In the wake of the September 11 attack in the United States and the Kiss Nightclub fire in Brazil, psychological assistance task forces for victims and their families were quickly organized. However, during pandemics it is common for health professionals, scientists and managers to focus predominantly on the pathogen and the biological risk in an effort to understand the pathophysiological mechanisms involved and propose measures for preventing, containing and treating the disease. In such situations, the psychological and psychiatric implications secondary to the phenomenon, both on an individual and a collective level, tend to be underestimated and neglected, generating gaps in coping strategies and increasing the burden of associated diseases.¹1. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of ebola, zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9:151-6.,²2. Morens DM, Fauci AS. Emerging infectious diseases: threats to human health and global stability. PLoS Pathog. 2013;9:e1003467.

Although infectious diseases have emerged at various times in history, in recent years, globalization has facilitated the spread of pathological agents, resulting in worldwide pandemics. This has added greater complexity to the containment of infections, which has had an important political, economic and psychosocial impact, leading to urgent public health challenges.²2. Morens DM, Fauci AS. Emerging infectious diseases: threats to human health and global stability. PLoS Pathog. 2013;9:e1003467.

3. Morens DM, Folkers GK, Fauci AS. Emerging infections: a perpetual challenge. Lancet Infect Dis. 2008;8:710-9.

4. Bloom DE, Cadarette D. Infectious disease threats in the twenty-first century: strengthening the global response. Front Immunol. 2019;10:549.

5. Malta M, Rimoin AW, Strathdee SA. The coronavirus 2019-nCoV epidemic: is hindsight 20/20? EClinicalMedicine. 2020;20:100289.-⁶6. Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, Baguelin M, et al. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand [Internet]. 2020 Mar 16 [cited 2020 Mar 19]. http://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf
http://www.imperial.ac.uk/media/imperial... HIV, Ebola, Zika and H1N1, among other diseases, are recent examples.¹1. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of ebola, zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9:151-6.

The coronavirus (COVID-19), identified in China at the end of 2019, has a high contagion potential, and its incidence has increased exponentially. Its widespread transmission was recognized by the World Health Organization (WHO) as a pandemic. Dubious or even false information about factors related to virus transmission, the incubation period, its geographic reach, the number of infected, and the actual mortality rate has led to insecurity and fear in the population. The situation has been exacerbated due to the insufficient control measures and a lack of effective therapeutic mechanisms.⁵5. Malta M, Rimoin AW, Strathdee SA. The coronavirus 2019-nCoV epidemic: is hindsight 20/20? EClinicalMedicine. 2020;20:100289.,⁷7. Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, evaluation and treatment coronavirus (COVID-19). StatPearls, Treasure Island: StatPearls PublishingStatPearls Publishing LLC.; 2020.,⁸8. Peeri NC, Shrestha N, Rahman MH, Zaki R, Tan Z, Bibi S, et al. The SARS, MERS and novel coronavirus (COVID-19) epidemics, the newest and biggest global health threats: what lessons have we learned? Int J Epidemiol. 2020 Feb 22. pii: dyaa033. doi: http://10.1093/ije/dyaa033. [Epub ahead of print]
http://10.1093/ije/dyaa033... These uncertainties have had consequences in a number of sectors, with direct implications for the population’s daily life and mental health.

This scenario raises a number of questions: is there a fear/stress pandemic concomitant with the COVID-19 pandemic? How can we evaluate this phenomenon?

To understand the psychological and psychiatric repercussions of a pandemic, the emotions involved in it, such as fear and anger, must be considered and observed. Fear is an adaptive animal defense mechanism that is fundamental for survival and involves several biological processes of preparation for a response to potentially threatening events. However, when it is chronic or disproportionate, it becomes harmful and can be a key component in the development of various psychiatric disorders.⁹9. Garcia R. Neurobiology of fear and specific phobias. Learn Mem. 2017;24:462-71.,¹⁰10. Shin LM, Liberzon I. The neurocircuitry of fear, stress, and anxiety disorders. Neuropsychopharmacology. 2010;35:169-91. In a pandemic, fear increases anxiety and stress levels in healthy individuals and intensifies the symptoms of those with pre-existing psychiatric disorders.¹¹11. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci. 2020 Feb 8. doi: http://10.1111/pcn.12988. [Epub ahead of print]
http://10.1111/pcn.12988...

