Industrial Psychiatry Journal

: 2020  |  Volume : 29  |  Issue : 1  |  Page : 1--8

Mental health aspects of pandemics with special reference to COVID-19

Kalpana Srivastava1, Suprakash Chaudhry2, Sowmya AV2, Jyoti Prakash1,  
1 Department of Psychiatry, AFMC, Pune, Maharashtra, India
2 Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil University, Pune, Maharashtra, India

Correspondence Address:
Dr. Suprakash Chaudhry
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil University, Pimpri, Pune, Maharashtra

How to cite this article:
Srivastava K, Chaudhry S, Sowmya AV, Prakash J. Mental health aspects of pandemics with special reference to COVID-19.Ind Psychiatry J 2020;29:1-8

How to cite this URL:
Srivastava K, Chaudhry S, Sowmya AV, Prakash J. Mental health aspects of pandemics with special reference to COVID-19. Ind Psychiatry J [serial online] 2020 [cited 2020 Dec 4 ];29:1-8
Available from:

Full Text

Pandemics are large-scale outbreak of disease that spreads rapidly, afflicting many persons simultaneously across multiple countries.[1] History tells us that as humans spread across the globe so did infections. Infections have been our constant companion since antiquity. Hunters and gatherers formed tribes that turned to farming and formed villages which gradually advanced to metropolis. Urbanization brought residents into denser neighborhoods, which combined with increasing populations are placing increasing pressure on the environment. Catastrophic pandemics have been occurring since antiquity and are frequently mentioned in ancient texts. Pandemics are associated with death, destruction, and devastation. Not surprisingly, pandemics are associated with long-term psychological consequences. A brief estimate of the effects of some of these pandemics is given below.

Antonine plague (AD 165)

The Antonine plague (the Plague of Galen) began in the far east. Soldiers returning to Rome from the far east brought back the infection which then spread throughout the Roman Empire. The pandemic killed about five million people.

Plague of Justinian (541–542)

The Justinian Plague (bubonic plague) started in central Africa and spread to Egypt and then hit the Byzantine Empire and many cities around the Mediterranean Sea, spreading with ease via a large number of ships, usually maintained in unhygienic condition, arriving into the ports. The plague killed about half the population of Europe, about 25 million people.

Japanese small pox epidemic (735–737)

The Japanese small pox epidemic affected most of Japan. As a consequence of this epidemic, approximately 1/3rd of the entire Japanese population (about 1 million) perished.[2]

The Black Death (1346–1353)

The Black Death or “The Plague” is the first pandemic about which reliable information is available. This pandemic of bubonic plague originated in China in 1334, spread through central Asia and northern India following the Silk Road, and reached Sicily in 1347. Over the next 5 years, it spread throughout Europe, Russia, and the Middle East. The mortality of untreated bubonic plague is close to 70%.[3] Over 50 years, the Black Death caused about 100 million deaths.[4] In subsequent centuries, the plague caused several outbreaks through Europe in causing death and destruction but never with the same ferocity as the initial pandemic.[5]

Smallpox (1519–1520)

The smallpox epidemic affected the native people of Mexico. It was brought by the European invaders. In this epidemic, about 5 million to 8 million people perished.[6]

Cocoliztli epidemic (1545 and 1576)

The Cocoliztli (probably indigenous hemorrhagic fevers) epidemics that began in 1545 and 1576 were catastrophic and killed about 7 million to 17 million people in the highlands of Mexico.[6]

The 17th-century great plagues

The 17th-century “great plagues” included the Great Plague of Seville (1647–1652), the Great Plague of London (1665-1666), and the Great Plague of Vienna (1679). A total of 3 million people died due to these plagues.

The Third cholera epidemic (1852)

The third cholera epidemic had the highest fatality of the epidemics in the 19th century. The pandemic originated in India and spread across the world. Over a million lives were lost due to this pandemic.

The third plague pandemic (1855)

The third plague pandemic began with the re-emergence of the disease from its wild rodent reservoir in the Yunnan province of China in 1855. From there, the disease advanced to K'unming in 1866, the Gulf of Tonkin in 1867, and the port of Pakhoi (now Pei-hai) in 1882 and Hong Kong in 1894. From there, it spread to ports in all continents by the infected rats traveling the international trade routes on the new steamships. For the next five decades, the pandemic waxed and waned throughout the world and ended in 1959. The third plague pandemic resulted in 15 million deaths, the majority of which were in India.[7]

Yellow fever (the late 1800s)

Multiple Yellow fever epidemics ravaged the Americas in the late 1800s, the last ending in 1905. Yellow fever claimed over 100,000 American lives. Though exterminated from America, yellow fever continues to ravage countries in the sub-Saharan Africa and tropical South America.

