Expert Commentary

How infectious disease outbreaks affect mental health: Insights for coronavirus coverage

To help journalists cover the psychological effects of the coronavirus, we gathered research that looks at how the public and health care workers reacted to prior outbreaks.

mental health coronavirus disease outbreak research
(Unsplash/Alex Boyd)

Government officials and public health leaders worldwide have worked around the clock battling the new coronavirus. Meanwhile, another pandemic requires their attention — the anxiety, depression, grief and fear that spread across communities as the death toll rises and schools, businesses and public places close to prevent COVID-19 infections.

“It is not only the illness that becomes a pandemic, but the same can be inferred about fear, mourning, and despair,” Jacqueline Levin, a psychiatrist at North Shore University Hospital in New York, writes in Psychiatry of Pandemics. “Providing psychiatric care to survivors and healthcare workers in the aftermath of a pandemic outbreak is a complicated, but crucial, imperative in the service of reducing the burden of human suffering.”

Adults respond to crises in a patterned way, notes researcher Ronald W. Manderscheid, an adjunct professor at the Johns Hopkins Bloomberg School of Public Health who is also the executive director of two national mental health organizations, the National Association of County Behavioral Health and Developmental Disability Directors and National Association for Rural Mental Health.

While one-third of adults will be able to function normally, Manderscheid explains that others either will become immobilized or hyperactive and hypervigilant.

“One of the lessons of managing all crises — wars, pandemics, terror attacks, natural disasters — is that our ability to respond will be predicated upon our ability to keep large populations in good mental health and to mitigate panic while we all ride out the storm,” he writes in a paper published in the Archives of Psychiatric Nursing in February 2007.

To help journalists cover the coronavirus pandemic and governments’ response to it, we’ve gathered academic studies that examine how prior outbreaks of infectious diseases such as Ebola, H1N1 and Severe Acute Respiratory Syndrome (SARS) affected the mental health of the public and hospital staff.

Below, you’ll find research on the psychological consequences of a pandemic, including how people respond to quarantine and isolation, and how the social stigma associated with contagious diseases can harm survivors. To help newsrooms think about solutions to these problems, we’re also spotlighting solutions-oriented research.

Effects on patients and the public

Preparing for an Influenza Pandemic: Mental Health Considerations
Perrin, Paul C.; et al. Prehospital and Disaster Medicine, June 2009.

In this paper, researchers from the Johns Hopkins Bloomberg School of Public Health examine the mental health consequences of a pandemic. They explain “psychological contagion” and how emotions such as fear, paranoia and anger “may drive behaviors that can include evacuation panic, resistance to public health measures, overburdening of hospitals and clinicians, blaming of the government, and abandoning responsibilities to families and jobs.”

The authors also highlight factors that make some people more likely than others to suffer adverse psychological outcomes — for example, living with someone who has the disease, being female or elderly or having lower levels of education.

They note that personality plays an important role in mental health. For example, people who have an internal locus of control — they believe they have control over events that influence their lives — “cope better with all crises and catastrophes because they view themselves as being in command of their lives and destinies,” they write. “Conversely, those with an external locus of control view themselves as victims of fate with little perceived self-efficacy in being able to influence many life events and outcomes.”

Impact of Isolation Precautions on Quality of Life: A Meta-Analysis
Sharma, A.; et al. Journal of Hospital Infection, forthcoming.

While isolating patients may help contain the risk of infection, those who are isolated experience higher rates of depression and anxiety than those who are not, find researchers from the University of Calgary and Alberta Health Services in Canada. They reviewed all academic articles published on the topic before March 2019 to determine how isolation affects patients’ quality of life and mental health.

The researchers note that isolation “generally involve[s] separate isolation rooms, enhanced environmental cleaning, and the use of additional personal protective equipment.” Among the main takeaways: “All studies except one showed negative impact of isolation precautions on anxiety. All studies suggested negative effect of isolation precautions on depression.”

Impact of Isolation on Hospitalized Patients who are Infectious: Systematic Review with Meta-Analysis
Purssell E.; Gould D.; Chudleigh J. BMJ Open, January 2020.