During epidemics, the number of people whose mental health is affected tends to be greater than the number of people affected by the infection.¹²12. Reardon S. Ebola’s mental-health wounds linger in Africa. Nature. 2015;519:13-4. Past tragedies have shown that the mental health implications can last longer and have greater prevalence than the epidemic itself and that the psychosocial and economic impacts can be incalculable if we consider their resonance in different contexts.¹¹11. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci. 2020 Feb 8. doi: http://10.1111/pcn.12988. [Epub ahead of print]
http://10.1111/pcn.12988... ,¹²12. Reardon S. Ebola’s mental-health wounds linger in Africa. Nature. 2015;519:13-4.

Since the economic costs associated with mental disorders is high, improving mental health treatment strategies can lead to gains in both physical health and the economic sector. In addition to a concrete fear of death, the COVID-19 pandemic has implications for other spheres: family organization, closings of schools, companies and public places, changes in work routines, isolation, leading to feelings of helplessness and abandonment. Moreover, it can heighten insecurity due to the economic and social repercussions of this large-scale tragedy.

During the Ebola outbreak, for example, fear-related behaviors had an epidemiological impact both individually and collectively during all phases of the event, increasing the suffering and psychiatric symptom rates of the population, which contributed to increases in indirect mortality from causes other than Ebola.¹³13. Shultz JM, Cooper JL, Baingana F, Oquendo MA, Espinel Z, Althouse BM, et al. The role of fear-related behaviors in the 2013-2016 West Africa ebola virus disease outbreak. Curr Psychiatry Rep. 2016;18:104. Currently, ease of access to communication technologies and the transmission of sensational, inaccurate or false information can increase harmful social reactions, such as anger and aggressive behavior.¹⁴14. Wang Y, McKee M, Torbica A, Stuckler D. Systematic literature review on the spread of health-related misinformation on social media. Soc Sci Med. 2019;240:112552.

Diagnostic, tracking, monitoring and containment measures for COVID-19 have been established in several countries.⁶6. Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K, Baguelin M, et al. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand [Internet]. 2020 Mar 16 [cited 2020 Mar 19]. http://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf
http://www.imperial.ac.uk/media/imperial... However, there are still no accurate epidemiological data on disease-related psychiatric implications or their impact on public health. A Chinese study provided some insights in this regard. Approximately half of the interviewees classified the psychological impact of the epidemic as moderate to severe, and about a third reported moderate to severe anxiety.¹⁵15. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020 Mar 6;17(5). pii: E1729. doi: http://10.3390/ijerph17051729.
http://10.3390/ijerph17051729... Similar data have been reported in Japan, where the economic impact has also been dramatic.¹¹11. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci. 2020 Feb 8. doi: http://10.1111/pcn.12988. [Epub ahead of print]
http://10.1111/pcn.12988...

Another study reported that patients infected with COVID-19 (or suspected of being infected) may experience intense emotional and behavioral reactions, such as fear, boredom, loneliness, anxiety, insomnia or anger,¹¹11. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci. 2020 Feb 8. doi: http://10.1111/pcn.12988. [Epub ahead of print]
http://10.1111/pcn.12988... as has been reported about similar situations in the past.¹⁶16. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395:912-20. Such conditions can evolve into disorders, whether depressive, anxiety (including panic attacks and post-traumatic stress), psychotic or paranoid, and can even lead to suicide.¹⁷17. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7:228-9.,¹⁸18. Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168:1245-51. These conditions can be especially prevalent in quarantined patients, whose psychological distress tends to be higher.¹⁶16. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395:912-20. In some cases, uncertainty about infection and death or about infecting family and friends can potentiate dysphoric mental states.¹¹11. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci. 2020 Feb 8. doi: http://10.1111/pcn.12988. [Epub ahead of print]
http://10.1111/pcn.12988... ,¹⁸18. Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168:1245-51.

Even among patients with common flu symptoms, stress and fear due to the similarity of the conditions can generate mental distress and worsen psychiatric symptoms.¹⁵15. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020 Mar 6;17(5). pii: E1729. doi: http://10.3390/ijerph17051729.
http://10.3390/ijerph17051729... ,¹⁹19. Park SC, Park YC. Mental health care measures in response to the 2019 novel coronavirus outbreak in Korea. Psychiatry Investig. 2020;17:85-6. Despite the fact that the rate of confirmed vs. suspected cases of COVID-19 is relatively low and that the majority of cases are considered asymptomatic or mild, as well as that the disease has a relatively low mortality rate,²⁰20. Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. [The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China]. Zhonghua Liu Xing Bing Xue Za Zhi. 2020;41:145-51.,²¹21. Wang Y, Wang Y, Chen Y, Qin Q. Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures. J Med Virol. 2020 Mar 5. doi: http://10.1002/jmv.25748. [Epub ahead of print]
http://10.1002/jmv.25748... the psychiatric implications can be significantly high, overloading emergency services and the health system as a whole.