Flu (1889–1890)

This flu pandemic occurred due to the H3N8 subtype of the influenza virus. The pandemic originated in Russia and thereafter spread across many countries in the northern hemisphere. The spread of this epidemic was facilitated by the arrival of the modern transport infrastructure. The flu resulted in about one million deaths.

Sixth cholera pandemic (1910–1911)

The sixth cholera pandemic also originated in India. It spread through ships and other means of transport to the Middle East, North Africa, Eastern Europe, and Russia. The pandemic claimed 8,00,000 lives.

The “Spanish Flu” pandemic (1918–1920)

”Spanish Flu” Pandemic was caused by the H1N1 influenza virus. It infected more than 25% of the global population. With a mortality rate of 10%–20%, it caused 50 million, possibly 100 million deaths. The Spanish Flu caused more deaths than the Black Death did in a century.[8],[9]

Asian flu (1957–1958)

The Asian flu was caused by new influenza A (H2N2) virus of avian origin. The influenza outbreak originated from Singapore, spread to Hong Kong and the eastern coast of the USA in the late 1950s and later died out after a vaccine was introduced. This influenza pandemic claimed about 1.1 million lives.

Hong Kong flu (1968)

The Hong Kong flu was caused by influenza A (H3N2) virus which originated from an avian influenza A virus and killed one million people. It continues to cause seasonal influenza A virus associated with severe illness in older people.

HIV pandemic

HIV/AIDS unlike all previous and subsequent pandemics is a slowly progressing global pandemic that has over decades affected all the continents and different populations. In addition, due to the lengthy survival of patients, it has brought a host of challenges in its wake. HIV has infected about 74.9 million individuals all over the world and about 32 million have died (end 2018) since 1981. Every year, it continues to cause about one million deaths globally.[10]

Severe acute respiratory syndrome (2002–2003)

The first pandemic of the 21st century was severe acute respiratory syndrome (SARS) caused by the SARS coronavirus (SARS-CoV). The condition manifested with severe respiratory symptoms and had a mortality of 10%. It began in China in November 2002 and affected fewer than 10,000 individuals in 26 countries. As a result of effective public health preventive measures worldwide, the pandemic was contained by the mid-2003.[11] For the first time during and after the SARS pandemic, the psychiatric aspects were studied all over the world. Valuable information on the psychological effects of an acute infectious pandemic on affected individuals, families, communities, health-care workers, quarantine, survivors of severe illness, etc., was gathered.[8],[12]

The H1N1 or “Swine Flu” Pandemic (2009-2010)

The Swine flu began in Mexico and affected over 10% of the population of the world. It caused an estimated 20,000 to500,000 deaths.[13],[14] Because the disease disproportionately affected healthy young adults, often quickly resulting in severe respiratory failure, it was perceived as extremely threatening. However, the final death rate was lower than the death rates of influenza. The initial announcements and warnings by the WHO caused alarm in the general public, but this changed to distrust and disgruntlement as the predicted dire consequences of the pandemic did not materialize.[15] Governments and health agencies were blamed for panic (”panicdemic”) and pushing vaccines without adequate study to enhance the profits of pharmaceutical firms at the cost of the general public (H1N1 vaccines worth 1.5 billion dollars were administered in 2009 in the USA alone).[8],[16]

The COVID-19 pandemic

The pandemic caused by novel CoV (COVID-19) began in Wuhan in China and has spread to 215 countries. It has already affected 7,000,000 individuals and killed 313,636. The virus is more transmissible than SARS-CoV and has a case fatality rate of 2.3%.[17] A unique feature of this pandemic is the accompanying “infodemic”– an excess of (mis) information on social media and elsewhere – which is a major hazard to mental well-being during this health crisis.[18]

 Psychological Factors in Pandemics

Despite their periodic occurrence and devastating consequences, surprisingly, pandemics have evoked minimal interest in mental health professionals, though the situation has vastly improved in the past decade.

