From the Editor

We read often about the physical health effects of COVID. But how does this pandemic affect mental health?

This week’s Reading has three selections, with two focused on this question.

In the first selection, we consider the psychological effects of COVID on health care workers. In a new JAMA Network Open paper, Jianbo Lai (of Zhejiang University School of Medicine) and co-authors look at mental health outcomes and the factors associated with them in China. “Among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and front-line health care workers have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.”


During this pandemic, many Canadians are self-isolating; in the coming weeks, many could be quarantined. In the second selection, we consider a new Lancet paper on quarantine and its psychological impact. Samantha K. Brooks (of King’s College London) and her co-authors write: “Given the developing situation with coronavirus, policy makers urgently need evidence synthesis to produce guidance for the public. In circumstances such as these, rapid reviews are recommended by WHO.”

Finally, in the third selection, we look at a NYT essay by Dr. Donald Berwick (of Harvard Medical School). He discusses the way health care providers have risen to the challenge of COVID. “We are witnessing professionalism in its highest form, skilled people putting the interests of those they serve above their own interests.”


Selection 1: Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

Jianbo Lai, Simeng Ma, Ying Wang, et al.

JAMA Network Open, 23 March 2020


Since the end of December 2019, the Chinese city of Wuhan has reported a novel pneumonia caused by coronavirus disease 2019 (COVID-19), which is spreading domestically and internationally. The virus has been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this report, we will refer to the disease, COVID-19. According to data released by the National Health Commission of China, the number of confirmed cases in mainland China has increased to 80 151 as of March 2, 2020, and confirmed cases have been reported in more than a dozen other countries. Moreover, person-to-person transmission has been recorded outside mainland China. On January 30, 2020, the World Health Organization held an emergency meeting and declared the global COVID-19 outbreak a public health emergency of international concern.

“Facing this critical situation, health care workers on the front line who are directly involved in the diagnosis, treatment, and care of patients with COVID-19 are at risk of developing psychological distress and other mental health symptoms.

So begins a paper by Lai et al.

Here’s what they did:

  • The study is cross-sectional, survey-based, and region-stratified.
  • They involved 1 257 health care workers in 34 hospitals from 29 January 2020 to 3 February in China.
  • “One clinical department was randomly sampled from each selected hospital, and all health care workers in this department were asked to participate in this study.”
  • “We focused on symptoms of depression, anxiety, insomnia, and distress for all participants, using Chinese versions of validated measurement tools.” To that end, several scales were used, including the PHQ-9.

Here’s what they found:

  • Occupational background: “Of the 1257 responding participants, 493 (39.2%) were physicians, and 764 (60.8%) were nurses. The response rates for physicians and nurses were 70.2% and 67.7%, respectively.”
  • Geographic background: “Of the participants, 760 (60.5%) worked in Wuhan, 261 (20.8%) worked in Hubei province outside Wuhan, and 236 (18.8%) worked outside Hubei province. Most participants were women (964 [76.7%]), were aged 26 to 40 years (813 [64.7%]), were married, widowed, or divorced (839 [66.7%])…”
  • “A considerable proportion of participants had symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]).”
  • “Multivariable logistic regression analysis showed that, after controlling for confounders, being a woman and having an intermediate professional title were associated with severe symptoms of depression, anxiety, and distress (eg, severe depression among women: OR, 1.94… severe anxiety among those with intermediate professional titles: OR, 1.82…).” Not surprisingly, they also find a geographic connection (in Wuhan) and with actual work done (that is, in the care of those with COVID).

The authors write:

Protecting health care workers is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental well-being in health care workers exposed to COVID-19 need to be immediately implemented, with women, nurses, and frontline workers requiring particular attention.

This paper is interesting because it presents new data on a (relatively) new problem.

Of course, there are clear limitations here. The data only covers Chinese health care workers in one province of that country – and this pandemic now stretches across many countries. Survey data itself is limited, though they claim a high participation rate.

It should be noted that high scores on depression and anxiety scales are different than people meeting criteria for major mental illness. That’s not to minimize the experience of some health care workers, so much as to note that we must avoid pathologizing it.

Still, the authors call for more psychological support seems reasonable.


Selection 2: “The psychological impact of quarantine and how to reduce it: rapid review of the evidence”

Samantha K Brooks, Rebecca K Webster, Louise E Smith, Lisa Woodland, Simon Wessely, Neil Greenberg, Gideon James Rubin

The Lancet, 26 February 2020


Quarantine is the separation and restriction of movement of people who have potentially been exposed to a contagious disease to ascertain if they become unwell, so reducing the risk of them infecting others. This definition differs from isolation, which is the separation of people who have been diagnosed with a contagious disease from people who are not sick; however, the two terms are often used interchangeably, especially in communication with the public. The word quarantine was first used in Venice, Italy in 1127 with regards to leprosy and was widely used in response to the Black Death, although it was not until 300 years later that the UK properly began to impose quarantine in response to plague.

So begins a paper by Samantha K. Brooks and her co-authors.

Here’s what they did:

  • They did a review of the psychological impact of quarantine using three electronic databases.
  • Of 3 166 papers found, 24 were included.
  • Eight papers drew from the Canadian experience with SARS. (!)

