The mental health effects of a pandemic are often neglected while health professionals deal with acute life-threatening risks.
A scientifically meaningful comparison between the Spanish flu and the current COVID-19 pandemic is fraught, as we argue below.
At best we can only hope to learn from relevant experiences from past pandemics or epidemics such as SARS or MEHRS, which may be translated into strategic planning and action in the event of future crises.
Sadly, pandemics are likely to recur. History has taught us that bitter lesson. We live in a complex ecosystem where we coexist with unfriendly pathogenic organisms ‘seeking’ to invade us. It is a battle we cannot always win. Despite major advances in medical knowledge, in the absence of a vaccine or cure we often resort to the time-honoured biblical strategy of isolation. This applies to the case of COVID-19 as it did to the Spanish flu.
While there are similarities between the impact of the Spanish flu and COVID-19 there are also stark differences. The world’s population in 1918 was around 2.5 billion. It is estimated that 500 million were affected, or 20% of the world’s population. Up to 50 million died or 10% of those infected. Young adults, especially those aged 20 to 40, were over-represented whereas with COVID-19 death rates are highest in the elderly. (1) It is likely that during the Spanish flu older people had partial immunity due to past exposure to other strains of the flu virus.
A with the Spanish flu, Australia seems better off than many other countries with the current pandemic.
However, the second and third waves of the pandemic in 1919 caused more damage than the first wave. We need to be cognisant of this as we appear to be recovering from the first wave in most states while Victoria is experiencing what appears to be a second wave.
The commonwealth government was only 18 years old at the time of the outbreak of Spanish flu in Australia and most of the states acted autonomously in implementing policies and practices, just as they do now. Quackery was rife and included zinc inhalations. Inoculations of a vaccine consisting of several strains of bacteria might have prevented bacterial pneumonia but had no impact on the viral infection. (1)
The causative agent, the influenza virus H1N1, was not isolated till a decade later and the genetic sequencing of the virus was not carried out until the mid 1990s when it was found to be H1N1 of the Avian variety. (2) By comparison, it only took weeks to genetically sequence the COVID-19 virus in early 2020.
The speed with which information and misinformation has spread about COVID -19 has been far greater than was true of the Spanish flu. We live in a digital age which aids and often hinders dissemination of reliable information creating a market based on quackery similar to experiences during the Spanish flu. Zinc lozenges and vitamin D have been promoted to prevent COVID-19 although there is little evidence to support their clinical efficacy. While these agents are relatively harmless, the same cannot be said for hydroxychloroquine, which has been recommended as a preventive agent by the US President Donald Trump, despite the risks of cardiac arrhythmia and death.
While Australia in 1919 was largely mono-cultural, mainly Anglo-Saxon, today about 25% of our population was born overseas and 50% have a family member born abroad. People bring their own health beliefs into the clinical environment and also rely on information gleaned from their country of origin which is readily available through the media.
Given these differences in health literacy, information dissemination by our health authorities requires accurate multi-lingual translations. These challenges, ever present during COVID-19, did not exist during the Spanish flu.
On balance, the Information Age may have helped to contain the spread of the virus and reduce the death toll during COVID-19, but levels of anxiety might be higher as a result of a greater volume of information and misinformation.
The methods used to contain the contagion are similar and rely on ancient principles of quarantine, isolation and social distancing to which we have added “lockdown”. Today, and in 1918-19, the causative virus was novel and had its origins in another species – avian in the case of Influenza H1N1, and possibly bats or other animals in the case of COVID-19.
The Spanish flu started in August 1918 and reached Australia in January 1919. It relied on ships carrying infected soldiers from Europe arriving in Australia after a four to six-week journey. Modern travel brought COVID-19 to our shores more rapidly. However, shipping, in the form of luxury cruise liners, certainly contributed to the spread of the virus in Australia, as it did elsewhere.
In both pandemics quarantine was imperfect. Returning soldiers in 1919 were quarantined in special facilities but breakouts were frequent, spreading the virus into the community. Quarantine has also been problematic in 2020: hotel-based, quarantined Australians returning from abroad have infected poorly trained security guards and taken the virus home.
Mental health implications
We need to acknowledge that managing the mental health effects of a pandemic are often neglected while health professionals deal with acute life-threatening risks. The literature on mental health problems created by the Spanish flu is sparse, while studies related to COVID-19 are speculative, descriptive and predictive in the absence of clinical trials that examine the efficacy of specific interventions in the peri or post COVID-19 period. As a result, despite at least 50,000 international publications about COVID-19 in the last six months, few deal with mental health issues.
