​The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak continues to ravage populations around the world. Global sex-disaggregated data indicate that more men than women are dying from COVID-19, contributed to in part by disproportionately higher rates of hypertension, and cardiovascular and respiratory disease in men, although it is, as yet, unclear whether gender differences extend to infection rates and vulnerability to the disease (Wenham et al., 2020). If emerging evidence in other countries is anything to go by, the physical and mental health, and social and economic impacts of the disease, will be inordinately borne by poor South Africans (noting that more than 50% of South Africans live below the poverty line). For example, 30 months after the SARS outbreak in 2003 (the first massive infectious disease outbreak of the 21st century), a third of survivors  met criteria for any psychiatric disorder, a quarter met criteria PTSD, and approximately 16% had depressive disorders. This underscores the importance of detecting and treating psychiatric illness in people with COVID-19, as well as in their contacts (Mak et al, 2009).

Currently, billions of people spanning more than 100 countries worldwide are either in full or partial lockdown – termed the 'world's greatest psychological experiment' (Van Hoof, 2020). While it may inadvertently be a mammoth 'experiment', the consequent physical and social distancing is demonstrating effectiveness in breaking the chain of transmission, by reducing the number of people infected by each confirmed case. This is also known as the basic reproduction number or 'R'. An R below one (R<1) – that is, each person with COVID-19 infecting fewer than one other person – is a desirable outcome. That said, the pandemic and the lockdown, independently and in combination, have unintended consequences by severing and inhibiting family and social norms, values and rituals, that will arguably exert a severe toll on the mental health of the world's population – not only in the immediate and short-term but for many years to come. The stress linked to the COVID-19 crisis, coupled with social isolation, is expected to lead to new episodes of mental illness for many South Africans and increase the risk of recurrence in those with pre-existing mental illness.

The economic repercussions of COVID-19 in South Africa will be dire, even with government-led packages of interventions intended to mitigate the impact. Research on the mental health consequences of economic crises has taught us that there is a significant relationship between severe economic recession and population-level psychological distress, including the emergence, and worsening, of mood, anxiety and substance-related disorders and suicidal behavior (Frasquilho et al., 2016). Past economic crises around the world have resulted in greater demands for general medical care, a greater use of prescription drugs and an increase in hospital admissions for mental illness (Silva et al., 2018). Social isolation, economic worries, heightened anxiety and guilt (about exposing others to the virus or not doing enough to help others) are all risk factors for suicidal behaviors (this includes suicidal thoughts, attempts, and completed suicide). Like other mass traumatic events, COVID-19 is expected to result in posttraumatic stress disorder (PTSD), with typical features of hypervigilance (centred on protection from infection), intrusive thoughts (related to infection, health, fears of dying), avoidance, and negative mood and cognitions (around fears of the world changing and the future being bleak) that will be subjectively distressing and persistently impact on day-to-day functioning over time (Horesh and Brown, 2020).  

Quarantines have also been imposed during other infectious disease outbreaks in the past 20 years, for example, in China and Hong Kong during the SARS outbreak (2002-2004) and in West Africa (2014-2016) during the Ebola outbreak. A recent review of the psychological impact of quarantine covering 24 studies that included the SARS, MERS, H1N1 and Ebola epidemics, found that the impact of quarantine was substantial and long-lasting (Brooks et al., 2020).  Wide-ranging sequelae included posttraumatic stress symptoms, depression, and alcohol abuse and dependence, with some evidence that quarantines of longer duration are associated with poorer mental health, specifically PTSD, over time. During previous infectious disease epidemics, common stressors endorsed during quarantine were a long period of quarantine, fears of being infected, frustration, boredom, shortage of supplies, inadequate information from public health authorities, financial loss, and stigma. These are stressors that are also being endorsed during the current pandemic.

