The effects of stress brought on by pandemic diseases

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Washing your hands frequently–a good way to prevent disease transmission

Pandemic diseases–such as COVID-19–can be extremely stressful. The uncertainty of transmission, the intense desire to protect family and friends (and yourself), the unknown of the impact of catching the disease itself, the inexorable spread, the panic and outright misinformation that can be spread by social media, the drumbeat of the news, empty store shelves … the disappearance of the normal.

What impacts can this stress have on human beings?

Quick bibliography: Articles–classic and recent–about the effects of stress brought on by pandemic diseases.

Garfin, D. R., Thompson, R. R., & Holman, E. A. (2018). Acute stress and subsequent health outcomes: A systematic review. Journal of Psychosomatic Research, 112, 107-113. [Cited by]

“Objective: To systematically review the relationship between acute posttraumatic stress symptoms (<1 month) and subsequent physical and mental health outcomes other than posttraumatic stress disorder (PTSD).

Methods: A systematic search of electronic databases (PubMed, PsycINFO, CINAHL, and Web of Science) was conducted to identify longitudinal studies examining the link between acute posttraumatic stress and physical and mental health. Inclusion criteria required assessment of acute posttraumatic stress (<1 month post-event) and at least one follow-up assessment of a physical or mental health outcome (not PTSD).

Results: 1,051 articles were screened; 22 met inclusion criteria. Fourteen studies examined physical health outcomes and 12 examined non-PTSD mental health outcomes. Early psychological responses to trauma were associated with a variety of short- (<1 year) and long- (≥1 year) term physical and mental health outcomes. Physical health outcomes included poor general physical health, increased pain and disability, lower quality of life, and higher risk of all-cause mortality. Significant psychological outcomes included more cumulative psychiatric disorders, depression, and anxiety. Significant psychosocial outcomes included increased family conflict.”

Goulia, P., Mantas, C., Dimitroula, D., Mantis, D., & Hyphantis, T. (2010). General hospital staff worries, perceived sufficiency of information and associated psychological distress during the A/H1N1 influenza pandemic. BMC Infectious Diseases, 10, 322. [PDF] [Cited by]

“Health care workers (HCWs) presented frequent concerns regarding their health and their families’ health and high levels of psychological distress during previous disease outbreaks, such as the SARS outbreak, which was associated with social isolation and intentional absenteeism. We aimed to assess HCWs concerns and anxiety, perceived sufficiency of information, and intended behavior during the recent A/H1N1 influenza pandemic and their associations with psychological distress.

More than half of the present study’s HCWs (56.7%) reported they were worried about the A/H1N1 influenza pandemic, their degree of anxiety being moderately high (median 6/9). The most frequent concern was infection of family and friends and the health consequences of the disease (54.9%). The perceived risk of being infected was considered moderately high (median 6/9). Few HCWs (6.6%) had restricted their social contacts and fewer (3.8%) felt isolated by their family members and friends because of their hospital work, while a low percentage (4.3%) intended to take a leave to avoid infection. However, worry and degree of worry were significantly associated with intended absenteeism (p < 0.0005), restriction of social contacts (p < 0.0005), and psychological distress (p = 0.036). Perceived sufficiency of information about several aspects of the A/H1N1 influenza was moderately high, and the overall information about the A/H1N1 influenza was considered clear (median 7.4/9). Also, perceived sufficiency of information for the prognosis of the infection was significantly independently associated with the degree of worry about the pandemic (p = 0.008).

A significant proportion of HCWs experienced moderately high anxiety about the pandemic, and their degree of worry was an independent correlate of psychological distress. Since perceived sufficiency of information about the A/H1N1 influenza prognosis was associated with reduced degree of worry, hospital managers and consultation-liaison psychiatry services should try to provide for HCWs’ need for information, in order to offer favorable working conditions in times of extreme distress, such as the current and future pandemics.”

Hawryluck, L., Gold, W. L., Robinson, S., Pogorski, S., Galea, S., & Styra, R. (2004). SARS control and psychological effects of quarantine, Toronto, Canada. Emerging Infectious Diseases, 10(7), 1206-1212. [PDF] [Cited by]

“As a transmissible infectious disease, severe acute respiratory syndrome (SARS) was successfully contained globally by instituting widespread quarantine measures. Although these measures were successful in terminating the outbreak in all areas of the world, the adverse effects of quarantine have not previously been determined in a systematic manner. In this hypothesis-generating study supported by a convenience sample drawn in close temporal proximity to the period of quarantine, we examined the psychological effects of quarantine on persons in Toronto, Canada. The 129 quarantined persons who responded to a Web-based survey exhibited a high prevalence of psychological distress. Symptoms of posttraumatic stress disorder (PTSD) and depression were observed in 28.9% and 31.2% of respondents, respectively. Longer durations of quarantine were associated with an increased prevalence of PTSD symptoms. Acquaintance with or direct exposure to someone with a diagnosis of SARS was also associated with PTSD and depressive symptoms.”