This paper, another review of the research on how isolation affects infected patients, also indicates segregation can have negative consequences for mental health. A group of researchers from City, University of London reviewed studies they found through several research databases up through December 2018. They concluded that “there are a number of apparently negative aspects to contact precautions, in particular with regard to psychological effects and a reduction in the quality of some aspects of [medical] care.”

“The data from the comparative studies suggest that although in many cases infective isolation precautions make little difference to psychological outcomes, where it does make a difference this is primarily negative,” they explain. “There were significant declines in mean scores related to control and self-esteem, and in many studies increases in the mean scores for risk of anxiety and depression.”

The authors note that some studies found that hospital staff spent less time with segregated patients. “Internal medicine interns spent less time with their isolated patients compared with non-isolated patients, the median times being 5.2 and 6.9 [minutes], respectively,” they write.  Healthcare workers saw them fewer times. They saw isolated patients an average of 2.1 times per hour and other patients 4.2 times per hour. Healthcare workers did spend more time on each visit with isolated patients, though — 4.5 minutes, on average, as opposed to 2.8 minutes with patients who were not isolated.

Positive Mental Health-Related Impacts of the SARS Epidemic on the General Public in Hong Kong and Their Associations with Other Negative Impacts
Lau, Joseph T.F.; et al. Journal of Infection, August 2006.

Although the SARS epidemic of 2003 was traumatic for residents of Hong Kong, many residents also experienced positive changes as a result of the outbreak, including improvements in social support and family relationships, this study finds.

Researchers from the Chinese University of Hong Kong asked 818 Hong Kong residents aged 18 and 60 years to compare their lives during the two months leading up to the outbreak with their lives during the two months afterward. The researchers learned that “some positive changes due to SARS had also been fostered in [the] midst of the negative impacts on mental health.”

More than 28% of the people who participated in the telephone survey reported receiving increased support from friends after the SARS outbreak and 39% said they received more support from family members when they were in need. More than 35% of respondents said they began sharing their feelings more frequently with family members. Meanwhile, 35% to 40% of those interviewed reported spending more time resting, relaxing and exercising.

“The better social and family support observed was in line with intensive media coverage depicting a more coherent and harmonious atmosphere in Hong Kong,” the researchers write. “Family and friends were much valued in this crisis. Family members were more likely to be spending time together with each other as they worried about and avoided going to public places.”

Survey Among Survivors of the 1995 Ebola Epidemic in Kikwit, Democratic Republic of Congo: Their Feelings and Experiences
De Roo, Ann; et al. Tropical Medicine and International Health, November 1998.

This study focuses on the experiences of 34 survivors of the 1995 Ebola epidemic in the Democratic Republic of Congo. Most had cared for sick family members before becoming infected themselves.

While many survivors watched friends and loved ones die of the disease and reported feeling rejected by society, all said they experienced an increase in religious faith. “All survivors felt they were strengthened through their belief in god,” the authors write. “And although most had lost family members, their religious belief was even greater after the epidemic.”

Effects on healthcare professionals

Local Public Health Workers’ Perceptions Toward Responding to an Influenza Pandemic
Balicer, Ran D.; et al. BMC Public Health, April 2006.

More than half of the 300-plus public health workers surveyed for this study said they likely would not report for duty during a pandemic. This paper, from researchers at Ben-Gurion University of the Negev and Johns Hopkins Bloomberg School of Public Health, examines the reasons employees at three county health departments in Maryland said they would be unlikely to show up for work during a pandemic influenza-related emergency.

The researchers note that 33.1% of study participants were clinical staff, including dentists, nurses and physicians. This group indicated a higher likelihood of reporting to work than did technical staff and support employees, who comprised 22.4% of the sample.

Nearly 70% of all employees who completed the anonymous survey in 2005 said they believed they’d be taking a personal risk by working during such an event. Most also said they did not think they would be asked to report to work. The researchers found that employees who were most willing to report to work tended to perceive themselves as being better able to address questions from concerned members of the public. They also were more likely to perceive their jobs as important to the health department’s response to the crisis.

“Lack of knowledge, ambiguity regarding one’s exact tasks, and questionable ability in performing one’s role as risk communicator were all significantly associated with a higher perceived personal risk and a two- to ten-fold decrease in willingness to report to duty,” the researchers write.

The Immediate Psychological and Occupational Impact of the 2003 SARS Outbreak in a Teaching Hospital
Maunder, Robert; et al. Canadian Medical Association Journal, May 2003.