Psychosocial stressors in pandemics

Pandemics are almost invariably characterized by ambiguity, misunderstanding, and a feeling of urgency.[19] As the causative agent is usually new, in the early stages of a pandemic, there is widespread ambiguity about the chances and effects of becoming infected, along with lack of information and understanding about the most effective mode of prevention and treatment.[20] Other psychosocial stressors related to pandemics include threats to the health of self and loved ones, lockdowns, social distancing, separation from family and friends, death of loved ones, social isolation due to quarantine, shortages of food and medicines, loss of earnings, closure of educational institutions and industries, and cancellation of functions and festivals.[21],[22]

Importance of psychological factors during pandemics

The current methods for combating pandemics are largely behavioral or educational interventions comprising of risk communication, vaccination adherence programs, personal protective measures, and social distancing. Extreme psychological distress related to actual or threatened infection is a significant issue. Psychological factors are also essential for understanding and combating the collective disorderly behavioral patterns displayed by people facing widespread, serious infection.

Effects of stressful life events and negative emotions on the immune system

Stressful life events and negative emotions suppress the immune system to some degree, resulting in enhanced susceptibility to infection.[23] Although the mechanisms of these effects are not exactly known, research has shown that stressors and negative emotions influence the production of lymphocytes and pro-inflammatory cytokines.[23] On the other hand, psychotherapeutic interventions such as cognitive behavioral therapy by decreasing a person's stress proneness and negative emotions, may reduce stress-related immunosuppression.[24]

The frantic chase for quack remedies and traditional therapies

A serious threat to the health of self or loved ones can impair the person's ability to make rational decisions.[25] At the beginning of a pandemic, reliable vaccines and medical treatment are often not available. In this scenario, to protect themselves and their loved ones, people in desperation turn to quack remedies and dubious traditional therapies. Traditional remedies for influenza include inhalation of vapors of carbolic acid, wearing necklaces of garlic, and drinking pine tar. Folk remedies for SARS included diets of turnips, vinegar, kimchee, or spicy foods, and even smoking cigarettes, all of which were ineffective. We may add cow's urine to this list. During the SARS pandemic, some people in China hired sorcerers, lit firecrackers, and burned fake money. People take large doses of vitamins or herbal supplements in the hope that this will boost their immunity.[22],[26]

Civil unrest, rioting, and violence

Widespread sickness, debility, and death during pandemics evoke prosocial, affiliative, supportive, behaviors in the form of mutual aid such as running community kitchens, ambulance services, or disposal of dead bodies.[27] However, civil unrest or riots have sometimes erupted during pandemics.[28] There are numerous examples of groups of citizens clashing violently with health workers, due to fears that the health workers were harming rather than helping them.[22] During the Ebola outbreak in September 2014, eight health-care workers and journalists reached the Guinean village of Worme to teach the villagers how to protect themselves against Ebola. But, the villagers, believing that the workers were spreaders of the disease, attacked and killed them.[29] Villagers in Zhejiang province of China protesting the local government's SARS policy attacked officials and broke windows and furniture of the local offices.[26] The recent attack on health-care workers in Indore and other parts of India can be added to the list.

Psychological reactions to stress, harm, and loss in pandemics

The majority of people are resilient to stress, and this may be more true for people from developing countries. Many persons who survive major stressful events do not suffer adverse psychological effects. Experience of the recent past however tells us that the psychological effects of pandemics are often larger than the medical effects. For instance, during the West African Ebola outbreak (2014–2015), the “epidemic of fear” affected more people than the epidemic itself.[22],[30] Similarly, during the 2003 SARS pandemic, the psychological morbidity greatly exceeded the medical morbidity in terms of both the number and duration of impact.[31],[32] Reactions of people to the stress of pandemic vary from fear to indifference to fatalism.[33] At one end of the spectrum are people who blatantly disregard the risks and refuse to follow the recommended health behaviors including hygiene practices, social distancing, and vaccination. At the opposite end of the spectrum are people who develop intense anxiety or fear. Psychologically, a moderate level of anxiety motivates people to address health threats, but severe anxiety is incapacitating.[22] Studies conducted during the early stages of the Swine flu pandemic reported that 24% of a UK community sample had significant anxiety,[34] while 83% of American college students reported some degree of anxiety about becoming infected.[20]

An online questionnaire survey of 400 residents of Karachi revealed that 94.5% were worried about the health of their family members, 88.8% feared going to market, 71% were not confident about the existing infection control measures, and 62.5% felt anxious on a daily basis. People >35 years had significantly higher levels of fear even at home. Use of social media was associated with anxiety and avoidance behaviors in people below 35 years. Graduates had significantly more fear for the safety of their health. Changes in behavior incorporated by the respondents included washing hands more frequently (87%), reduced physical contact (86.5%), canceled plans (84.5%), and reduced visits to health-care facilities (74.5%).[35]

