Coronavirus disease 2019 (COVID-19) and the response efforts created an omnipresent effect of COVID-19 to individuals in the United States and globally in 2020. This literature review was written in 2021, one year after the outbreak, and recent studies have reported that the COVID-19 pandemic was an event that elicited behavioral, emotional, and psychological turmoil and can be considered as a traumatic event (Ettman et al., 2020).  Individuals living through community-wide disasters, such as viral infections, have an immediate risk to their mental and physical health as well as their social relationships (Norris et al., 2002). Therefore, one’s mental health is sensitive to traumatic events as well as the social and economic consequences (Ettman et al., 2020). This literature review will examine the behavioral, emotional, and psychological turmoil such as increased anxiety, depression, substance use, post-traumatic stress symptoms and how it has been connected to previous viral illnesses and the implications from the COVID-19 pandemic.

Viral Infections and Illnesses

Viral infections and their mental health effects have been well documented as early as the 20^th century. In the 20^th century, there have been three major viral and illness outbreaks: ‘Spanish flu’ in 1918, ‘Asian flu’ in 1957, and ‘Hong Kong flu’ in 1968 (Douglas et al., 2009). The ‘Spanish flu,’ a H1N1 virus, is a noteworthy virus of the 20^th century. The ‘Spanish flu’ spread was catastrophic as it spread across the globe resulting in 500 million individuals becoming infected and approximately 50 million deaths. However, the purpose of the literature review will examine more recent, well documented, and studied viral outbreaks.

A more recent viral infection, COVID-19, stemmed from the Corona Virus family in late 2019. COVID-19 was first reported in the Wuhan, China; shortly thereafter, on January 7^, 2020, the novel Corona Virus was genetically sequenced and found to be linked to the respiratory disease (World Health Organization, 2020)

Implications of COVID-19 Illness Outbreak

The COVID-19 outbreak in 2020 caused many countries around the globe to initiate health response efforts to decrease the transmission of the virus which effected individuals’ physical and mental health. The response efforts vary in their swiftness to initiate precautionary health measures for their citizens which included banning travel, avoiding mass gathering, and even banning or limiting the amount of outdoor exercise (Frank & Grady, 2020). In the United States, 42 states were placed in a stay-at-home or shelter-in-place advisories which affected approximately 316 million individuals or 96% of the population. Due to these advisories, individuals have experienced disruption to their daily routine, physical and social isolation, food insecurity, and unemployment and financial stress (Ettman et al., 2020). Individuals also experienced disruption in social engagement such as avoiding crowded places and limiting their use of public transportation to reduce transmission of the virus (Usher et al., 2020). The viral symptoms created unique global challenges due to the increase susceptibility compared to other viral infections and their high mortality rate (World Health Organization, 2018). In response to the rapid and lethal spread of the virus, many countries created policies to enter into a “lockdown” to prevent the COVID-19 spread (Frank & Grady, 2020).

Quarantine vs. Isolation

It is important to note that the individuals experiencing COVID-19 cannot be accurately described as undergoing quarantine or isolation because of the unyielding nature of the virus and the various response to the virus on a national level. Social isolation, whether quarantine or isolation, creates a negative, unpleasant experience. The unpleasant experience of social isolation is often exacerbated if they are diagnosed with a contagious disease (Brooks et al., 2020). Individuals are separated from their families and loved ones while experiencing a loss of freedom as well as an uncertainty of the duration of their current state (Brooks et al., 2020). The negative effects may also include post-traumatic stress symptoms, stress, boredom, fear, frustration, inadequacy, and financial loss (Esterwood & Saeed, 2020). Children during quarantine and isolation reported experiencing isolation, social exclusion, and fear from other children due to school closures, and disruption to their daily routine (Esterwood & Saeed, 2020).

