Click HERE for more articles at Annals, Academy of Medicine, Singapore homepage Mental Health Strategies in COVID-19—Cyrus SH Ho et al 155 Commentary Mental Health Strategies to Combat the Psychological Impact of Coronavirus Disease 2019 (COVID-19) Beyond Paranoia and Panic 1 1 2,3 Cyrus SH Ho, MBBS, MRCPsych, FAMS, Cornelia YI Chee, MBBS, MMed (Psychiatry), Roger CM Ho, FRCPsych, FRCPC, FAMS On 30 January 2020, the World Health Organization After DORSCON was raised to Orange, it triggered (WHO) declared the outbreak of coronavirus disease off—on the same day—widespread panic buying of 2019 (COVID-19) an international public health food items and toiletries across the country, leading emergency after the number of cases soared across many stores to run out of supplies at short notice. This 34 regions in Mainland China and surpassed that of phenomenon was attributed to the intentions of locals severe acute respiratory syndrome (SARS) in 2003. The who wanted to stock up on groceries after they feared virus was believed to have originated from a wholesale exposure to heightened viral transmission. Additionally, seafood market in the city of Wuhan in the province the Ministerial Task Force that was convened to manage of Hubei towards the end of December 2019. Shortly the COVID-19 outbreak had suggested the country after, the number of cases increased exponentially in needed to be psychologically prepared for the fallout from Wuhan and nearby cities and provinces before spreading the current outbreak to be worse than the 2003 SARS throughout the world. crisis. The magnitude of fear and uncertainty among Located approximately 3432 km from the epicentre the public was so excessive that it prompted the Prime of Wuhan, Singapore is a densely populated city-state Minister of Singapore to address the public and reassure of 5.7 million who saw 1,592,612 international visitors them that the country has adequate food supplies, while in 2019; of these, 380,933 were visitors from Mainland at the same time urging calm and prudence with their China.1 After a tourist from Wuhan was identified as purchases. The response of locals to the pandemic, which the first case of COVID-19 infection on 23 January has been likened to mass hysteria and paranoia, has led 2020 in Singapore, the country responded decisively by many to question their mental health and resilience. initiating a series of public health measures to contain More than a month into the current pandemic, 77,816 the outbreak that included travel advisories, restriction of people from around the world have been infected as entry into the country by individuals who had travelled of 22 February 2020, of which 21,147 have recovered to Mainland China in the preceding 2 weeks, mandatory from the illness and 2360 have died.2 Outside Mainland quarantine for contact cases and rigorous contact tracing China, 32 countries and territories were affected, with of individuals linked to confirmed COVID-19 cases. Singapore ranked third as having the most number of On 7 February 2020, Singapore raised the Disease confirmed COVID-19 cases after South Korea and Japan. Outbreak Response System Condition (DORSCON) Of the 86 cases that were tested positive for the virus —a colour-coded framework that maps the current with real-time reverse transcriptase-polymerase chain 3 disease situation in the country—from Yellow to Orange reaction, 47 patients had recovered and been discharged. after there was confirmatory evidence of community In an infectious disease outbreak, the mounting fear that transmission of the virus involving several confirmed is aroused in individuals is a common phenomenon and COVID-19 patients who were not linked to any existing can lead to erratic behaviour in them. It can afflict anyone cases and had no travel history to China. At the Orange irrespective of gender and sociodemographic status. level, the outbreak is deemed to have moderate to high This is true of COVID-19, especially when there is still impact on the health of the public. The last time it was much speculation surrounding its mode of transmission raised to Orange was during the H1N1 flu pandemic and the disease is spreading at an unparalleled rate with in 2009, and would also have been the case during the no definitive treatment in sight. In the early days of SARS outbreak in 2003 had it been in place. the COVID-19 outbreak in Mainland China, a survey 1Department of Psychological Medicine, University Medicine Cluster, National University Health System, Singapore 2Department of Psychological Medicine, National University of Singapore, Singapore 3Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore Address for Correspondence: Dr Cyrus Ho Su Hui, Department of Psychological Medicine, University Medicine Cluster, National University Health System, Level 9, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228. Email: [email protected] March 2020, Vol. 49 No. 3 156 Mental Health Strategies in COVID-19—Cyrus SH Ho et al found that 53.8% of respondents rated the psychological rumination on contracting the virus, the behaviour and impact of the outbreak as moderate or severe, 16.5% social interactions of individuals with others can be reported moderate to severe depressive symptoms, profoundly remodelled. 