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The COVID-19 pandemic exerted an extraordinary impact on public mental health to an extent not yet fully understood. Risk perception shaped psychological and behavioral responses, including experiences of distress, psychiatric disorders, and engagement in pandemic-related health behaviors. COVID-19 created unique aspects of evolving risk with various communities disproportionately impacted. The unique nature and duration of the pandemic required public-private partnerships that leveraged and adapted promising practices to promote essential elements that foster well-being after disasters. Early findings are reviewed, and further research will inform on best practices for protecting public mental health during future pandemics.
Keywords: Covid-19, Pandemic, Preparedness, Mental health, Public health, InterventionsPublic mental health practices and principles are critical in response to COVID-19 as well as in other pandemics and disasters.
Distress reactions and health risk behaviors are early and common responses to COVID-19 in addition to psychiatric disorders.
Risk and protective factors related to adverse psychological and behavioral health effects result from pre-event factors, aspects of impact, and recovery variables.
Early interventions use an evidence-based framework to enhance well-being, reduce distress, and mitigate disorders.
Adapting interventions from high-risk occupations provides a rapid and tailored response to enhance organizational sustainment.
The COVID-19 pandemic is an unprecedented global disaster that has killed 5,203,000 people to date, 1 having an impact on nearly all sectors of society. The public's experience of the pandemic has been altered by the collision of multiple disasters: civil unrest, racial inequity, economic crises, political strife, and other events, such as hurricanes, floods, and mass violence. These events pull at the fault lines of communities and amplify distress, mistrust, and uncertainty, altering how these events are experienced. Addressing public mental health needs involves an understanding of where risk is concentrated and how it changes over time to allow for more timely and tailored interventions that are altered to meet current and evolving needs. In disasters, certain populations bear a disproportionate burden of risk. For instance, in COVID-19, health care workers have experienced prolonged threats to health and safety for themselves and their families as well as exposure to death and dying. 2 People of color became sicker and died with greater frequency, with black and Hispanic citizens experiencing a 3-fold greater reduction in life expectancy than whites, directly resulting from the COVID-19 pandemic. 3
Disasters cause an established range of adverse mental health effects, with pandemics creating unique impacts related to fear, uncertainty, and changing risk perceptions. Assessment and treatment of psychological disorders are aspects of managing public mental health during pandemics. Responses, such as distress reactions and health risk behaviors, also confer significant public mental health burden. The scope and magnitude of these events require a public mental health framework for interventions that focuses on disease prevention and wellness in addition to the treatment of disorders. Public health emergencies need coordinated and sustained public health approaches across various services and sectors of society. 4 These community-based approaches include public health education, communication, organizational sustainment, and leadership, all of which focus on fostering wellness, preventing disease, and promoting recovery. 5
This article examines current findings from the pandemic and identifies gaps in the understanding of public mental health impact and mitigation strategies. Preparing for future pandemics requires examination of lessons learned and implementing relevant system changes, which require sustained commitment and collaboration from public and private sector entities.
Disasters create adverse mental health effects, from distress to disorders, with various effects beginning early and others emerging over time,6, 7, 8, 9 some of which last for months or years and may result in prolonged or chronic functional impairment and disability. Pandemics produce unique psychological effects, related primarily to fear, and altered risk perception. 10 This perception of risk influences engagement in health behaviors required to control the outbreak, such as physical distancing, mask wearing, handwashing, and vaccinations. 10 During COVID-19, prolonged uncertainty, isolation and quarantine, concerns about shortages, and changing health recommendations exacerbated underlying concerns.
Psychological and behavioral responses to disasters are depicted in Fig. 1 . Psychiatric disorders often manifest after weeks or months with available evidence-based treatment. Other responses occur that often receive less clinical and media attention but cause significant public mental health burden. Distress reactions and risky health behaviors are well-established manifestations of disasters, including pandemics. In the severe acute respiratory syndrome (SARS) outbreak of 2007, approximately 40% of ICU nurses experienced significant insomnia, 11 which is associated with work errors, accidents, mental health disorders, exacerbation of cardiovascular and immune diseases, cognitive symptoms, and functional impairment. During COVID-19, for instance, insomnia has been studied largely in the context of sequelae from SARS coronavirus 2 infection, rather than as a distress reaction resulting from the experience of living through a pandemic, the latter having a far greater potential impact on public mental health.