Here’s what they found:

  • “Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger.”
  • Stressors during quarantine: longer quarantine duration, infection fears, frustration and boredom, inadequate supplies, and inadequate information.
  • Stressors post quarantine: finances and stigma.
  • “This Review suggests that the psychological impact of quarantine is wide­ranging, substantial, and can be long lasting.”

They make six specific recommendations to mitigate the consequences of quarantine:

Keep it as short as possible

“Longer quarantine is associated with poorer psychological outcomes, perhaps unsurprisingly, as it stands to reason that the stressors reported by participants could have more of an effect the longer they were experienced for.”

Give people as much information as possible

“People who are quarantined often fear being infected or infecting others. They also often have catastrophic appraisals of any physical symptoms experienced during the quarantine period… Ensuring that those under quarantine have a good understanding of the disease in question, and the reasons for quarantine, should be a priority.”

Provide adequate supplies

“Officials also need to ensure that quarantined households have enough supplies for their basic needs and, impor­tantly, these must be provided as rapidly as possible.”

Reduce the boredom and improve the communication

“Boredom and isolation will cause distress; people who are quarantined should be advised about what they can do to stave off boredom and provided with practical advice on coping and stress management techniques.”

They suggest that people under quarantine should have a mobile phone. They also find evidence for support lines.

Health-care workers deserve special attention

“Health­care workers themselves are often quarantined and this Review suggests they, like the general public, are negatively affected by stigmatising attitudes from others.”

Altruism is better than compulsion 

“Reinforcing that quarantine is helping to keep others safe, including those particularly vulnerable (such as those who are very young, old, or with pre­existing serious medical conditions), and that health authorities are genuinely grateful to them, can only help to reduce the mental health effect and adherence in those quarantined.”

This is a good paper, and adds nicely to the overall discussion of when to use quarantine (often simplified to the conflict between public health and individual freedom). The recommendations are particularly helpful, though it is a “rapid review,” and thus not as exhaustive as it could be. As well, the papers themselves are very different in their designs, populations, and assessment tools.

I note that the authors make some very specific recommendations that are interesting and practical. How to deal with the challenge of health care workers on quarantine? They note some evidence for phone support. What to do with marginalized populations? They wonder if there is a role for those who are quarantined to receive phones, not just food and supplies.


Selection 3: They Don’t Hide From the Coronavirus, They Confront It

Donald M. Berwick

The New York Times, 23 March 2020


‘I’m having flashbacks to the Boston Marathon bombing,’ my daughter said.

She was a newly minted physician on the day the bombs went off seven years ago, when the police rolled a man on a stretcher into her hospital’s emergency department. His blood had spilled onto the floor and someone began to wipe it away.

‘Don’t bother,’ the officer said, ‘there is a lot more where that came from.’ When she tells that story, my daughter always mentions the dread she felt. How many more victims would arrive, and when?

Now, she faces a similar sense of dread, as demand for Covid-19 care could swamp her hospital and patients who could have been saved may die as the ventilator supply runs out.

So begins an essay by Dr. Berwick.

He notes the good news story of this pandemic:

As the world writhes in the grip of Covid-19, the epidemic has revealed something majestic and inspiring: millions of health care workers running to where they are needed, on duty, sometimes risking their own lives. I have never before seen such an extensive, voluntary outpouring of medical help at such a global scale.

He mentions a few stories, including of an Italian physician:

Dr. Roberto Stella, age 67, was president of the medical association in the Varese region of northern Italy. When the supplies of protective equipment ran out, he continued to care for patients. A colleague quoted him: ‘We have run out of masks,’ he said, ‘but we don’t stop.’ Dr. Stella died from Covid-19 a few days after that in a Como hospital.

The essay does mention technological innovations through the pandemic:

  • “Intensive care doctors in Seattle connect with intensive care doctors in Wuhan to gather specific intelligence on what the Chinese have learned: details of diagnostic strategies, the physiology of the disease, approaches to managing lung failure, and more. The three-page, single spaced document, full of lessons, circulates immediately and widely through social media platforms, a gem borne of pure, professional commitment.”
  • “Facebook starts a “COVID-19 USA Physician/APP Group” on March 13. It has 57,000 members on March 15, and 105,000 on March 18.”
  • “The Journal of the American Medical Association, even while moving its staff home for social distancing, sets new records for speeding helpful scientific studies, peer reviewed, onto the web. Knowledge grows.”

Dr. Berwick is a terrific writer and speaker. This essay doesn’t disappoint. The story of Dr. Stella is moving (and humbling). Dr. Berwick also notes an interesting development: how technology has changed the way those of us in health care handle a crisis.

COVID isn’t the first pandemic; it is, however, the first one in the age of social media.

He mentions in this essay some examples, including a Facebook group with tens of thousands of physicians. I can think of other examples, not as big, but important nevertheless. At a Toronto hospital, for instance, ED physicians exchange information about handling COVID cases in real time using WhatsApp, posting images of X-rays and discussing lab results, not unlike a past generation might have had a conversation in the doctors’ lounge – but the conversation includes people in the hospital and those at home, unbound by geography. A short, practical, and amusing video by psychiatrist David Goldbloom on the do’s and don’ts of telemental health, tweeted about by a colleague here in Canada, is widely viewed in Israel by physicians, allowing our colleagues far away to tap Toronto knowledge. A group of Canadian medical students has put together a daily summary of the latest in COVID literature, emailed out to health care providers across the country (through MailChimp).

Twitter, it turns out, isn’t just about cat videos.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.