Comparisons with the Spanish flu pandemic are difficult, given the paucity of reliable data. Nurses reported the feelings of hopelessness suffered by frontline doctors in Australia. One Norwegian study showed a seven-fold increase in suicides comparing rates before and after the flu.
There is also some evidence of neuropsychiatric manifestations caused by the Spanish flu.
Structural damage to the brain during acute influenza illness may manifest itself with acute or latent psychiatric symptoms such as confusion, delirium and cognitive disturbance. Encephalitis Lethargica occurred in up to a million cases of Spanish flu causing drowsiness, movement disorders and confusion. Years later large numbers of Parkinson’s disease cases were connected with Spanish flu as a possible cause for Parkinson’s. (5)
To make an informed estimate about the mental health consequences of the Spanish flu we can draw on studies about the pandemics of SARS in 2003 and swine flu H1N1 in 2009. During the SARS pandemic 36% of patients admitted to hospital in the US had symptoms of mental illness. (3)
Given the extent of Spanish flu and high morality, similar percentages would have probably applied to those confined to their beds, either at home, in hospitals or other care facilities. Projecting this estimate onto the current prevalence of COVID-19, over 3000 patients in Australia may now be in need of psychiatric care. In the US the number may exceed 1,000,000. Hawryluck (3) also studied the psychological effects of quarantine on 129 patients during the SARS epidemic in Canada and found that 28.9% met the criteria for PTSD and 31.2% met criteria for clinical depression.
Concern has been expressed about the mental health of health workers, especially those on the frontline. Grace et al (4) found the presence of psychological distress amongst 45.7% of doctors caring for SARS patients compared with 17.5% among those not caring for these patients.
In 1919, psychiatry as a medical discipline was in its infancy and it remained so for another 40 years. In Victoria asylums had been opened in Ararat, Beechworth, Kew (Willsmere) and Royal Park between 1867 and 1916 but drug therapy was limited to barbiturates with the introduction of phenobarbital in 1912. There is little evidence for psychotherapies or community-based treatment in 1919. Those approaches to mental health were not developed till the 1970s.
During and after the outbreak of the Spanish flu it is highly unlikely that those suffering depression, anxiety or PTSD, would have received any formal treatment unless they were so severely disturbed that admission to an asylum was required where the main treatment was restraint and isolation.
In Australia, as in other countries, it is also difficult to separate the effects of flu induced mental illness from the psychiatric problems caused by WW1 which ended in 1918 and left a legacy of mental illness including shell shock which we now call PTSD. Some 15,000 Australians died of the flu but over 60,000 Australian soldiers died on the war fronts. Many of the remaining 300,000 suffered physical and mental trauma for which alcohol (for many) was the only relief.
Domestic violence was common so mental illness in families was compounded. Given the lack of medical knowledge at this time, shell shock was considered by some clinicians to be a sign of personal weakness, as described in Pat Barker’s novel The Regeneration Trilogy. The Great Depression did not arrive until a decade later, but the insecurity of employment after the Great Strike in Australia in 1917 was another factor contributing to stress and mental illness.
The Spanish flu period shares some of the characteristics of Australia under COVID-19 where a major recession has seen the creation of abnormal joblessness, especially among young adults.
Fortunately, mental health services in 2020 are well advanced, although they are stretched at the best of times and not readily accessible in rural and remote Australia.
It is anticipated that service provision will deteriorate as unemployment and economic hardship grow. Beyond Blue, which provides community-level mental health support, has reported a 40% increase in calls for help during the pandemic compared to the same time last year (personal communication). The link between unemployment and mental health has been well documented following previous recessions, unrelated to any pandemic. Given job insecurity in modern Australia, even during “normal times” the fear of joblessness is a source of anxiety. (6,7,8,9)
Evolution of the 2020 pandemic
Understanding the evolving nature of mental health problems arising during the current pandemic requires us to distinguish between three stages: 1. pre-pandemic phase; 2. acute pandemic phase; and 3. post-acute pandemic phase.