Psychological and behavioral responses to pandemics and disasters.
Disasters, such as a hurricane, an earthquake, and a mass shooting, that are a single event and occur over a discrete period typically progress through well-established community phases. Initially, a honeymoon phase occurs when resources and support are brought to a community and individuals come together to connect and rebuild with the hope of being made whole again. Later, a disillusionment phase occurs when resources diminish, and mounting stressors reduce a sense of hope. Anniversary reactions remind individuals and communities of what has been lost. Finally is a reconstruction phase, when individuals find ways to make meaning of the event and move forward in the context of a new normal. COVID-19 disrupted these phases by limiting social connection and diminishing community cohesion, which made planning and allocation of community mental health resources more difficult.
COVID-19 differs from other disasters by the very nature of the threat as well as its scope, magnitude, and duration. Even those with experience responding to disasters (eg, first responders, emergency workers, law enforcement, and health care workers) were ill-prepared for a novel infectious disease that has been hard to predict, caused significant illness, resulted in relatively high mortality, and presented significant risk to personal and family safety. Although risk mitigation is essential during COVID-19, risk cannot be eliminated. When the threat is a highly contagious respiratory virus, there is nowhere safety can be guaranteed. All members of society had to determine the extent to which loved ones, friends, and colleagues—traditionally a source of comfort, connection, and companionship—represented a threat to health and safety. These supportive resources often were less accessible due to required or voluntary physical distancing or quarantine after an exposure.
Health care workers played an essential role in preventing illness and death from COVID-19. Inadequate supplies, shifting policies and procedures, working outside their scope of care, and requirements to practice altered standards of care led to feelings of distress for some workers. Stigmatization by neighbors, friends, and family added to the burden of health care workers. 12 The extremes of COVID-19 caused mental health to become an increasingly significant threat to safety for health care workers around the world. 2
Like most public health emergencies, the pandemic has pulled at the fault lines within society, further exposing divisions. These are predictable effects of disasters that have a broad impact on health, safety, security, and economics, particularly when they require sustained and changing behaviors to manage effectively. Community conflict over mask wearing, school closures, and vaccine acceptance were exacerbated by the emergence of more contagious and lethal viral variants, all of which served to fuel community anger and resentment and diminish social cohesion.
Protecting health involves understanding psychological symptoms and behavioral effects of disasters. Symptoms of psychological disorders have received considerable attention, with studies demonstrating elevated rates of depression and anxiety during COVID-19 that persisted in communities around the world 13 and created considerable health burden, which benefited from evidence-based interventions. Beyond symptoms of disorders, insomnia, increased use of alcohol and tobacco, and family violence were responses to COVID-19, having an impact not only on individual health but also on the ability to sustain operations in occupational settings that were critical to maintaining community functioning.
Insomnia is a growing public health problem associated with worsening of underlying physical and mental health conditions, 14 diminished cognitive performance, 15 and impaired immune system. These create significant risks, particularly during a pandemic when decision making around family health behaviors and the ability to fight illness are critical to community health. COVID-19 had a negative impact on sleep around the world, with insomnia rates of 20% to 45% and health care workers reporting some of the highest overall rates, 16 where nurses and those working most closely with sick patients were at greatest risk. 17 Insomnia is both a risk factor for and an adverse clinical feature of numerous mental health conditions with elevated insomnia ratings in health care workers associated with higher rates of probable posttraumatic stress disorder (PTSD). 18 Nochaiwong and colleagues 13 reviewed the global prevalence of mental health symptoms from 32 countries and from approximately 400,000 participants and found a 27.6% prevalence of sleep disorders. Improved sleep can enhance the ability to solve problems, make decisions, and engage in behaviors needed to promote health during a pandemic and may be done through public health education about the benefits of re-establishing sleep and other daily routines, regular exposure to sunlight, calming behaviors that reduce arousal, and limiting exposure to disaster-related media. Access to self-directed cognitive behavioral therapy for insomnia using online and app-based programs and other technologies that foster calming and lower arousal may be useful as well, particularly when face-to-face health care is limited.
