accidents, and intentional acts of mass destruction, a primary concern is post-traumatic stress disorder (PTSD) arising from exposure to trauma. Medical conditions from natural causes such as life-threatening viral infection do not meet the current criteria for trauma required for a diagnosis of PTSD, but other psycho- pathology, such as depressive and anxiety disorders, may ensue.
Some groups may be more vulnerable than others to the
psychosocial effects of pandemics. In particular, people who contract the disease, those at heightened risk for it (including the elderly, people with compromised immune function, and those living or receiving care in congregate settings), and people with preexisting medical, psychiatric, or substance use problems are at increased risk for adverse psychosocial outcomes. Health care providers are also particularly vulnerable to emotional distress in the current pandemic, given their risk of exposure to the virus, concern about infecting and caring for their loved ones, short- ages of personal protective equipment (PPE), longer work hours, and involvement in emotionally and ethically fraught resource- allocation decisions. Prevention efforts such as screening for mental health problems, psychoeducation, and psychosocial support should focus on these and other groups at risk for adverse psychosocial outcomes. Beyond stresses inherent in the illness itself, mass home-
confinement directives (including stay-at-home orders, quaran- tine, and isolation) are new to Americans and raise concern about how people will react individually and collectively. A recent review of psychological sequelae in samples of quarantined people and of health care providers may be instructive; it revealed numerous emotional outcomes, including stress, depression, irritability, insomnia, fear, confusion, anger, frustration, boredom, and stigma associated with quarantine, some of which persisted after the quarantine was lifted. Specific stressors included greater duration of confinement, having inadequate supplies, difficulty securing medical care and medications, and resulting financial losses. In the current pandemic, the home confinement of large swaths of the population for indefinite periods, differ- ences among the stay-at-home orders issued by various jurisdic- tions, and conflicting messages from government and public health authorities will most likely intensify distress. A study conducted in communities affected by severe acute respiratory syndrome (SARS) in the early 2000s revealed that although com- munity members, affected individuals, and health care workers were motivated to comply with quarantine to reduce the risk of infecting others and to protect the community’s health, emo- tional distress tempted some to consider violating their orders. Opportunities to monitor psychosocial needs and deliver support during direct patient encounters in clinical practice are greatly curtailed in this crisis by large-scale home confinement. Psychosocial services, which are increasingly delivered in pri- mary care settings, are being offered by means of telemedicine. In the context of Covid-19, psychosocial assessment and moni- toring should include queries about Covid-19–related stressors (such as exposures to infected sources, infected family members, loss of loved ones, and physical distancing), secondary adversi- ties (economic loss, for example), psychosocial effects (such as depression, anxiety, psychosomatic preoccupations, insomnia, increased substance use, and domestic violence), and indicators of vulnerability (such as preexisting physical or psychological conditions). Some patients will need referral for formal mental
health evaluation and care, while others may benefit from sup- portive interventions designed to promote wellness and enhance coping (such as psychoeducation or cognitive behavioral tech- niques). In light of the widening economic crisis and numerous uncertainties surrounding this pandemic, suicidal ideation may emerge and necessitate immediate consultation with a mental health professional or referral for possible emergency psychiatric hospitalization.
On the milder end of the psychosocial spectrum, many of the experiences of patients, family members, and the public can be appropriately normalized by providing information about usual reactions to this kind of stress and by pointing out that people can and do manage even in the midst of dire circum- stances. Health care providers can offer suggestions for stress management and coping (such as structuring activities and maintaining routines), link patients to social and mental health services, and counsel patients to seek professional mental health assistance when needed. Since media reports can be emotion- ally disturbing, contact with pandemic-related news should be monitored and limited. Because parents commonly underesti- mate their children’s distress, open discussions should be encour- aged to address children’s reactions and concerns. As for health care providers themselves, the novel nature of
SARS-CoV-2, inadequate testing, limited treatment options, insuf- ficient PPE and other medical supplies, extended workloads, and other emerging concerns are sources of stress and have the po- tential to overwhelm systems. Self-care for providers, including mental health care providers, involves being informed about the illness and risks, monitoring one’s own stress reactions, and seeking appropriate assistance with personal and professional responsibilities and concerns — including professional mental
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