An Internet-based survey carried out in Italy between March 27 and April 6, 2020, received 18,147 responses. Posttraumatic stress symptoms (PTSS) were present in 37%, adjustment disorders in 22.9%, high perceived stress in 21.8%, anxiety in 20.8%, depression in 17.3%, and insomnia in 7.3% of the respondents. All the selected outcomes were associated with any recent COVID-related stressful life event, job loss, being a woman, and of younger age. PTSS, anxiety, and Alcohol dependence syndrome (ADS) were associated with quarantine, while working more than usual was associated with PTSS, perceived stress, and ADS. Death of a loved one due to COVID-19 was associated with PTSS, depression, perceived stress, and insomnia.[36]

During pandemics, apart from the infected individuals, health-care workers are also stigmatized. This unfortunate trend has manifested in Indian landlords demanding their tenants, who are health-care workers, to vacate their premises.

Pandemic-related psychosocial stressors may trigger or exacerbate psychiatric disorders, including mood disorders, anxiety disorders, substance use disorders, and posttraumatic stress disorder (PTSD).[37],[38] Bereavement or loss of loved ones in the pandemic may be followed by complicated grief or a depressive episode. Exposure to widespread mortality, including the deaths of loved ones in the pandemic, may result in PTSD.[21],[22] As a pandemic develops, the general public adapts to the threat and anxiety is dissipated. However, in few individuals, the adverse psychological effects can be severe and persistent.[39]

Management of pandemics

The onset of a pandemic is accompanied by an outcry for medicines and vaccines. Apart from the cost, the process of developing a new vaccine is long and time-consuming. Therefore, the vaccine will not be available when it is needed the most. This must be understood by all. Similarly, the discovery of new drugs is also time-consuming and expensive. Using drugs without clinical trials is fraught with risks. One should guard against the tendency to treat, under stressful conditions, anecdotal reports as maxims. At least the official media should ensure that reliable information about the pandemic is made available for the general public. At the beginning of an epidemic, measures to interrupt transmission that could be implemented immediately, gaining time for improving the medical infrastructure, and pharmaceutical development are the nonpharmaceutical interventions. The three steps of nonpharmaceutical interventions for reducing contact rates between susceptible individuals and the virus are quarantine, social distancing, and locking down the epicenter.[40]

Risk communication

The paramount public health goal during a pandemic is to control the outbreak at the earliest with minimal disruption. Effective risk communication is crucial for realizing this goal.[41]

Risk communication comprises dissemination of information required by the general public to assist them decide about ways to guard themselves from the infection. During a pandemic, fear, panic, rumors, conspiracy theories, and distrust of authorities abound. This can be worsened by sensational reports in the media and fake news in social media.[22]

Creating and preserving trust through authentic and clear communication is vital. However, this is easier said than done because in the beginning of a pandemic, there is a dearth of information about the causative agent and its prevention. During the present CoV pandemic in China, the official media initially downplayed the extent of the epidemic. This resulted in public mistrust of the government's decision-making capability.[18]


Based on the experience of dealing with contagious diseases, a connection between passage of time and the onset of symptoms was drawn. It was also noted that, after a period of time, individuals who did not develop symptoms of the disease would probably neither develop the disease nor spread the disease. Based on this observation, the medieval society instituted mandatory isolation. Quarantine was first mandated in 1377 in Ragusa (city-state of Dubrovnik). All new entrants to the city were required to wait for 30 days on a nearby island before entering the city.[42] Due to its efficacy during the Black Death, the practice of quarantine spread throughout Europe. Apart from this, quarantine also includes isolating the infected, the suspicious, and their close contacts to prevent the community spread of the infectious disease. To this day, quarantine continues to be a highly controlled, nationally and internationally governed public health measure to prevent infectious diseases.[8],[43]

Hygiene measures

Hygiene measures that are usually recommended include handwashing with soap and water, covering coughing and sneezing, avoiding touching one's face, cleaning surfaces that are frequently touched, and using facemasks. While practices such as covering coughs and handwashing are normally acceptable to the general public, use of facemasks is less acceptable.[44],[45] Despite the acceptability of handwashing, studies indicate that individuals frequently do not follow handwashing recommendations, especially when they are not observed by others.[46] Further, only individuals who perceive themselves as having a high risk of infection are likely to adhere to handwashing recommendations.[22],[47]

Social distancing

Social distancing must be applied immediately, strictly, and steadily to be effective.[48] Social isolation due to social distancing is also overcome partially by social media. Preemptive school closure can slow the spread of infection. Apart from disruption of studies due to school closure, children lose access to school nutrition programs.[22] The economic hardship due to industrial lockdown is a more important problem that deserves immediate attention of the government.