In conjunction with actions to help infected and quarantined patients, strategies targeting the general population and specific groups must be developed, including health professionals who are directly exposed to the pathogen and have high stress rates.²²22. Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020;7:e14. Although some protocols for clinicians have been established, most health professionals who work in isolation units and hospitals are neither trained to provide mental health assistance during pandemics¹1. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of ebola, zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9:151-6.,¹⁷17. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7:228-9. nor receive specialized care. Previous studies have reported high rates of anxiety and stress symptoms, as well as mental disorders, such as post-traumatic stress, in this population (especially among nurses and doctors), which reinforces the need for care.²²22. Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry. 2020;7:e14.,²³23. Huang JZ, Han MF, Luo TD, Ren AK, Zhou XP. [Mental health survey of 230 medical staff in a tertiary infectious disease hospital for COVID-19]. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 2020;38:E001.

Other specific groups are especially vulnerable in pandemics: older adults, the immunocompromised, patients with previous clinical and psychiatric conditions, family members of infected patients and residents of high-incidence areas. In these groups, social rejection, discrimination, and even xenophobia are frequent.¹⁷17. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7:228-9.

Providing psychological first aid is an essential care component for populations that have been victims of emergencies and disasters, but there are no universal protocols or guidelines for the most effective psychosocial support practices.²⁴24. Dieltjens T, Moonens I, Van Praet K, De Buck E, Vandekerckhove P. A systematic literature search on psychological first aid: lack of evidence to develop guidelines. PloS one. 2014;9:e114714. Although some reports on local mental health care strategies have been published, more comprehensive emergency guidelines for such scenarios are unknown,¹1. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of ebola, zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9:151-6.,¹⁷17. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7:228-9.,¹⁹19. Park SC, Park YC. Mental health care measures in response to the 2019 novel coronavirus outbreak in Korea. Psychiatry Investig. 2020;17:85-6. since previous evidence refers only to specific situations.²⁴24. Dieltjens T, Moonens I, Van Praet K, De Buck E, Vandekerckhove P. A systematic literature search on psychological first aid: lack of evidence to develop guidelines. PloS one. 2014;9:e114714. In Brazil, a large developing country with pronounced social disparity, low education levels and humanitarian-cooperative culture, there are no parameters for estimating the impact of this phenomenon on the population’s mental health or behavior. Will it be possible to implement effective preventive and emergency actions aimed at the psychiatric implications of this biological pandemic in broad spheres of society?

Specifically for this new COVID-19 scenario, Xiang et al., suggest that three main factors should be considered when developing mental health strategies: 1) multidisciplinary mental health teams (including psychiatrists, psychiatric nurses, clinical psychologists and other mental health professionals); 2) clear communication involving regular, accurate updates on the COVID-19 outbreak; and 3) establishing safe psychological counseling services (for example, via electronic devices or apps).¹⁷17. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7:228-9.

Finally, it is extremely necessary to implement public mental health policies in conjunction with epidemic and pandemic response strategies before, during and after the event.¹³13. Shultz JM, Cooper JL, Baingana F, Oquendo MA, Espinel Z, Althouse BM, et al. The role of fear-related behaviors in the 2013-2016 West Africa ebola virus disease outbreak. Curr Psychiatry Rep. 2016;18:104. Mental health professionals, such as psychologists, psychiatrists and social workers, must be on the front line and play a leading role in emergency planning and management teams.¹1. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of ebola, zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9:151-6. Assistance protocols, such as those used in disaster situations, should cover areas relevant to the individual and collective mental health of the population. Recently, the WHO²⁵25. World Health Organization. Global Health Estimates 2016: disease burden by cause, age, sex, by country and by region, 2000-2016. Geneva: WHO; 2018. and the U.S. Center for Disease Control and Prevention²⁶26. Center for Disease Control and Prevention. Mental health and coping during COVID-19. Atlanta: CDC; 2020. published a series of psychosocial and mental health recommendations, several of which are included in Box 1. This is in line with longitudinal data from the WHO demonstrating that psychological factors are directly related to the main causes of morbidity and mortality in the world.²⁵25. World Health Organization. Global Health Estimates 2016: disease burden by cause, age, sex, by country and by region, 2000-2016. Geneva: WHO; 2018. Thus, increased investment in research and strategic actions for mental health in parallel with infectious outbreaks is urgently needed worldwide.¹1. Tucci V, Moukaddam N, Meadows J, Shah S, Galwankar SC, Kapur GB. The forgotten plague: psychiatric manifestations of ebola, zika, and emerging infectious diseases. J Glob Infect Dis. 2017;9:151-6.

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