Alcohol often is used to manage sleep problems and distressing emotions, both of which are exacerbated during disasters. In March 2020, an online survey of US adults by the American Psychiatric Association revealed 8% of Americans already had begun increasing their consumption of alcohol. 19 Three months later, in June 2020, the Centers for Disease Control and Prevention found 13.3% of adults increased use of substances to manage pandemic-related distress. 20 Pollard and colleagues 21 quantified changes in alcohol use comparing the period during the pandemic with data from the year prior and observed 75% of adults reporting 1 additional drinking day per month, with 41% of women reporting increased binge drinking and a 39% increase on the Short Inventory of Problems scale related to use of alcohol. These findings have important public mental health implications. Even in the absence of alcohol use disorder, the increased use of alcohol within a community is associated with higher rates of accidents, violence, work and other errors, physical health ailments, and impaired decision making. The last can be particularly problematic when choices about pandemic behaviors have greater consequences for family health and safety. Home confinement, unemployment, work and family stresses, and the persistent availability of alcohol compounded these problems. Limiting access to alcohol as an intervention must be balanced against acute health consequences of abrupt discontinuation. Public health education, community support services, and timely and tailored resources to help mitigate the distress that often leads to increased alcohol use are important aspects of future interventions.
Grief is a near universal aspect of disasters, resulting from loss of possessions, health, perceptions of safety, and certainty about the future. Disenfranchised grief involves loss that is not acknowledged openly, validated socially, or mourned publicly in ways that promote healing, such as the inability to be at the bedside of dying loved or gather at a funeral service due to COVID-19–related health restrictions. Bereavement from the death of a loved one during disaster increases adverse mental health effects, with some estimates of 9 people experiencing bereavement for every COVID-19 death. 22 Hillis and colleagues 23 found more than 1.5 million children had a caregiver die from COVID-19, with the potential for this to increase greatly as more lethal viral variants became increasingly common. Evidence-based and actionable resources to support of children following the death of a caregiver were an important aspect of health education during COVID-19. 24
Feeling safe during disasters is important to health, with decreased perceptions of safety associated with insomnia, increased substance use, depression, posttraumatic stress symptoms, and general psychological distress. 25 COVID-19 represents an amorphous and ongoing threat to safety, and further understanding the extent to which perceptions of safety influenced the onset of psychological and behavioral response is critical in developing effective interventions for future pandemics. The pandemic also created significant disruption to work-life balance, with virtual education and remote work commonplace. The presence of mental health symptoms and exposure to disasters both have been associated independently with occupational difficulties and impairment, including absenteeism and presenteeism. 26 , 27 Leveraging and adapting effective workplace health promotion programs that address unique changes required in the home-work environment during COVID-19 also can enhance pandemic preparedness.
Responses to disasters include distress reactions, health risk behaviors, psychiatric disorders, and resilience. Understanding both the psychological and behavioral impacts of a pandemic on society provides the most robust understanding of community public mental health impacts.
Pandemics are characterized by fear and uncertainty that alter perceptions of risk, which directly influence engagement in recommended health behaviors. The ability to alter risk perception is essential to optimizing health behaviors required to control a pandemic.
Adverse responses to pandemics that negatively affect community functioning and occupational performance are important targets for interventions that protect health and sustain operations.
Far more is known about what creates risk for illness than what protects health. Risk and protection in COVID-19 result from a dynamic interplay of biopsychosocial factors related to predisaster factors, impact characteristics, and post-disaster recovery variables. From an occupational and public health perspective, stressors, such as living through a pandemic, can be thought of like a toxin, such as lead or radon. To understand the impact, it is important to know aspects of the exposure, such as who, when, how much, the response over time, and which factors buffered against negative effects. Health surveillance during and after disasters is complex and challenging but critical to understanding where risk is concentrated and how it changes over time, which is essential to developing timely and tailored interventions. Certain populations are at increased risks during disasters and certain groups bear a disproportionate burden of risk. COVID-19 created unique, although often predictable, challenges.
Health care workers had unique and wide-ranging experiences throughout the pandemic, such as (1) being called heroes where communities clapped for them, (2) lacking basic personal protective equipment (PPE) to maintain personal safety, (3) being required to decide which patients lived or died due to constrained resources, (4) begin stigmatized by friends and neighbors, and, ultimately, (5) being vilified by patients and public officials who opposed health recommendations. 28 Health care workers represent a group with numerous risk and protective factors that evolved throughout the pandemic ( Table 1 ). Although the transition to recovery is far less clear during COVID-19, the factors listed provide an understanding of how risk and protection evolve throughout a pandemic life cycle.
Risk and protective factors for health care workers during COVID-19