The reason for lockdown is that by greatly decreasing person-to-person contact, lockdowns at least in the short term will reduce people-to-people transmission of infection, resulting in a flattening of the curve of fresh cases and avoiding/delaying an exponential take-off. Prior to the lockdown in India the doubling period of COVID-19 positive cases was three days—almost the same as in other countries without a lockdown. Calculations revealed that at this rate, the infection would spread from 100 people to 420 million persons in 66 days. A peak of the epidemic was predicted in mid-May, that our health system was unprepared. As a result of the lockdown, the doubling time increased to 8 days, which gave us an extra 4 weeks to organize our health infrastructure. The aim of the lockdown phase one was fully achieved. Lockdown is a temporary measure; it cannot and will not stop infections as is being proved by the increasing infections reported daily.[49] Total or partial lockdown has been implemented in nearly 200 countries. The world's largest and most restrictive mass quarantines have been implemented by India, followed by France, Italy, New Zealand, and Poland. The USA and the UK have partly enforced lockdown. China initially placed Wuhan City under quarantine, but later extended it to 15 other cities. Countries with no lockdowns include Sweden, South Korea, Tajikistan, Japan, Indonesia, Belarus, Malawi, Nicaragua, and Taiwan. The results of lockdown are now readily available. If lockdown was a panacea, then it would be expected that chaos would prevail in countries that did not implement it. Unfortunately, the results belie our expectations. While some countries with lockdown did have low deaths/million population, similar results are found in countries that did not implement lockdown. Interestingly, even mathematical modeling has given evidence against total lockdown. Founded on data from Wuhan city, experts developed a data-driven susceptible-exposed-infectious-quarantine-recovered (SEIQR) models to imitate the consequences of lockdown of the epicentre city along with social distancing on the pandemic. They concluded that in order to reduce the epidemic size and mortality, the practical and cost-effective strategy would be the implementation of social distancing in the epicenter city first, followed by the province, and then the entire nation without implementing lockdown in the epicenter city.[40]

Lockdown, a temporary delaying tactic, is now sought to be converted to a method of treatment, with people expressing shock and surprise that COVID-19 is spreading despite implementing strict lockdown. There is even talk of deploying paramilitary forces to implement it. (One wonders if the forces would be given the onerous task of hunting and eliminating the dangerous virus.) An objective evaluation of the utility of prolonged lockdowns is urgently required. Extending the lockdown indefinitely may/may not eradicate the virus but is more likely to kill the people from starvation, malnutrition, and intercurrent illnesses.

Emotional reactions to lockdown

The abrupt and total lockdown clamped down on India due to the COVID-19 pandemic caused mammoth disruptions to our daily lives. The loss of control over our lives and our futures may engender overpowering feelings of doom and desperation. The emotional reaction to lockdown may occur in five stages including disbelief (at the sudden and total alteration in their lives), anger (at loss of freedoms), sadness (as a result of adjusting to the new reality), acceptance (as a result of adaptation and resilience), and hope (optimism). These stages are almost like the stages of grief because both are accompanied by an overwhelming sense of loss. It must be clarified that this is not a universal phenomenon, and the emotional reactions of individuals to a crises-like lockdown vary: some people experience no symptoms, few will experience extreme reactions, and most people are in between. Further, these stages of the emotional reaction are not experienced in any sort of linear order, and people may even move back and forth between the stages till they reach the final and most beneficial stage of acceptance.[50]