Viral Illnesses Impacting Diversity Issues: Racial, ethnic, age, and low socioeconomic status

Viral illnesses and their effects on mental health are not evenly distributed across the population. Individuals who have lower incomes and less accumulated wealth are more likely to experience mental illness; particularly, those who are unemployed and experiencing financial hardship (Ettman et al., 2020). Historically, racial and ethnic minoritized individuals experience a disproportionate burden of death and illness during public health emergencies such as the 2009 H1N1 virus and the Zika virus (Center for Disease Control and Prevention, 2021). COVID-19, among other viral infections, negatively affect vulnerable groups like racial and ethnic minorities but also younger adults, health care workers, caregivers or caretakers, as well as those individuals’ receiving treatment for a pre-existing psychiatric condition (Stephenson, 2021). According to the CDC, approximately 75% of individuals between 18 to 24 and 50% of individuals between the ages of 25 to 44 reported at least one mental or behavioral health symptom due to COVID-19 (Stephenson, 2021). In regard to racial groups being affected by viral infections, 52% of Hispanics reported they were negatively impacted by COVID-19 (Stephenson, 2021). Additionally, 21% of Hispanic and 19% of Black individuals had seriously considered suicide within the past 30 days (Stephenson, 2021). Although the rates for mental health issues do not significantly differ among the general population, there are ethnic and racial disparities for mental health services that result in Black and Hispanic individuals having decreased access to mental health and substance use treatment (Double Jeopardy, n.d). Some racial and ethnic minorities live in densely populated areas such as low income areas, public housing, or multigenerational homes making it more difficult to social distance or self-isolate (Double Jeopardy, n.d). Also, social racial and ethnic disparities create inadequate assess to clean water and plumbing, as well as jobs that do not offer the paid time off or the option to work from home (Center for Disease Control and Prevention, 2021).  These factors contribute the inability to comply with the COVID-19 mandates to help reduce the risk of spreading the transmission of the virus (Center for Disease Control and Prevention, 2021).

The decreased access to mental health services compounded with the additional stressors of COVID-19 results in racial minorities, Black and Hispanics, to have at higher vulnerability of experiencing mental health issues such as anxiety and mood disorders due to COVID-19 (Double Jeopardy, n.d). The higher vulnerability experienced by racial and ethnic minorities affects their ability to anticipate, confront, repair and recover from the effects from a viral illness (Center for Disease Control and Prevention, 2021).

Overview of Anxiety and Mood Disorders Related to Illnesses and Pandemics

Anxiety and mood disorders are common mental health conditions in the general population around the world (Coughlin, 2012). Mood disorders are expected to be the second leading cause of global disease by 2030 (Okusaga et al., 2011). Anxiety and mood disorders is a broad category that encompasses Generalized Anxiety Disorder (GAD), Post-Traumatic Stress Disorder (PTSD), Acute Anxiety Disorder, Panic Disorder, Major Depressive Disorder (MDD), Bipolar Disorder, and other mood disorders (Coughlin, 2012). The scope of the literature review will also include suicide to understand the severity and toll one’s mental illness imposes on an individual. Also, the risk of attempting suicide is significantly higher in individuals with a mood disorder diagnosis (Okusage et al., 2011).

Anxiety and Response to Viral Infections, Illnesses, and Pandemics

Anxiety, also with other associated behaviors and emotions, was a commonly seen diagnosis in reaction to previous pandemics. Individuals in England, Scotland, and Wales engaged in significant behavioral changes as a precautionary measure after the H1N1 Swine flu (Rubin et al., 2009). The significant behavioral changes included increased hand washing and surface cleaning in over 38% of the individuals in the study (Rubin et al., 2009). In 5% of individuals, there was avoidance behavior such as avoiding large crowds or using public transportation (Rubin et al., 2009). The changes in the behavior was correlated with high levels of anxiety in the individuals becoming infected with the virus (Rubin et al., 2009).

Jeong et al. (2016)’s study examined individuals that were isolated for two weeks because they had been in contact with patients infected with MERS. Jeong et al. (2016)’s study examined the prevalence of anxiety symptoms, as well as anger, from being infected with MERS during the isolation period and four to six months after the isolation period. The results indicated 47% of individuals experienced anxiety symptoms during the isolation period and 19.4% of the individuals continued to experience anxiety four to six months after the isolation (Jeong et al., 2016). An additional study examined 1700 individuals in 2105 during the MERS Korean outbreak (Sergeant et al., 2020). Individuals with a pre-morbid mental health disorder had an increase in the likelihood of developing persistent anxiety post exposure (Sergeant et al., 2020). This study indicated the lasting effects of anxiety and how it can be experienced after one is infected with a viral illness.

