Into the future with COVID: stress, depression, endemic/pandemic … will there ever be “normal” again?

Will we ever return to the world of 2019? A time before COVID-19 dominated the education, work, mental and physical health–the very existence of billions of people. Globally, millions have died, hundreds of millions have tested positive, and those estimated numbers are surely all undercounts (Johns Hopkins University, Coronavirus Resource Center).

The coronavirus is still with us and will continue to be into the future. There will be new variants, millions more will test positive, millions more will probably die, though the worst effects will continue to be among those who suffer the most from society’s inequalities–the poor, the old and very young, the sick, people from minority communities, those who live in countries with fewer resources, etc.

How do we emerge from the COVID-19 pandemic? Will COVID-19 become like the annual flu (which kills tens of thousands in the United States every year)? What short-term and long-term impacts will we experience as the virus moves from pandemic to endemic?

While many people may welcome the chance to reemerge and take part again in social activities involving crowds, individuals who are immunocompromised cannot take the same risk. Others may have come to prefer their life in isolation or may have found real benefit in it; an extreme of social withdrawal is known as the “Cave Syndrome.”

What does the research say? Research from past disease outbreaks can be used to inform the aftermath of COVID-19.

Featured articles (these articles have been added to Science Primary Literature):

*Mak, I. W. C., Chu, C. M., Pan, P. C., Yiu, M. G. C., & Chan, V. L. (2009). Long-term psychiatric morbidities among SARS survivors. General Hospital Psychiatry, 31(4), 318-326. [PDF] [Cited by]

“Objective: Severe acute respiratory syndrome (SARS) was the first massive infectious disease outbreak of the 21st century. However, it is unlikely that this outbreak will be the last. This study aimed to evaluate the long-term psychiatric morbidities in survivors of SARS.

Method: This is a cohort study designed to investigate psychiatric complications among SARS survivors treated in the United Christian Hospital 30 months after the SARS outbreak. Psychiatric morbidities were assessed by the Structured Clinical Interview for DSM-IV, the Impact of Events Scale–Revised and the Hospital Anxiety and Depression Scale. Functional outcomes were assessed by the Medical Outcomes Study 36-Item Short-Form Health Survey.

Results: Ninety subjects were recruited, yielding a response rate of 96.8%. Post-SARS cumulative incidence of DSM-IV psychiatric disorders was 58.9%. Current prevalence for any psychiatric disorder at 30 months post-SARS was 33.3%. One-fourth of the patients had post-traumatic stress disorder (PTSD), and 15.6% had depressive disorders.

Conclusion: The outbreak of SARS can be regarded as a mental health catastrophe. PTSD was the most prevalent long-term psychiatric condition, followed by depressive disorders. Our results highlight the need to enhance preparedness and competence of health care professionals in detecting and managing the psychological sequelae of future comparable infectious disease outbreaks.”

*Mak, I. W. C., Chu, C. M., Pan, P. C., Yiu, M. G. C., Ho, S. C., & Chan, V. L. (2010). Risk factors for chronic post-traumatic stress disorder (PTSD) in SARS survivors. General Hospital Psychiatry, 32(6), 590-598. [PDF] [Cited by]

“Background: Post-traumatic stress disorder (PTSD) is one of the most prevalent long-term psychiatric diagnoses among survivors of severe acute respiratory syndrome (SARS).

Objectives: The objective of this study was to identify the predictors of chronic PTSD in SARS survivors.

Design: PTSD at 30 months after the SARS outbreak was assessed by the Structured Clinical Interview for the DSM-IV. Survivors’ demographic data, medical information and psychosocial variables were collected for risk factor analysis.

Results: Multivariate logistic regression analysis showed that female gender as well as the presence of chronic medical illnesses diagnosed before the onset of SARS and avascular necrosis were independent predictors of PTSD at 30 months post-SARS. Associated factors included higher-chance external locus of control, higher functional disability and higher average pain intensity.

Conclusion: The study of PTSD at 30 months post-SARS showed that the predictive value of acute medical variables may fade out. Our findings do not support some prior hypotheses that the use of high dose corticosteroids is protective against the development of PTSD. On the contrary, the adversity both before and after the SARS outbreak may be more important in hindering recovery from PTSD. The risk factor analysis can not only improve the detection of hidden psychiatric complications but also provide insight for the possible model of care delivery for the SARS survivors. With the complex interaction of the biopsychosocial challenges of SARS, an integrated multidisciplinary clinic setting may be a superior approach in the long-term management of complicated PTSD cases.”

*Taylor, S., & Asmundson, G. J. G. (2020). Life in a post-pandemic world: What to expect of anxiety-related conditions and their treatment. Journal of Anxiety Disorders, 72, 102231. [PDF] [Cited by]

“When the current pandemic comes to an end, as it eventually will, many people will have lived through all kinds of stresses and losses, including the loss of friends and loved ones due to the novel coronavirus, the loss of jobs, the bankruptcy of businesses, and foreclosures on homes. For some people, marriages and other relationships will have crumbled under the stress of self-isolation and mounting financial hardships. If the research on natural disasters serves as a guide, as a result of the current pandemic an estimated 10 % of people will develop severe psychological problems, such as mood disorders, anxiety disorders, or posttraumatic stress disorder (PTSD). But the percentage could be much higher. In the wake of the SARS outbreak in 2003, a number of people developed PTSD. A four-year follow-up study of 70 survivors of SARS, for example, found that 44 % developed PTSD. Even after recovering from SARS, PTSD persisted for years in almost all (82%) of these sufferers. PTSD symptoms tended to be more severe in people who had a high perceived life threat, low social support, and more close relatives who suffered from, or died, from SARS. Other studies of SARS have reported similar findings. It is likely that the current coronavirus will also lead to cases of PTSD. Isolation and confinement, even if only for a few weeks, can cause lasting psychological problems. People quarantined for prolonged periods in cramped accommodation, sharing a bedroom with multiple occupants, or trapped at home in an abusive or coercive relationship, may be especially vulnerable to developing PTSD symptoms during and after the outbreak. Emerging evidence also suggests it is likely that many medical and non-medical health care workers will develop PTSD.”

For more information, search Science Primary Literature (database).

See also –

Long COVID: what it is, impacts, and treatments

The effects of stress brought on by pandemic diseases

Pandemics–history, control, and prevention

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