Psychiatric effects of lockdown

People under severe stress and in isolation may exhibit various symptoms of psychological stress (low mood, anger, irritability, and emotional exhaustion) and disorder including insomnia, anxiety, depression, and PTSS.[1] Socializing is a major part of the daily routine of some people, particularly the elderly, and homemakers look forward to it. Sudden and complete stoppage of this pleasurable activity can produce a sense of loneliness and a disturbed mental state. People with substance use disorders may develop withdrawal symptoms due to enforced abstinence. Due to the stress of lockdown, persons with known psychiatric disorders such as depression, anxiety, and psychotic disorders such as schizophrenia may suffer from an exacerbation or relapse of symptoms. This could also be due to lack of their psychotropic medications. Lockdown invariably leads to social isolation, which adds to sensory deprivation and a general sense of fear and suspicion that may strengthen delusional ideas and fantasy thinking in people, especially those vulnerable to psychiatric disorders. The genuine fear of themselves or their loved ones falling prey to COVID-19 is a stressor and may precipitate a mental breakdown in vulnerable population. The sustained sensational reportage in electronic media, exaggerated headlines in television news, and fake news on social media adds to the heightened anxiety and terror that is detrimental to mental health.[49]

Psychological effects of loss of employment

Loss of employment is one of the most painful and traumatic events a person has to endure. Apart from the increased risk of hypertension, diabetes, and heart disease, the individual develops anxiety, self-doubt, loss of self-esteem, a sense of disappointment, failure or hopelessness, depression, and strained family relationships.[51] Job loss in an individual activates a process of comprehensive adjustment in his/her personal, family, and social life. It entails a loss of contact with an area and persons with whom an affective bond has been established and therefore may be followed by a period of grieving. Apart from normal grief, dysfunctional grieving has been described including anticipatory grief, felt before the loss; inhibited grief, with no outward signs of grief for an extended period of time and pathological denial of loss; prolonged grief, which is prolonged and intense: the individual is incapacitated, spends much time contemplating the death, longing for reunion, is unable to adjust to life without the individual, and daily function is impaired on a long-term basis; and complicated grief, when the typical processes of normal grieving are accentuated and prolonged with impaired ability to engage in daily activities. Dysfunctional grief favors somatization and prevents its resolution. Risk factors for dysfunctional grief include unexpected loss of job; inadequate compensation and adverse monetary impact of the loss; and the use of different coping strategies, for example, avoidant coping in the face of loss. Protective factors for dysfunctional grief include resilience, religious beliefs, social support, posttraumatic growth, and strong personality or hardiness.[52]

A study of 244 unemployed people revealed that 94.3% and 58.7% of the participants had depressive and anxiety symptoms, respectively. Some jobless individuals with high anxiety and depression scores had developed maladaptive coping strategies such as self-blame, denial, and substance use.[53] However, job loss has few long-term effects. Analysis of the consequences of job loss on subjective well-being (SWB) during 3 years before to 3 years after job loss revealed that the responses to job loss is not a unitary experience and per se are poorly represented by a single trajectory that models the mean. Assessment of a single mean response pattern showed that on an average, an individual's SWB reduces severely after job loss and does not revert to preunemployment levels even years after the event, which is in agreement with earlier research.[54],[55] In contrast to this, modeling multiple homogeneous patterns of response revealed that 68.8% cope well with this event, with little long-term fall in SWB. Further, the decrease in SWB in response to job loss was temporary for the majority of individuals because they revert to earlier levels by 1 year after job loss.[56]

Evolutionary trends of pandemics reflected in culture

A nation's ability to react suitably to a pandemic depends on the policy, protocols, regulations, and norms of its institutions and also the beliefs and behaviors of its citizens. The behavior of an individual is fashioned by millions of years of genetic evolution, thousands of years of cultural evolution, and also the experiences of his/her lifetime. During the COVID-19 pandemic, analysis revealed that nations having well-organized, competent governments with strict, custom-enforcing cultures had the lowest rate of increase in COVID-19 cases adjusted for population and also the least deaths controlling for per capita gross domestic product, inequality, and median age. Collectively, these describe 41% of the variance. To rephrase, societies and cultures having institutions that promote behaviors that decrease caseloads and citizens who obey the rules have better outcomes.[57],[58]


The psychological reactions of people to pandemics are complex, variable, difficult to understand, and not yet fully explored. Reactions of people to the stress of pandemic vary from fear to indifference to fatalism. At one end of the spectrum are people who blatantly disregard the risks and refuse to follow the recommended health behaviors. At the opposite end of the spectrum are people who develop intense anxiety or fear. Although the majority of the population are resilient to the stress of pandemics, many manifest health anxiety and distress, and some develop psychiatric disorders including mood disorders, anxiety disorders, PTSD, and substance use disorders. As a pandemic develops, the general public adapts to the threat and anxiety is dissipated. However, in few individuals, the adverse psychological effects can be severe and persistent. Prolonged lockdown as a containment strategy needs reevaluation so that the treatment does not become worse than the disease.


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