; 362: PLoS One. 104: 1353- J Infect J Infect 252- 8 . .