 This study looks at the psychological and occupational impact of a SARS outbreak on a large hospital in Canada during the first month of the outbreak in 2003. In those first four weeks, 19 people developed SARS, including 11 health care workers.

“Prominent among the varied responses of individual staff members were themes of fear, anxiety, anger and frustration,” write the authors, who, at the time of the study’s publication, worked at Mount Sinai Hospital in Toronto, a teaching hospital affiliated with the University of Toronto. “Many expressed conflict between their roles as health care provider and parent, feeling on one hand altruism and professional responsibility and, on the other hand, fear and guilt about potentially exposing their families to infection. Some nurses on units that had no patients with SARS felt that their needs became secondary. Collaboration and collegiality were observed in units that volunteered to send staff to other units to assist with care.”

Supervisors and other leaders felt compelled to be at work. “Throughout the hospital,” the authors explain, “it was found that many staff required ‘permission’ from peers or supervisors to refrain from doing too much … There were wide discrepancies in workload between those subjected by circumstances or personal attitudes to over-work and those prevented from working by quarantine or a ‘nonessential’ designation.”

Stigma associated with infectious disease

Influenza Stigma During the 2009 H1N1 Pandemic
Earnshaw, Valerie A.; Quinn, Diane M. Journal of Applied Social Psychology, May 2013.

This study looks at how the stigma associated with H1N1, also known as swine flu, compares with the stigma associated with infectious diseases such as AIDS and cancer. Researchers examine the role stigma plays in people’s desire to separate themselves from someone who has been infected with a harmful, contagious illness.

“Understanding the relationship between stigma and people’s desire for physical distance from others with infectious disease is critical to the extent that it can inform strategies to protect public health during future influenza pandemics,” write the researchers, from Yale University and the University of Connecticut.

The scholars wanted to know whether healthy individuals would continue to avoid people with an infectious disease if the stigma did not exist. To find out, they conducted an online survey in November 2009, at the height of the H1N1 pandemic in the U.S. They sought feedback from college students — 219 students at the University of Connecticut — because they were among the subgroups with an elevated risk of H1N1 infection, the authors note.

What they learned: University students felt more prejudice toward people infected with H1N1 than those living with cancer or HIV/AIDS. Their survey responses also indicate that “reductions in influenza stigma may not entirely undermine public health officials’ goals to increase physical distancing.”

“Although prejudice contributes to the relationship between H1N1 threat and physical distance, the relationship between H1N1 threat and physical distance would remain without prejudice,” the authors explain. “Consequently, it may be possible to reduce people’s feelings of prejudice toward others with influenza while maintaining their desire for distance from others with influenza.”

Addressing Disease-Related Stigma During Infectious Disease Outbreaks
Fischer, Leah S.; et al. Disaster Medicine and Public Health Preparedness, December 2019.

In this paper, researchers discuss how the social stigma associated with infectious disease outbreaks can harm people who are living with the disease and hinder public health officials’ efforts to detect and prevent it in communities.

“People may hold prejudices and perpetuate discriminatory behavior based on such stigma,” write researchers from the U.S. Centers for Disease Control and Prevention. “Stigma may be internalized by people who currently have a disease or who have survived a disease. Stigmatized individuals may see themselves as inferior to others and worthy of self-hate due to their disease status.”

The stigma associated with a disease can discourage people from getting tested and seeking treatment. The researchers note that a review of 21 studies published from November 2006 to February 2007, found that HIV-related stigma is associated with lower odds of people disclosing they have HIV.

“Health-related stigma and the perception that one might be HIV-infected were also associated with never receiving an HIV test among black/ African American and Hispanic/Latino young adults, lower medication adherence, and higher levels of depression, anxiety, excessive worry, avoidant coping strategies, and suicidal ideation,” the authors write. “HIV stigma has been associated with substance abuse and sexual risk-taking.”

As a part of their analysis, the researchers outline six steps to help identify and reduce stigma before, during and after an infectious disease outbreak.

Solutions-oriented research

Coping With Stress During Infectious Disease Outbreaks
Report from the U.S. Substance Abuse and Mental Health Services Administration, October 2014.