Pre-pandemic phase
Nightly TV footage emerging from Wuhan, Hubei Province, China in mid to late January showing overcrowded hospitals, people dying in the streets and others forced into isolation by the authorities was met with a variety of emotional responses ranging from denial to escalating fear and alarm. By March panic buying and supermarket brawls over toilet paper and other goods were reported. Hoarding of essentials, especially sanitisers and many food items, became common and spread panic across the suburbs of Melbourne and Sydney. (10) As with SARS, increased anxiety about the possibility of contracting the virus gave rise to a tendency to discriminate against people of Asian appearance. COVID-19 was sometimes referred to as the China virus, the Wuhan virus or the New Yellow Peril. (11)
Acute pandemic phase
As the COVID-19 infections slowly seeped into the Australian community from returning holiday makers and others, the next phase began with policies of quarantine, social and physical distancing and by mid-March lockdowns of various kinds in different states. People were required to stay at home unless they needed medical treatment, exercise, to purchase essential foods and drugs, or work if working at home was not possible. Schools, gyms, public venues, restaurants, large gatherings at home and outside were no longer possible. Pandemic planning was well advanced based on mathematical modelling that anticipated up to 130,000 cases would be detected requiring large quantities of personal protective equipment for the safety of health workers and up to 7500 ventilators for the worst cases.
Daily briefings by the prime minister and chief medical officer were screened on the nightly news. Suddenly with no end date in sight, job losses mounting and a recession seeming inevitable, people were confronted with uncertainty (12) which exacerbates fear, anxiety, insomnia and ultimately leads to depression and PTSD.
These problems are more profound in those with pre-existing mental health issues, in particular those with generalised anxiety disorder. During the 2009 H1N1 pandemic 25% to 33% of the community experienced high levels of stress and anxiety (13). From this we learned that special consideration needs to be given to other high-risk groups, including health workers, those placed in full isolation through quarantine procedures, the existing and newly unemployed, the homeless and the isolated elderly.
Although there is no hard data yet, there is legitimate concern about the impact of isolation during COVID-19 on alcohol and substance abuse, domestic violence and with school closures and children learning at home the possibility of child abuse. (14)
There is anecdotal evidence from Victoria Police pointing to an increase in call outs for domestic violence, although the true incidence may never be known as victims are unlikely to call the police in the presence of the perpetrator.
The psychological consequences of hospitalisation are far reaching, too. They range from the acute effects of hypoxia and metabolic changes to the mental impact of a prolonged and traumatic hospital admission with the possibility of confronting a near death experience. PTSD will no doubt linger for many years beyond the pandemic (as it did with the Spanish flu) and steps to mitigate this as well as depression are required in addition to managing the physical rehabilitation of patients. These stressors are worse with longer periods of confinement and with financial loss. (15,16)
Post-acute phase
With the easing of restrictions for social engagement, the opening of schools, pubs and restaurants as well as fewer limits to travel and competitive professional sport comes the threat of a second or subsequent wave of the pandemic. This is already happening in Victoria.
In Australia we have watched the contrast in morbidity and mortality in countries such as Sweden, the US and the UK where there have been no restrictions or delayed controls, compared with Taiwan, South Korea and Australia that introduced timely and tight restrictions. We also have before us the sobering example of Singapore, which experienced a second wave with over 7000 new cases in one week.
The possibility of a second wave following a long period of isolation generates more uncertainty, fear, apprehension, anxiety and worries about the reintroduction of tight controls to contain the next and subsequent waves until and if a vaccine is available. Australians are still asked to practise social and physical distancing, use sanitisers, wash their hands, work from home if possible and most recently in Melbourne to wear masks outside the home if it is not possible to keep 1.5 meters distance from the next person.
During this period we will witness the emergence of more mental illness as those who are still suffering from the first wave of the pandemic will be joined by others whose optimism has worn thin because of the uncertain future and fears of a long-term economic decline.
Conclusions
While the devastation caused by both the Spanish flu and COVID-19 have been immense, the general lack of mental health data pertaining to both pandemics requires us to make cautious comparisons.
However, the SARS pandemic of 2003 provides some useful learnings which sadly, with the exception of Taiwan and a small number of other countries including Australia, have not adopted during the current pandemic. As of 9 July 2020 Taiwan, with a population of 24 million has only 448 cases and seven deaths, while the US with a population of 300 million has 3 million cases and 132,310 deaths.
Much has been learned about the nature of the virus but much more needs to be learned about its psycho-social impact on communities across the globe and the effect of the imminent economic recession on the physical and mental well-being of this, and subsequent, generations.
Dr Leon Piterman is Professor of General Practice, Monash University, Victoria
Emerita Professor Marika Vicziany is Economic Historian, Monash University, Victoria
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