Mental health during the COVID-19 pandemic

        COVID-19 is a respiratory disease caused by the SARS-CoV2 virus. While it can infect almost everybody, certain populations are at risk of developing severe/critical cases that endanger and even cost people their lives. The main reason for the lethality of this virus has not been determined.  This is why people are asked to maintain physical distance and reduce the risk that a member of a vulnerable population becomes infected. This distancing also reduces the chance that hospitals or healthcare professionals become overwhelmed by a sudden increased in people with respiratory disease.  Keep in mind, that along with new COVID-19 cases, there are other patients that these professionals encounter on a daily basis, since people haven’t stopped having accidents or other health complications.

         These preventative measures (distancing) are likely to increase stress and the development of mental health disorders. While our bodies have “built-in” mechanisms for coping with short and long term stress, prolonged stressful situations may lead to:

• Anxiety: a generalized fear or feeling of dread about anticipated events. Anxiety has verifiable physiological responses and long term pathological consequences.
• Depression: a generalized lack of desire or interest in normal activities, feelings of hopelessness, changes in appetite and changes in sleep patterns.
• Post-traumatic stress disorder (PTSD): is characterized by distressing thoughts associated with a traumatic event, nightmares, changes in thoughts and moods and avoidance behavior. Those affected typically have to deal with long-term consequences of the traumatic situations that caused PTSD.

         In this article you will find information about the effects of corona-virus infection on the human central nervous system. It will explore the effects of physical distancing and quarantining based on previous viral outbreaks. Finally, there will be recommendations regarding the best steps you can take to minimize the impact of physical distancing and/or isolation on your mental health.

Current approaches to control the COVID-19 pandemic

         Physical distancing (often erroneously called social distancing) is the practice of maintaining at least six feet (two meters) of distance between each individual. This is to reduce the likelihood that respiratory droplets from an infected person may find their way into the respiratory track of a healthy person, infecting the healthy person ¹.

         A second strategy is to shelter in place and shares the same purpose as physical distancing. By remaining in a location for extended periods of time, individuals reduce their risk of coming into contact with surfaces that may contain virus or coming into contact with an individual that is infected. It also has the added benefit of reducing your likelihood of having an accident outside of your home.

         People that have been infected with the virus and have recovered are asked to isolate from others while their bodies naturally get rid of the remaining virus. This is because the virus can remain in recovered individuals for many weeks ². Even with common colds (which COVID-19 is not) this is good advice, because individuals can remain infectious days after they start to “feel better”.

         People with COVID-19 and are hospitalized with respiratory distress often receive a combination of respiratory therapy and experimental medications meant to reduce the development of life-threatening complications. Various trials are currently underway to develop vaccinations which may provide long-term protection against the SARS-CoV2 virus.

         All of these strategies are meant to “flatten the curve” by reducing the number of people that are infected with SARS-CoV2 and reduce the number of people requiring treatment in the hospital.

Effects of corona virus infection on the central nervous system

         While we still don’t know much about how COVID-19 disease progression affects the central nervous system (CNS), there is some literature regarding infection by other corona viruses. The following section reviews the literature regarding the consequences of mental health in two previous outbreaks: SARS and MERS.

         Viral infection results in increased production and release of inflammatory proteins called cytokines (Note: cytokines are a very complex protein class and sometimes have inflammatory roles, while they sometimes have anti-inflammatory roles. To make this even more confusing the roles they have are dependent on the cell and its surrounding environment). Increased stress reduces proper regulation of the immune system leading to increased and unregulated inflammation. This inflammatory activity in the brain may contribute to cognitive impairment.  For example, an overwhelming immune response known as “cytokine storm” can allow inflammatory mediators, like cytokines and chemokines into the brain and can have long-lasting consequences on the brain ^3,4. For example, research in laboratory mice infected with SARS-CoV1 have reported increased cytokines in the CNS and neuron cell death (Netland et al., 2008). Increased cytokines throughout the body increase immune cell infiltration into the CNS, and their entry disrupts normal neurological function ⁶.  In humans, coronavirus infection (SARS-CoV1), caused central nervous system damage ⁷. Long term consequences of exposure to the SARS-CoV1 virus include symptoms of post-traumatic stress disorder (PTSD), depression, pain disorder, panic disorder and obsessive compulsive disorder ⁸.

         Although there is currently no evidence that COVID-19 can cause degenerative neurological disease (Troyer et al.,  2020), it is important to remember that it is a new disease in the human population. Currently,  consequences of COVID-19 include loss of smell and taste ¹⁰.