This report discusses how people might react after learning about an infectious disease outbreak and which responses are common signs of anxiety and stress. The report also offers advice on how to manage and alleviate stress and know when to ask for professional help.

For example, the authors recommend people pay attention to their feelings. “Recognize how your own past experiences affect your way of thinking and feeling about this event, and think of how you handled your thoughts, emotions, and behavior around past events,” they write.

Another suggestion: Limit time spent reading or watching news about the outbreak. “You will want to stay up to date on news of the outbreak, particularly if you have loved ones in places where many people have gotten sick. But make sure to take time away from the news to focus on things in your life that are going well and that you can control.”

The H1N1 Crisis: A Case Study of the Integration of Mental and Behavioral Health in Public Health Crises
Pfefferbaum, Betty; et al. Disaster Medicine and Public Health Preparedness, March 2012.

This academic article summarizes the Disaster Mental Health Subcommittee’s observations and recommendations for meeting the public’s mental health needs during a public health crisis such as the H1N1 pandemic. The subcommittee is part of the National Biodefense Science Board, which provides expert advice to the secretary of the U.S. Department of Health and Human Services on issues related to current and future chemical, biological, nuclear and radiological agents, including infectious diseases.

The subcommittee stressed the need for “an integrated approach to addressing mental and behavioral health issues across the broader range of public health preparedness and response activities,” the authors explain. It recommended interventions that “address uncertainty, enhance resilience and coping, and foster adaptive behavior in dealing with messaging and community mitigation strategies as well as the disease itself.”

The subcommittee also noted the importance of both the content and delivery of public health-related messages. “With respect to content, the subcommittee suggested that messages anticipate issues that have high psychosocial impact, such as perceived scarcity of resources, varied implementation of federal guidance across state and local jurisdictions, and perceived fairness and equity,” the paper’s authors write.

The subcommittee also pointed out the need for public education about how people’s mental health and behavior might be affected by disasters and where they could go for help.

Stigma, Health Disparities, and the 2009 H1N1 Influenza Pandemic: How to Protect Latino Farmworkers in Future Health Emergencies
Schoch-Spana, Monica; et al. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, September 2010.

This paper looks at how the 2009 H1N1 pandemic affected migrant and seasonal farmworkers in the U.S. The authors also outline five steps the country can take to better protect these individuals, who are especially vulnerable to pandemic influenza because of their economic, health and social status.

At the outset of the 2009 H1N1 influenza, which originated in Mexico, the authors explain that “Mexican nationals and Mexican commodities were shunned globally, and, in the United States, some media personalities characterized Mexican immigrants as disease vectors who were a danger to the country.”

To better understand the barriers farmworkers faced in getting vaccinated against H1N1 and seeking medical treatment, researchers interviewed 31 executives from community clinics, government agencies and advocacy organizations as well as industry and academic experts.

After completing the interviews, the researchers, from the Johns Hopkins Center for Health Security and a nonprofit research organization called the Center for Biosecurity, made these five recommendations

  • “Anticipate the problem of stigma; incorporate protections into preparedness planning.”
  • “Design culturally competent campaigns for education, mass prophylaxis, and treatment targeted at migrant and seasonal farmworkers during a health emergency.
  • “Improve housing and work conditions to enable migrant and seasonal farmworkers to follow public health guidance on disease containment.”
  • “Expand the reach of the U.S. healthcare system to provide adequate protections for migrant and seasonal farmworkers, including those who are undocumented.”
  • “Implement immigration reforms that move migrant and seasonal farmworkers from the margins of society.”

The researchers note that expanding services that improve the physical and mental health of migrant and seasonal farmworkers helps keep Americans healthy. “People who are scapegoats are often reluctant to seek medical care when they are sick and go ‘underground,’ putting themselves and others at risk,” they write. “From a herd immunity perspective, raising the level of farmworkers’ access to basic prevention and treatment services may reduce the opportunity for disease transmission within the larger population.”


Need help covering COVID-19? We teamed up with Harvard epidemiology professor Bill Hanage to create a tip sheet offering guidance on such things as choosing experts andassessing the newsworthiness of new theories and claims. Another one of our tip sheets features advice on preparing to cover epidemics from veteran health reporter Helen Branswell. We’ve got lots of other resources to help journalists understand and ask good questions about the new coronavirus.

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