Aside from an increased prevalence of anxiety in individuals infected with a virus, care takers also experience similar psychological outcomes. Care takers, also frequently referred to as caregivers, are defined as individuals that are a family member or friend, healthcare worker, or a nontraditional healer who is treating the sick (Van Bortel et al., 2016). Elizarrarás-Rivas et al. (2010)’s study examined the psychological response of family members of patients hospitalized for H1N1 in Mexico. The majority of family members in the study reported sub-threshold levels of stress and depression however, the levels of anxiety were much higher. Approximately 75% of family members reported levels of anxiety and 15% reported high levels of anxiety for their family member that was infected with H1N1 virus (Elizarrarás-Rivas et al., 2010). Elizarrarás-Rivas et al. (2010)’s results also determined that older age, higher level of education, and the female gender were variables that are more strongly associated with higher reports of anxiety (Elizarrarás-Rivas et al., 2010).

Anxiety was also seen in caretakers during the Ebola Virus. During the Ebola Virus, care takers began to feel significant fear, anxiety, as well as helplessness that they may be exposed to the virus and succumb to their own death (Van Bortel et al., 2016). Additionally, care takers began experiencing the psychological effects such as anxiety, frustration, and grief in their responsibilities to care of the individual, particularly if the individual was a family member (Van Bortel et al., 2016). The caretakers’ frustration stemmed from the guilt of being unable to look after or save their patients (Van Bortel et al., 2016). The frustration and guilt was coupled with working long hours, overwhelmed with caring for multiple individuals, limited safety equipment, and the high mortality rate of the Ebola Virus (Van Bortel et al., 2016). The increased level of anxiety effected not only care takers on an individual level but also on a community level. At a community level, there are psychological consequences such as disruption and uncertainty of the future as the community members shift into new roles that were previously occupied of those who had passed away.

Depression and Response to Viral Infections, Illnesses, and Pandemics

Depression was another commonly seen diagnosis in previous viral infections as an implication for one’s mental health. Park et al. (2020)’s study conducted a 12 month investigation of long term mental health outcomes of related risk factors in individuals that were exposed to MERS in Korea. PTSD and Depression were  the main outcomes measured the Park et al. (2020)’s study. Park et al. (2020)’s study found in the post-infection phase with MERS, individuals reported a 27% depression rate after 12 months This rate of depression was more comparable than individuals infected with SARS in Hong Kong with a depression diagnosis rate of 13.3% (Mak et al., 2010).

Bah et al. (2020)’s study examined the prevalence and predictive factors of anxiety, depression, and PTSD among individuals that have been infected with the Ebola Virus. Bah et al. (2020)’s results concluded close to half of the individuals that were infected with the virus showed the possibility of meeting the criteria for depression. This is consistent with other studies that examined individuals in Sierra Leone and found a 35% rate of depression four months after receiving care of the Ebola Virus (Bah et al., 2020). The literature also supports Keita et al. (2017) results that examined long term depression rates in individuals infected with the Ebola Virus. Keita et al. (2017) concluded individuals that were infected with Ebola Virus in Guinea, for a period of around 8 months, had a 15% rate of presenting with depressive symptoms.   Furthermore, the depressive symptoms created negative consequences such as individuals having difficulty reintegrating in society (Keita et al., 2017). Previous literature has also indicated that females have higher rates of depression than males (Keita et al., 2017). However, the depressive symptoms identified in the individuals did not appear to present a particular pattern or how an individual responded to the treatment in this study (Keita et al., 2017).

Post-Traumatic Stress Disorder and Response to Viral Infections, Illnesses, and Pandemics

Wu et al. (2008)’s study examined 549 hospital employees from a hospital in Beijing during the 2003 SARS outbreak. The initially study sought to examine the alcohol abuse and dependence symptoms among the hospital employees that had been exposed to the SARS outbreak (Wu et al., 2008). However, the study also assessed the participants exposure to the outbreak, symptoms of post-traumatic stress and depression. Wu et al. (2008) found that post-traumatic symptoms were significantly associated with hospital employees that have been exposed to the SARS outbreak and were associated with alcohol abuse/dependence symptoms 3 years after the outbreak. Therefore, the SARS outbreak indirectly impacted the hospital employees drinking behavior but also created post-traumatic stress symptoms. Wu et al. (2008) results indicated that additional health conditions and risk factors can manifest creating complexity in a psychiatric diagnosis. For hospital employees in China, the effect of being quarantined in a hospital due to SARS was seen as a predictor for post-stress symptoms even up to three years after being exposed to the virus (Brooks et al., 2020).

