The rise of the novel coronavirus outbreak has upended life across the globe. With billions of people adjusting to the limitations of life in the age of the pandemic, many are struggling to cope with the stress related to the various ramifications of it. We’re worried about our own health and that of our loved ones. We’re concerned about paying the rent or mortgage, the future of our finances, and the impact of the outbreak on the world economy. This is enough to make anyone feel anxious. We've asked Professor Neil Greenberg, an expert in mental ill-health and consultant occupational and forensic psychiatrist based at King's College London, and Professor Joseph El-Khoury, an expert in adult psychiatric and addiction conditions based at the America University of Beirut, to weigh in on the impact of the pandemic on mental health and how individuals can manage their coronavirus-related anxieties during these unprecedented times in modern history.
What effects can self-isolation have on mental health?
Professor Neil Greenberg: In most cases, it will be frustrating with no long term ill effects. If the quarantine is poorly handled, in that the reasons for the isolation are poorly understood or not agreed with, there are insufficient basic supplies (food, medicines, sanitary products etc.), where remote communication is not possible and where the period of removal from the rest of society is elongated, then there can be long term negative impacts such as depression or post-traumatic stress symptoms.
Professor Joseph El-Khoury: We have to keep in mind that a pandemic of this scale has not been experienced for over 100 years, despite some limited outbreaks in China (SARS-1) and Africa (Ebola) in the last three decades. The research on the impact is scarce. Instead, we look at what happened in 1918, but this was a dramatically different world and the lessons are difficult to translate to our era. This specifically applies to quarantine and the level of isolation in terms of scale (many millions of people over many weeks and months) is completely new to all societies. What we know of quarantine we know from previous outbreaks which were smaller in scale and impact. What we also know is from prisoners in self-isolation or from astronauts or submariners, but these are special groups so we cannot generalise. What is happening is that we are now learning the impact as we experience it and mental health experts are sharing their notes and expertise from across the globe.
I think many people want to know, what approaches or practices would you suggest for managing one’s anxiety and stress while navigating this pandemic? What mental health "tools" have you personally been using?
NG: The best things to do is to restrict your access to the media which can provoke anxiety in many people, to listen to and rely on official sources for information about the virus and what to do, to keep in touch with people regularly even if for short periods and to try and keep physically well in terms of diet, sleep, exercise and doing things you enjoy as a good state of physical health is good for your mental health too. I have been doing my best to stick to the guidance above.
JE: The recommendations, which include the ones released by the WHO, are actually very simple but not easy to implement. All professionals agree that if you already have anxiety or a psychiatric condition you are more likely to suffer more anxiety during this phase. But also, some people who have never experienced anxiety will also develop it for the first time. This can become disproportionate and lead to behaviour that is distressing to them and others such as constant disinfection, constant checking of the news, limiting all activities to what they consider completely safe and neglecting quality of life ‘until corona has passed’. So, the advice for all people is to maintain a heathy routine, no matter how small, that retains elements of their pre-corona life. This includes healthy eating patterns, healthy sleep pattern, dedicating time for work and time for other activities. It is also advised to focus on one or two new ‘self-development’ activities that can keep you motivated. The third piece of advice is around social connection. Technology has allowed us to stay connected with the world even when in physical isolation. Imagine how it would have been only 20 years ago. We need to make use of this advantage by not spending most of our time learning about pandemics and following 24 hours news but connecting with current circles and developing new circles. A final piece of advice is to avoid self-medication at all costs whether with pills or any substance. If you feel that you are not coping seek help.
With many healthcare workers around the world dealing with unprecedented levels of overwork, how can they deal with emotions and stress?
NG: To speak to colleagues and supervisors they trust and to try and create a narrative, with colleagues, about what they have done and why unpleasant outcomes occurred. It’s not helpful to spend a lot of time blaming yourself or others for not being perfect all the time – the situation is an exceptional one and everyone is fallible. If you are a supervisor, it’s really important that you upskill so you feel confident in speaking about mental health with your team. If you develop problems that are persistent and impairing seek help early on to prevent a crisis and help prevent you from becoming seriously unwell.
JE: Frontline healthcare workers are one of the identified high-risk groups. They must balance their own safety, with that of their care to the patient, with being faced with high death rates among these patients and among their colleagues, with the safety of their families. The support has been consistent across the world from the public but what is needed is real material support in PPEs, financial support, shorter duties, testing, in addition to psychological support given by experienced professionals. This is being done in the UK, the US and even in Lebanon in the last few weeks. Unfortunately, taboos and stigma still exist and many prefer not to seek professional help. We have heard of high profile suicides in the US lately and this is really tragic when help should be available.
Fears around our mortality are weighing heavily on the minds of many and that’s something we don’t typically talk about. How can we respond to that?
