Fears, Outbreaks, and Pandemics: Lessons Learned

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SIGNIFICANCE FOR PRACTICING PSYCHIATRISTS

FIGURE. Outbreaks can affect mental illness at various levels

TABLE.Summary of memorable epidemics/pandemics

The influenza virus itself was not selective in its victims, belying notions of gender, class, and racial superiority. . . . Anyone might become ill, anyone might provide comfort.Nancy K Bristow¹

Infectious outbreaks have shaped the psyche of humanity for times immemorial. Epidemics and pandemics propagate fear and erratic behavior and, long after they are over, remain entrenched within the global psyche, often in the form of folk tale and literary or historical accounts. Naturally, logically, and unsurprisingly, the larger the scale of an outbreak, the larger the impact and magnitude of its sequelae. The black plague pandemic, starting in 1345, claimed up to 100 million lives and is still the topic of lively speculation and research to this day; the influenza pandemic of 1918 still receives attention. The Table summarizes major historical outbreaks, with estimated lives affected.

In recent years, media attention has shaped outbreak coverage in various ways, heightening alarm while serving as a useful tool for encouraging precautions and prevention. However, pandemic spread of infectious diseases has also been a cause of concern because of increased air travel and an overall increase in global connectedness. Smaller outbreaks receive much media coverage as infectious diseases thought to be eradicated resurface, but also in highlight of crowded or unsanitary conditions. Outbreaks of mumps, measles, and polio have been noted in various communities (such as jails, detention centers, daycare centers). Large numbers of refugees, victims of global strife, often have limited access to medical care, and have been found to lack required levels of sero-prevalence needed for herd immunity for vaccine-preventable infections.²

Outbreak, epidemic, and pandemic are all terms that are coming back into the human lexicon after decades of complacency about the protections of modern medicine. An “outbreak” is a sudden increase in a condition, or disease cluster-infectious or otherwise. An “epidemic” is defined as a widespread occurrence of an infectious or non-infectious disease in a community at a particular time; whereas a “pandemic” is an epidemic that crosses country and continent boundaries.

The effect of outbreaks on mental illness can be loosely conceptualized as:

• Potentially affecting existing illnesses;

• Precipitating new-onset mental symptoms in children or adults, possibly related to the interplay of immunity and mental illness; and

• Causing distress in the caretakers of affected individuals (Figure).

Alternatively, the psychiatrist can consider the effects in terms of acute versus chronic issues.

Outbreaks as precipitating risk factors for mental illness

Regardless of exposure, the stress of media news and fear of injury or death can contribute to a mental breakdown, whether mood-related or psychotic. This is not, however, a well-studied area. Small studies from the Ebola outbreak in Sierra Leon and from the H1N1 outbreak in 2009 indicated an increase in depression, anxiety, and somatoform presentations.^3,4

In the acute phase, the onset of an outbreak can understandably instill fear in most individuals. This fear and concern can be amplified by pre-existing anxiety and depressive disorders. Personal reactions may differ, although increased rumination about the possibility of acquiring an illness or having already acquired an illness can profoundly modify behavior and socialization.

The effect of outbreaks on psychosis has not been studied fully, but worsening paranoia and the incorporation of outbreak-related facts into delusional thinking is highly likely; resulting delusional parasitosis is a possible logical extension of this event chain. Patients with mental illness have a higher rate of cutaneous/skin disorders at baseline and intensifying media coverage can exacerbate concern about dermatological manifestations.⁵ Severe anxiety can also precipitate a relapse into substance abuse in highly susceptible individuals as the stress level increases.

Furthermore, for patients struggling with depression or anxiety who are also parents, the effects can be deepened as concerns of protecting children arise. Psychiatrists may sometimes have to allay guilt feelings of parents worried about having caused their children’s illness, or not done enough to prevent it.

In youths, adult behavior may set the tone for coping skills, but the existence of certain personality characteristics or symptoms shape response to crisis. In rare cases, mental issues can be protective-children with social phobia have been found to have delayed onset of measles, mumps, and rubella, presumably because of their reluctance to socialize.⁶

Lastly, anxiety and a feeling of helplessness can encourage the adoption of unproven methods and remedies that can be harmful or outright toxic. A solid therapeutic rapport between the patient and the psychiatrist can go a long way in managing those fears and reducing associated unhealthy behaviors.

Bidirectional effect of mental illness and immunity

As our understanding of the interaction between immunity and mental symptoms grows, it is obvious that worsening mental symptoms (eg, depression) can render a person more susceptible to certain physical ailments. This is supported by studies showing lower IgG titers of measles in individuals with major depressive disorders and diminished response to herpes zoster vaccination in elderly persons with depression.^7,8 Yet, psychoneuroimmunology findings do not consistently apply to children and adolescents, and at least one study has found that adolescents with depression exhibited an enhanced response to the influenza vaccine. Thus, more studies are needed in this area.⁹

Conversely, some infections can cause longstanding sequelae. Some are relatively well characterized, such as post-measles subacute sclerosing panencephalitis (SSPE), which occurs 7 to 10 years after a measles illness and present swith neuropsychiatric symptoms. Although SSPE-related mortality decreased with increased measles vaccine use, it is currently experiencing a resurgence.

Similarly, maternal infectious processes are related to mental problems in offspring. Following close to two million Swedish-born people for more than 40 years, Al-Haddad and colleagues¹⁰ found an increased rate of autism and depression following severe maternal infections.