In the face of the restrictions and accompanying economic hardship, South African youth and  persons with pre-existing mental illness may be especially hard hit by the potentially severe and long-term mental health consequences of COVID-19. The stress, fear and emotional pain induced by the rapid and aggressive spread of infection, coupled with the scale of prolonged grief linked to the sudden and massive loss of life, will be felt for years to come, and by successive generations. This pandemic, like other pandemics, also shares features of unpredictability, widespread community impact, mass fatalities, and persistent effects (Sprang and Silman, 2013). The persistent negative effects of stress, fear and profound loss are encroaching on every facet of existence. There are two considerations worth noting. Firstly, prolonged stress has adverse biological effects on the body and the developing brain. Exposure to stressful life events in children and adolescents (who in South Africa make up a third of the population), particularly when those events are prolonged and unpredictable, are associated with disrupted neurodevelopment, and social, emotional, and cognitive impairments in youth, and with medical and psychiatric disorders, disability, and even premature death in adulthood (Nemeroff, 2016). Secondly, excessive and prolonged stress can induce changes in our genes by altering their expression, with these changes passed on to future generations, with wide-ranging deleterious health effects. Put another way, the enduring stress of the current pandemic may result in the continuation of disadvantage through enduring genetic changes, passed on by parents to future generations (Yehuda and Lehrner, 2018). It is for these and other reasons, as outlined below, that it is critical from a public mental health perspective to identify and address the mental health impact of COVID-19.This needs to happen in the population at large but particular attention needs to paid to risk groups that include, but are not limited to, health care workers, women, youth, the elderly, and the mentally ill. Equally important but not covered in this article are other groups - refugees, migrants, and people living with disabilities - who should not be forgotten.

Health care workers

South African health care workers are already facing many of the challenges experienced by health care workers managing patients with COVID-19 in other parts of the world. This includes coping with the scale of disease and death, shortages of staff and essential resources (including personal protective equipment), grief, and, moral distress associated with the rationing of ventilators and other factors (Jackson et. al. 2020). The mental health impact of COVID-19 on health care workers is beginning to be documented in many countries around the world. For example, health care workers in Wuhan, China, against the backdrop of high infection risk and inadequate infection protection, have faced enormous work pressures, overwork, exhaustion, frustration, discrimination, isolation, and lack of contact with their families. This has resulted in symptoms of stress, anxiety, depression, insomnia, denial, anger and fear - negatively impacting work ability and decision-making capacity (Kang et al., 2020). Shortly after the outbreak, between February 17 to 24, 2020, a survey of 4679 doctors and nurses from 348 hospitals in 31 provinces of mainland China found that nearly one-sixth of the staff were experiencing psychological distress that required  psychological or psychiatric management, with symptoms of depression more common than symptoms of anxiety (34.6% versus 16.0%) (Liu et al., preprint, 2020).

Besides working in unsafe, under-resourced and morally distressing situations, the emotional distress in health care workers is further being contributed to clinical uncertainties (e.g. clinical management guidelines that are rapidly evolving), ambiguity about the trajectory of the pandemic, and concerns about short and longer-term medical outcomes (Liu et al., 2020). Long-term negative outcomes in health workers who were quarantined during the SARS outbreak included the experience of more severe symptoms of posttraumatic stress than members of the general public who had been quarantined, greater stigmatisation than the general public, more avoidance behaviours after quarantine (such as minimizing direct contact with patients and not reporting to work), feelings of isolation, fear, guilt, depression, anxiety, loneliness and helplessness (Reynolds et al. 2008). 

Emphasising the mental wellness of health care workers through this pandemic by way of proactive monitoring of wellness, addressing work and health concerns, and instituting measures to foster resilience, will be key to delivering high-quality safe and effective care. This will require concerted efforts on the part of hospital management and clinical leaders to: (i) make health care workers feel valued, (ii) manage work expectations with compassion, (iii) communicate clearly and efficiently on COVID-19 protocols and clinical guidelines, (iv) ensure the provision of sufficient personal protective equipment and resources, (v) create safe spaces to encourage open dialogue, (vi) provide informational resources on managing stress and burnout, (vii) identify mental health professionals who are available to provide assistance, and (viii) engender a supportive work culture (Dewey et al, 2020).