Wu et al. (2008)’s results was consistent with Mak et al. (2010)’s study conducted in Hong Kong. Mak et al. (2010) results indicated that 47.8%, almost half, of the participants in the study that had contracted SARS had experienced PTSD. Also, 25.6% of the participants continued to experience PTSD after 30 months post-exposure. As previously mentioned, Park et al. (2020)’s study examined the MERS outbreak in 2015 in Korea. The prevalence of PTSD in the participants 12 months after being infected with MERS was 42.9% (Park et al., 2020). The increased rate of PTSD was also seen with a decrease quality of life with the individuals. The PTSD prevalence was documented as comparable to 41.7% of individuals developed PTSD after being exposed to SARS in a hospital in Singapore (Park et al., 2020). The individuals that contracted SARS had a higher rate of PTSD than patients with Human Immunodeficiency Virus (HIV), individuals in an intensive care unit, or individuals that were in a human made disaster that were diagnosed with PTSD (Park et al. 2020). Park et al. (2020) attributed that high anxiety levels, the stigma of receiving the virus, and having a family member pass away from MERS were predictors for the diagnosis of PTSD. However, Park et al. (2020) noted that the individuals that were diagnosed with PTSD had a higher score for negative coping strategies as well compared to individuals that were not diagnosed with PTSD. The feeling of anger arising in individuals who were have experienced trauma, such as a viral outbreak, is an important factor in the development of PTSD (Jeong et al., 2016). This suggests that useful coping strategies may be helpful and should be included in the treatment intervention.

Implications for the Current COVID-19 Pandemic

The current literature results are consistent with the new studies on COVID-19 and mental health. The mental health impact of viral infections is compounded with stressors such as lack of finances and stigma of receiving the virus (Ettman et al., 2020). An overview of the results in China involving mental health and COVID-19 have found students and gender as significant factors for experiencing negative health effects from the pandemic. Similarly, the initial studies conducted in America found factors involving gender, income, education experienced high levels of stress, anxiety, and depression from the pandemic. Additionally, initial studies conducted in America found health care workers face a higher risk of developing PTSD and suicidal ideations during COVID-19.

Conclusion

The increased prevalence of mental and behavioral health conditions associated with COVID-19 highlights the impact of the pandemic and the treatment of these conditions. The pandemic requires communication and collaboration from a multidisciplinary mental health care approach to adequately manage the increase in psychological disorders and the psychological impact from COVID-19 (Esterwood & Saeed, 2020). The multidisciplinary mental health care approach in the United States, and other countries, provides the opportunity, such as community base interventions and telepyshcology, for supportive care and prevention focused interventions from evidenced based treatments (Esterwood & Saeed, 2020).  This will also allow individuals to bridge the connection of mental health services for racial and ethnic minorities or community areas with limited mental health services (Double jeopardy, n.d.). Alas, it can be concluded that viral infections, along with COVID-19, affect the mental health in individuals and their communities. Therefore, it is imperative to provide individuals and certain population groups that may be more high risk of experiencing mental health related disorder with the appropriate psychological interventions and strategies. The appropriate interventions and strategies can help ensure the perseveration of the general population mental health for COVID-19 and the next viral infection.

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Sheela Joshi, PsyD

Sheela Joshi is a fifth year Clinical Psychology PsyD student at Nova Southeastern University. She has earned her masters in Marriage and Family Therapy at Nova Southeastern University and her bachelor’s degree at University of Miami in Biology. Sheela is a Registered Marriage and Family Intern with the state of Florida. She is currently completing an APA accredited internship at VA Tennessee Valley Healthcare System. Sheela’s clinical interests are trauma, substance use, and family/couples.