Other after-effects of infections are less well understood. It is possible that the stress caused by infections distorts the relationship between the immune system and the CNS, triggering or consolidating a depressive process.¹¹ Additionally, receiving the flu vaccine can worsen depressive symptoms in individuals with pre-existing depression or those pre-disposed to depression.¹²

Stigma

Stigma and shaming are closely intertwined with the nature of an outbreak. As recent pandemics have illustrated, humanity still has the potential to discriminate against its members for various afflictions. Individuals with human immunodeficiency virus face stigma on a regular basis, often with devastating results.Visible skin disease or scars contribute to stigma and subsequent psychosocial impairment.¹³ Historical examples of such stigma may be found in stories of individuals with leprosy, although other skin diseases (eg, cutaneous leishmaniasis and hidranetis suppuritiva), and facial disfigurement of any kind; all of these have been associated with stigma and shunning.^13,14

In addition to communicable diseases and in light of recent debate on the benefits of preventive interventions, stigma can also extend to groups who are vaccinated versus those who are not. As communicable diseases resurge, the potential for a new group of target individuals that can be discriminated against also emerges, especially if lasting skin effects linger.

Anti-stigma measures can target a wide range of conditions, from HIV to mental illness to diseases with visible skin markings, and education is the most widely used measure. In the area of epidemics, psychiatry can have a pivotal role in promoting inclusiveness and anti-discriminatory practice, as well as helping patients deal with micro-aggressions and resulting mental symptoms.

Proactive approaches to understanding and managing outbreaks

In past decades, many infectious outbreaks have alarmed the public. The reasons for these vary from reduced immunity and under-vaccination to the emergence of new viral strains (as in the case of influenza). Salmonella outbreaks clusters are fairly common, but typically do not cause wide-ranging alarm beyond involved communities. Pertussis outbreaks occur in highly vaccinated communities when there is divergence between strains used in vaccines and those prevaqlent in the population.^1,15

The role of psychiatry varies depending on the etiology of the crisis and the magnitude of the impact on the community; psychiatrists also can facilitate the dialogue about vaccination-related choices. A heated debate is not unusual with the discussion of vaccinations. To better understand the shifts in perspective on vaccinations, the prospect theory of behavior may act as a potential framework to explain current attitudes towards mandatory vaccinations. While not all-encompassing, it may guide clinicians i nto a smoother discussion.

The prospect theory of behavior posits that decision-making varies based on whether gains versus losses are expected in a given situation as well as the extent and magnitude of expected gain/loss.¹⁶ “Loss aversion”-preferring to risk a greater loss rather than incurring a small yet certain loss-is a tenet of this model. The hypothesis is that when a major loss is expected but uncertain (such as a communicable disease that may never occur), risk-taking may increase, while gains may make an individual less prone to take risks.

Prospect theory has been used to provide an operationalized framework for various health-related behaviors including management of chronic diseases as well as to distinguish attitudes in clinical versus non-clinical decisions.^17,18 Moreover, prospect theory can be helpful in framing the health care message underlying informed consents.¹⁹ In a study of women with children, Abhyankar and colleagues 20 found that the intent to get the measles, mumps, and rubella (MMR) vaccine for one’s child varied on whether the women were exposed to a loss-framed versus a gain-framed message, with variations in perceptions of vaccine efficacy.

A careful risk benefit analysis is needed for any community affected by outbreaks of infectious disease, and ongoing monitoring is essential. Perspective and accumulated experience can shape decision-making. For example, with a case of influenza virus, the choice of oseltamivir is a public health decision that benefits communities and saves lives. However, oseltamivir is associated with an increased odds ratio of adverse neuropsychiatric adverse effects including confusion, hallucinations, psychosis, anxiety, depression, mania, sleeping disorder, aggression, suicidal ideation, encephalitis, ataxia, and vertigo.^21,22 Acute and long-term neuropsychiatric symptoms with untreated influenza illness can further complicate matters.²³

From an individual perspective, choosing to use a medication with known potential adverse effects may very well be subject to an emotional component congruent with prospect theory and subject to risk-taking paradigms. Decisions would conceivably change depending on the level of stress of the individual and surrounding circumstances, such as a raging epidemic.

Lessons learned and the role of psychiatry

The last few pandemics have yielded valuable lessons in terms of global responses. In a review of efforts since 1952, the World Health Organization noted that surveillance networks were instrumental in monitoring and mitigating the spread of influenzas viruses.²⁴ It is hoped that similar organizational effort can target other re-emerging communicable diseases. Organized resources are crucial in terms of detection and marshalling quick local and community-wide responses, combined with proactive identification and treatment of index cases.

Addressing pandemics is now a science; it is a far cry from the panic that occurred in 1918. Responses are technically innovative and utilize extensive communication and monitoring to keep communities safe. The role of psychiatrists ranges widely from identifying vulnerable individuals and caring for them to reducing stigma through public education. In addition, psychiatrists’ contributions are crucial to institute proper policies to avoid contaminations and further spread of disease.

Disclosures:

Dr Moukaddam is Associate Professor, Menninger Department of Psychiatry and Behavioral Science, Baylor College of Medicine, Ben Taub Adult Outpatient Services Director, Medical Director, STAR (Stabilization, Treatment, and Rehabilitation) Program for Psychosis, Houston, TX. She reports no conflicts of interest concerning the subject matter of this article.

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