Effects of control strategies on mental health and what to expect

         The strategies employed to reduce the spread of COVID-19 are unparalleled in the experience of most contemporary Americans. Humans are social animals and as such, it is not easy to practice physical distancing. Therefore these experiences likely contribute to increased stress during the pandemic. In fact, previous populations dealing with coronavirus outbreaks have reported high incidence of psychological distress ³. Consequently, you can expect to feel increased anxiety. This is because we worry about our own health and the health of close relatives. We also worry about the health of the entire population of our country and all of humanity. The anxiety is worsened by feelings of inadequacy in being able to ensure the safety of the family. Many people, even those not living by themselves, might feel lonely which increases anxiety.

         An increased sense of fear is also normal. This fear comes from increased scrutiny of our own behaviors and the behavior of others. Initially, the pandemic fear was also caused by difficulty in securing groceries.

         An important source of frustration is the temporal aspect of a pandemic. We are easily frustrated when we don’t know how long things will remain in the current (undesirable) condition. This may lead to lose one’s temper, and makes it easier to feel anger towards the behavior of others, especially when you believe they are putting your security at risk. All of these contribute to an increased desire to use alcohol or other drugs as a coping mechanisms.

         Finally, health care professionals aiding COVID-19 patients are at increased risk of post-traumatic stress disorder (Lee et al.,  2018). These personnel must manage the responsibilities of their jobs along with all of the aforementioned stressors. We will continue to learn about the consequences of infection for a long time. It is important to consider that people may develop neurological disease as a consequence of COVID-19. This means that we may need to mobilize mental health personnel to affected areas and monitor people, including the health of the professionals currently addressing the physical symptoms of the pandemic. This is likely going to require a long term commitment and resources.

Recommendations ¹²

Physical distancing, isolation and quarantines are likely to impact our mental health. What actions can we take to reduce the impact of these strategies?

1) Be aware and manage expectations

All of the strategies we are currently using to “flatten the curve” are likely to have psychological consequences. These are stressful times. Be aware that you are stressed. This is normal.

You will likely be less productive when trying to work from home. This is normal and to be expected. Take it easy on yourself and the goals you set. You will have to learn to re-evaluate your productivity under new circumstances.

2) Maintain your daily routines

Identify parts of your daily routine that are changing. Acknowledge that things have changed, but don’t give yourself a hard time. Everything has changed. It’s natural that some of the daily routines are changed.

Maintain your routine as much as possible. The previous point aside, if a particular part of your routine doesn’t need to change, then work as hard as possible to maintain that part of the routine in your day.

• • If you usually workout in the mornings or afternoons, before work or after work, then continue to do that.
  • Wake up at the same time you used to when you were traveling to a workplace.
  • Shower, shave, clean your teeth on your regular schedule.
  • Get dressed and prepared the same way as if you were commuting to your workplace.

3) Develop good sleep practices. Sleep is important to proper emotional responses ¹³. Recommendations ¹⁴ to enhance your sleep hygiene include:

Increase your exposure to sunlight. Indirect sunlight is effective so open up your blinders or curtains.

Reduce caffeine and alcohol. Especially 2-3 hours before bed.

Exercise is great and helps with sleep. But you should not hit the gym or exercise right before going to bed. Also, don’t put any stress on your workout. Exercise helps, stress does not.

Don’t keep a clock in your bedroom, since you will feel tempted to check it in the middle of the night.

Do not use your bed for anything other than sleep or sex. No eating, reading, working or talking on the phone while in bed.

Always go to bed at the same time. Always get up from bed at the same time.

Develop a sleep routine and strategy during your waking hours. Do not try to figure out how you are going to fall asleep when you are in bed. This will cause stress and reduce the chance you will fall asleep.

You should only take sleep aid drugs that may be “habit forming” under medical advice and supervision. These drugs may be useful if taken under these conditions and relatively short periods of time. They are also likely to be appropriate if a mental health professional has previously diagnosed other mental disorders.

4) Improve awareness of yourself.

Breathe: focus on your breath. How do you breathe? How long does it take you to inhale and exhale? Do you breathe differently under different circumstances? Focusing on your breath will help you become more self-aware.

Take your body temperature: While it has been generally acknowledged that the temperature of an average human is 98.6 ⁰F (37 ⁰C) it has recently been reported that the “average” body temperature changes over time (Protsiv et al.,  2020). Changes like improved hygiene, better diets and awareness of germ theory have contributed to reducing the “average” body temperature. What is your average temperature? Does your body temperature change with activities you are carrying out or time of day?

Keep a Journal: Consider keeping a journal while starting new projects at home to monitor your thoughts and reactions to new projects. Especially notice differences between the methods you use and those of collaborators or teachers.