Taha, S. A., Matheson, K., & Anisman, H. (2014). H1N1 was not all that scary: Uncertainty and stressor appraisals predict anxiety related to a coming viral threat. Stress and Health : Journal of the International Society for the Investigation of Stress, 30(2), 149-157. [Cited by]

H1N1 reached pandemic proportions in 2009, yet considerable ambivalence was apparent concerning the threat presented and the inclination to be vaccinated. The present investigation assessed several factors, notably appraisals of the threat, intolerance of uncertainty, and familiarity with the virus, that might contribute to reactions to a potential future viral threat. Canadian adults (N = 316) provided with several scenarios regarding viral threats reported moderate feelings of anxiety, irrespective of whether the viral threat was one that was familiar versus one that was entirely unfamiliar to them (H1N1 recurrence, H5N1, a fictitious virus: D3N4). Participants appraised the stressfulness of the threats to be moderate and believed that they would have control in this situation. However, among individuals with high intolerance of uncertainty, the viral threat was accompanied by high levels of anxiety, which was mediated by aspects of appraisals, particularly control and stressfulness. In addition, among those individuals that generally appraised ambiguous life events as being stressful, the viral threat appraisals were accompanied by still greater anxiety. Given the limited response to potential viral threats, these results raise concerns that the public may be hesitant to heed recommendations should another pandemic occur.”

Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., & Ho, R. C. (2020). Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of Environmental Research and Public Health, 17(5), 1729. [PDF]

The 2019 coronavirus disease (COVID-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. Research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. The aim of this study was to survey the general public in China to better understand their levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak. The data will be used for future reference.

Methods: From 31 January to 2 February 2020, we conducted an online survey using snowball sampling techniques. The online survey collected information on demographic data, physical symptoms in the past 14 days, contact history with COVID-19, knowledge and concerns about COVID-19, precautionary measures against COVID-19, and additional information required with respect to COVID-19. Psychological impact was assessed by the Impact of Event Scale-Revised (IES-R), and mental health status was assessed by the Depression, Anxiety and Stress Scale (DASS-21).

Results: This study included 1210 respondents from 194 cities in China. In total, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. Most respondents spent 20–24 h per day at home (84.7%); were worried about their family members contracting COVID-19 (75.2%); and were satisfied with the amount of health information available (75.1%). Female gender, student status, specific physical symptoms (e.g., myalgia, dizziness, coryza), and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (p < 0.05). Specific up-to-date and accurate health information (e.g., treatment, local outbreak situation) and particular precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05).”

Yu, H. Y. R., Ho, S. C., So, K. F. E., & Lo, Y. L. (2005). The psychological burden experienced by Hong Kong midlife women during the SARS epidemic. Stress and Health, 21(3), 177-184. [Cited by]

“The objective of this study was to assess the psychological burden experienced by women in midlife during the outbreak of Severe Acute Respiratory Syndrome (SARS) in Hong Kong. 126 women aged 50–64 year who were previously enrolled in an ongoing study on cardiovascular risks during January 2002 to March 2003, with the baseline psychological tests done, were interviewed over the telephone in May 2003. Depressive symptoms and emotional distress before and during SARS were assessed using the Center of the Epidemiological Study of Depression Scale (CES‐D) and Perceived Stress Scale (PSS). Differences in the CES‐D and PSS scores over SARS were noted with higher scores during the SARS outbreak, indicating more depressive symptoms and emotional distress. The proportion of women who scored above the cut‐off of the CES‐D scale also increased. Logistic regression analysis identified three factors as being significantly associated with emotional high stress during SARS: felt scared (adjusted odd ratios (OR) 3.77, 95 per cent confidence interval (CI) 1.50–9.43), sleep was restless (adjusted OR 3.97, 95 per cent CI 1.48–10.63) and having financial losses (adjusted OR 5.56, 95 per cent CI 1.57–19.68). Financial loss was independently related to the increase in stress level over SARS. A significant psychological impact of the SARS outbreak on Hong Kong midlife women was demonstrated. Emotional distress was related to risk perception and financial loss. Clear preventive measure recommendations and coping strategies for financial strain would possibly reduce the public stress and panic.“

For additional research about the effects of stress brought on by pandemic diseases, please see the Science Primary Literature Database.

Questions?  Please let me know (engelk@grinnell.edu).

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