Women

During the lockdown, women disproportionately bear the burden of childcare, home schooling and domestic chores. They are also more vulnerable to intimate partner violence which has seen a global surge during the COVID-19 pandemic. During this time of crisis and rampant fear, children may seek more attachment from and be more demanding on parents. Home schooling, maintaining regular routines, and providing emotional support and reassurance will likely fall more heavily on the shoulders of women. It is important to bear in mind that mood and anxiety disorders are more prevalent (at least a two-fold higher rate) in women (Grant and Weissman, 2007). For women with pre-existing psychiatric disorders, the stress and unpredictability of the situation, and the serious risk that COVID-19 poses to self and family, can trigger a relapse of anxiety and depression. Limited access to women's health services, including obstetric care and sexual and reproductive services (Wenham et al., 2020), may further add to the psychological stress and distress that women may experience during confinement. Very recent evidence from a study that assessed PTSD symptoms in residents in Wuhan (China) and surrounding cities one month after the December 2019 COVID-19 outbreak, found that women compared to men were disproportionately affected by symptoms of PTSD stemming from COVID-19, which included re-experiencing symptoms, negative alterations in cognition or mood, and hyper-arousal (Liu et al., 2020).

Children

Although relatively fewer children and adolescents are infected with SARS-CoV-2 compared to the general population, children can be vectors of transmission and, as such, play a role in the spread of SARS-CoV-2 in families and communities. The physical, social, and mental health needs of children and their families must be factored into measures that are implemented to mitigate against the long-term effects of this trauma. In a study of mental health related to the SARS pandemic in 2003 and the Swine Flu pandemic in 2009, 30% of isolated and quarantined children and 25% of isolated or quarantined parents showed clinically relevant symptoms of PTSD (Sprang and Silman, 2103). Moreover, posttraumatic stress scores (an indication of symptom severity) were four times higher in children who had been quarantined compared to those who had not been quarantined. Children and adolescents over this time may experience fear and sadness and should be given the freedom to communicate their distress in a safe and supportive environment. Family conflict during the period of lockdown may be intensified, as parents need to juggle work from home, whilst caring for children. Furthermore, and of particular concern, is that this is a time when children may be more vulnerable to abuse and violence in the home and via the internet. Children may present with attention, concentration and learning difficulties, general uncontrollable worries about what is happening now and what the future holds, sleep and appetite changes, and increased irritability and defiance. During the Ebola outbreak in West Africa in 2014 to 2016, school closures during the outbreak contributed to spikes in child neglect, sexual abuse and teenage pregnancies. It is important that parents identify and monitor children's emotions, validate these emotions, provide reassurance, regularly connect with their children during the lockdown, re-establish routines as a family, and limit media exposure to COVID-19.             

Elderly

Approximately 10% of the South African population is 60 years or older. This age group has a heightened susceptibility to COVID-19 infection and a high mortality once infected. More than 95% of the COVID-19 deaths worldwide have occurred in individuals older than 60 years, the majority of whom have underlying medical problems, including cardiovascular and respiratory disease. The rapid transmission of SARS-CoV-2 and the high death rate could exacerbate the risk of mental health problems and worsen existing psychiatric symptoms, further impairing daily functioning and cognition in the elderly (Yang et al., 2020). Quarantine and public transport restrictions affect access to health services. Community-dwelling older people in South Africa are likely to be more marginalized. They are also less likely to have access to accurate information and facts about the COVID-19 pandemic and community-level COVID-19 screening and testing that is currently being rolled out. These challenges may be even greater in the face of pre-existing psychiatric conditions, such as dementia. Older adults, especially those with cognitive decline or dementia, may become more anxious, angry, stressed, agitated and withdrawn during the outbreak or while in quarantine. Elderly with dementia may, by virtue of memory loss, have difficulties in remembering personal protective procedures, such as hand and respiratory hygiene, and understanding public health warnings, which could expose them to a higher risk of infection (Wang et al., 2020). In addition, older people in old age homes are often highly dependent on the support from carers in maintaining their daily routines, staying active, and for meals. Diminished support, coupled with the lack of visitation by, and face-to-face contact, with family members, may increase fear, anxiety, and mistrust. Living in close proximity with fellow elderly residents, is a potential 'incubator of infection', with mounting evidence from other countries of high COVID-19 infection rates in nursing homes (Llyoyd-Sherlock et al., 2020). Additionally, in the absence of mandatory testing in old age homes in South Africa, elderly cases may be missed and deaths from COVID-19 related complications misattributed to other causes. Experience from China has shown that residents in nursing homes, in the absence of group activities and communal meals, became more socially isolated. Combined with this, levels of anxiety among staff in nursing homes in China increased, under the dual stress of fear of infection and worries about the health of residents. This was a significant contributor to exhaustion and burnout after a month-long lockdown (Wang et al., 2020).