5) Be compassionate.

First and foremost, be compassionate towards yourself. It is hard to acknowledge stress, but be aware that you are feeling it. Be aware of your complaints to others. It is normal to complain, but be aware that you are doing it. Understand the purpose of your complaint and the basis of your arguments.

Be compassionate towards others. Everyone is stressed. They might be lacking sleep, feel lonely, anxious and/or depressed. Not everyone will have the best strategies to deal with the stress of the situation. Be understanding of others view-points, even when you don’t share them. You can share your best resources to reduce stress with others.

6) Stay in touch with family and friends. Remember the strategy is physical distancing, not social distancing. You can take advantage of all of methods of communication available to us in the 21^st century. Reach out to those you love and share with them your feelings, including your frustrations and personal victories.

7) Understand the current situation, the risks to yourself and to others.

Identify and use credible sources of information.

Stay in the present. There is a lot of information (including this page) that tries to contextualize our current situation.

• • Using historical analogies or trying to borrow observational data from other events that have caused people to physically distance is useful.
  • It is important to understand that the current situation presents unique challenges and will require unique solutions.
  •  
  • Communicate with family, friends, collaborators and ask them for resources they believe may be able to provide reliable information.

Discuss similarities and differences of the measures being taken in your communities. Share the best ideas and try to enhance our response as a society.

Communicate your ideas about COVID-19. Talk to people you trust about your attitudes towards those that are infected. Discuss possible sources of stigma. Challenge ideas you disagree with in a respectful manner.

Be happy, stay healthy. Happiness and a healthy lifestyle will boost your immune system.

Acknowledgements:

We would like to thank Yasmin Diodonet, LCPC, for her revision of this article.

Bibliography:

1. Chu, D. K. et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet (London, England) 6736, 1–15 (2020).
2. Zhou, F. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 6736, 1–9 (2020).
3. Kim, H. C., Yoo, S. Y., Lee, B. H., Lee, S. H. & Shin, H. S. Psychiatric findings in suspected and confirmed middle east respiratory syndrome patients quarantined in hospital: A retrospective chart analysis. Psychiatry Investig. 15, 355–360 (2018).
4. Mak, I. W. C., Chu, C. M., Pan, P. C., Yiu, M. G. C. & Chan, V. L. Long-term psychiatric morbidities among SARS survivors. Gen. Hosp. Psychiatry 31, 318–326 (2009).
5. Netland, J., Meyerholz, D. K., Moore, S., Cassell, M. & Perlman, S. Severe Acute Respiratory Syndrome Coronavirus Infection Causes Neuronal Death in the Absence of Encephalitis in Mice Transgenic for Human ACE2. J. Virol. 82, 7264–7275 (2008).
6. Dantzer, R. Neuroimmune interactions: From the brain to the immune system and vice versa. Physiol. Rev. 98, 477–504 (2018).
7. Wu, Y. et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain. Behav. Immun. 1–5 (2020). doi:10.1016/j.bbi.2020.03.031
8. Lam, M. H. B. et al. Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors long-term follow-up. Arch. Intern. Med. 169, 2142–2147 (2009).
9. Klopfenstein, T. et al. Features of anosmia in COVID-19. Med. Mal. Infect. 4–7 (2020). doi:10.1016/j.medmal.2020.04.006
10. Troyer, E. A., Kohn, J. N. & Hong, S. Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms. Brain. Behav. Immun. 0–1 (2020). doi:10.1016/j.bbi.2020.04.027
11. Vorspan, F., Mehtelli, W., Dupuy, G., Bloch, V. & Lépine, J. P. Anxiety and Substance Use Disorders: Co-occurrence and Clinical Issues. Curr. Psychiatry Rep. 17, (2015).
12. Lee, S. M., Kang, W. S., Cho, A. R., Kim, T. & Park, J. K. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr. Psychiatry 87, 123–127 (2018).
13. Dickerson, D. Seven tips to manage your mental health and well-being during the COVID-19 outbreak. Nature (2020). doi:10.1038/d41586-020-00933-5
14. Simon, E. Ben et al. Losing neutrality: The neural basis of impaired emotional control without sleep. J. Neurosci. 35, 13194–13205 (2015).
15. Altena, E. et al. Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy. J. Sleep Res. 1–7 (2020). doi:10.1111/jsr.13052
16. Protsiv, M., Ley, C., Lankester, J., Hastie, T. & Parsonnet, J. Decreasing human body temperature in the United States since the industrial revolution. Elife 9, 1–11 (2020).