NG: Do not be afraid to speak about death and threat. Don’t overly dwell on it, but avoidance is not helpful and can sustain negative thoughts and fears. Speak a little to people you trust ideally ones who understand what you have experienced and have experienced similar things themselves.
JE: Developed countries are much less comfortable with deaths in large numbers than countries where mass tragedies happen more or less regularly or where the population has not been exposed to recent war and conflict. I think the best way to approach this problem is to understand that death is inevitable, in particular for those of an advanced age. We can deal with the grief by providing the best care possible in the best condition but also ensure dignity in healthcare and in death. Some of the pictures we have seen and stories we have heard of overflowing morgues and not enough hospital beds creates a type of moral injury that will affect these societies in the long term.
Are there steps that can help mitigate emotionally distancing ourselves as we socially distance from people?
NG: Use remote means, e.g. Skype, Zoom etc. to stay in touch. Try to connect with others a little and often just as you would most likely do if you were out more or at work. Also, try and build in time before or after meetings to connect socially (remotely) rather than signing on a minute before a meeting starts.
JE: Physical contact and non-verbal communication are essential needs for human beings who are ‘social creatures’. And some societies such as ours rely even more on it. While virtual connection has been very helpful it cannot replace this need. I feel that with the pandemic progressing into its maintenance phase we need to find ways to safely reconnect physically. This, of course, will depend on how much we learn about COVID-19 and whether we do develop this herd immunity or the testing that goes with it. Until then most people have been circulating in small ‘safe’ clusters (a family, a flatter etc.) It is more difficult for single people who live alone for example, as happens in many western urban centres.
Children's lives have changed dramatically. How can we help our kids deal with everything happening around them?
NG: Be honest with them but don’t provide more information than they can cope with depending on their age. Also, try to contain their anxieties and don’t share your concerns about the future too much. Be confident for them and explain that whatever happens, you are all in it together. Also, allow and encourage them to stay connected remotely to their friends and your wider family.
JE: Kids will be impacted by their parents primarily and their peers of course. Anxious parents will lead to anxious children. There are excellent resources online that are targeting kids of all ages trying to explain the pandemic. Parents need to again maintain a semblance of routine for children that would be created around a normal school day. I advise against lying to children and misinforming them as they will access contradictory information elsewhere and will lose trust in your message and beyond it. Instead frame the message realistically while providing reassurance that everything is being done to protect you and them. Also, involve them in the safety measures so they feel empowered.
With the constant barrage of confusing and overwhelming bad news, are there ways for people to stay informed without getting overwhelmed and making their anxiety worse? For example, should we be mindful of our news intake — how, and how often, we’re taking in updates about the virus?
NG: Definitely restrict your exposure to never-ending media stories especially if you find it makes you anxious. Try to check news only once a day and do not have alerts on your phone for each new news story. Rely on official sources of information for ‘facts’ rather than speculative media stories.
JE: Disconnect from 24 hours new as much as possible. Limit notifications from such websites, avoiding pandemic related conversations that seem to lead to nowhere, and focus on analysis articles and commentaries that go beyond number counting and doomsday stories. Of course, use reliable sources that rely on references and valid experts. Also, focus on other news, even when these are not positive but simply to remember that not everything needs to be seen through the ‘coronavirus’ angle. The coronavirus counting apps are particularly toxic as they provide no context when all experts have warned against comparing countries.
What are some ways that people can support family and friends during this time?
NG: Be kind. Send gifts, messages, connect remotely and share anything fun with friends and family to create a sense of community even if you cannot see people face to face. If someone is struggling stay in touch with them and encourage them to seek help.
JE: Be available but do not overwhelm. Ask whether they want help (and what kind of help - may not be related directly to COVID-19). Do not impose it. Families have had to either distance themselves physically or actually spend all their time together. Both situations can have an impact. Be aware of your own 'emotional space' and that of others. This will allow you to protect yourself psychologically and to be present for others effectively.
What worries you the most when it comes to people's mental health during this pandemic and do you fear that there will be a long term mental health impact of Covid-19?
NG: I think the biggest impact will be from the financial impacts which will follow the crisis. We know that economic downturns are associated with poor mental health and sadly suicide rates increase. Thus, getting country’s economies going is going to be good for their population’s mental health.
JE: In the early days of the pandemic there was hope that this global challenge would bring people together. The reality is much more complex whether we think of collaboration between countries or simply at the level of a community or a family. I fear that the pandemic will leave people with a primordial urge to self-preserve, which is instinctive, to protect themselves and those closest to them while neglecting the common good. Unfortunately, this is exactly the strategy that can lead to conflicts and social stressors. There is a big role for governments in being a source of trust and taking effective measures to ensure social security in its widest sense while protecting civil liberties. The longer the pandemic and its economic fallout persists the more likely the mental health impact will be deeper and more persistent.