Patients with mental illness

COVID-19 poses unique challenges for the management of hospital inpatients and outpatients with psychiatric illness. Prior to the pandemic, public sector psychiatric services in South Africa, especially at district and community levels, were already overstretched and under-resourced in terms of bed capacity and shortages of mental health personnel. The deployment of these staff within hospitals to assist with the screening and management of suspected and confirmed COVID-19 cases in general medical settings will further add to this challenge. In addition, psychiatric units in hospitals in the public sector are typically characterised by overcrowding and sharing of dining, bathroom and daily activity spaces (e.g. for group activities such as occupational therapy and group psychotherapy). Patients with mental illness, in view of their compromised and disordered mental states, disorganized behaviour, impulsivity, suboptimal self-care and impaired insight, may not be in a position to exercise infection prevention control measures and protect themselves in the face of COVID-19. Existing social isolation, loneliness, homelessness, and poorer physical health in patients with serious mental illness (e.g. schizophrenia, bipolar illness) are added risks during the pandemic. As a result of the high rates of co-occurring physical illness (e.g. diabetes, cardiovascular disease) – at least two-fold higher than the general population – patients with mental illness have a heightened vulnerability to developing COVID-19 pneumonia and other complications. Furthermore, the high co-occurrence of overweight/obesity, lack of exercise and other unhealthy lifestyle factors associated with psychiatric illness, and the side effects of psychotropic medication, cannot be underestimated. During the pandemic, patients with serious mental illness will need assistance with maintaining healthy habits, including diet and physical activity, in addition to self-management of chronic mental and physical health conditions (Druss, 2020).

As was the case in Wuhan and many other cities in China, lockdown measures and suspension of public transportation were significant barriers to psychiatric patients accessing care and obtaining their monthly maintenance psychotropic medication from hospital outpatient clinics that were often distant from their homes (Xiang et al., 2020). A three-pronged approach was used to manage patients. Logistical challenges to managing suspected and confirmed cases were addressed as follows: A 30-bed ward in an infectious disease hospital in Wuhan was first established for psychiatric patients on 3 February 2020 but the rapid escalation in cases and the hospital bed demand required delineating alternative, isolation wards in psychiatric hospitals for psychiatric patients with suspected and confirmed COVID-19, which carried the risk of nosocomial (hospital-acquired) infection. A third strategy was establishing temporary quarantine hospital facilities 'Fang Cang'), by converting gymnasiums, and exhibition and sports centres for this purpose, to manage clinically stable psychiatric patients with mild-moderate symptoms of COVID-19 infection (Xiang et al., 2020).

In summary, a comprehensive set of multi-sectoral interventions targeting mental health, well-being and resilience for the general population, and for vulnerable groups, will be needed in this country – during the lockdown and through the different stages of this evolving pandemic. We need to learn more about the vulnerable groups, locally, through sound research. There are a number of mental health studies in the planning at Stellenbosch University. We can certainly learn from the successes and challenges of other countries who are already deeper into this crisis. As this is a novel, ravaging and little known virus, let us rather over-estimate than under-estimate the mental health sequelae of this disease and the resources that will be required.

ABOUT THE AUTHOR: Prof Soraya Seedat is the head of the Department of Psychiatry at the Faculty of Medicine and Health Sciences, Stellenbosch University, and the SARChI Chair in PTSD.

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