28.8% reported moderate to severe anxiety symptoms, Psychological responses are associated with particular 4 and 8.1% reported moderate to severe stress levels. health-seeking behaviours. In a community survey of Compared to the SARS outbreak 17 years ago, the fear uninfected individuals during the SARS crisis in Hong among the public was even more palpable as increased Kong, it was found that those with a moderate level of air travel and entrenched global connectedness made anxiety and stronger perception of risk of contracting the spread of COVID-19 appeared much more rampant. SARS were more likely to take comprehensive, Extensive coverage of the pandemic by the mass media precautionary measures to protect themselves from the also influences the physical and psychological response virus.14 Nonetheless, the feelings of helplessness and of the public to the infectious disease threat, which anxiety can often motivate individuals to resort to the may amplify their apprehension even when it is used use of unproven methods and remedies that may prove to encourage them to take precautionary and preventive detrimental to their health. measures to protect themselves from the virus.5,6 Medical responders—including first responders Research has demonstrated the wide and profound such as paramedics and ambulance personnel—and psychological impact outbreaks can have on people. healthcare workers (HCWs) have been found to display For individuals without mental illness, an outbreak can heightened stress and become emotionally affected and induce psychiatric symptoms; in those with pre-existing traumatised, and they also experience higher levels of mental illnesses, their conditions could be aggravated and anxiety and depression.15 This is understandable since cause distress to their caregivers. Regardless of exposure, the anxiety and fear of becoming infected is higher from individuals may experience fear and anxiety of falling greater risk of increased exposure. There is also fear of ill or dying, helplessness or blame those who are ill, infecting their loved ones and children. The delicate 7 which can potentially trigger off a mental breakdown. balance between the call of professional duty, altruism Significant psychiatric morbidities have been found to and fear for oneself and others often causes conflict and vary from anxiety, depression, panic attacks, somatic dissonance in many HCWs.16 symptoms and post-traumatic stress disorder (PTSD) to Studies have shown that HCWs who work in emergency delirium, psychosis and even suicidality,7–9 and have been departments, intensive care units and isolation wards associated with younger age and increased self-blame.10 have a greater risk of developing adverse psychiatric In those who are grieving the sudden and traumatic outcomes than those from other job departments. This loss of loved ones from the current outbreak, an inability could be attributed to their direct exposure to infected 11 to gain closure can lead to anger and resentment. patients and the demanding nature of their work.17 A In patients and those who are quarantined, they may study from Singapore reported that doctors and those experience guilt, shame or stigma. Studies have who were single were at a higher risk of developing reported high prevalence of psychological distress in psychiatric symptoms than nurses and those who those who undergo a longer period of quarantine, and were married.18 A systematic review of the impact a it is also associated with increased PTSD prevalence disaster can have on the mental health of HCWs has 12 that is correlated with depressive symptoms. In the identified common risk factors for the development of community, there is distrust of others in terms of psychological morbidities that include lack of social disease spread and the capability of the authorities and support and communication, maladaptive coping and health services to contain the outbreak. With cessation lack of training.17 of community services and collapse of work industries During pandemics, the focus of public health that impact adversely on the economy, many individuals authorities and the mass media is on biological and incur financial losses and run the risk of unemployment, physical repercussions of the outbreak than on mental further intensifying the negative emotions experienced health issues. However, with a growing number of by them.13 reports on the increasing mental health burden caused At the international level, communities that have been by the COVID-19 outbreak, there have been more affected by the outbreak may be targeted for blame and calls for measures to enhance mental health support stigma by other countries over fear of infection and for the public.