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Throughout 12,000 years of human history, pandemics have killed an estimated 300 million to 500 million people, with the bubonic plague decimating an estimated 60% of the European population during the Middle Ages. Despite modern advances in medicine, 

 has caused more than 1 million reported deaths in less than a year. Aside from the death toll, the pandemic has triggered significant emotional, physical, and economic problems around the world. But even in the midst of this crisis, nations have an opportunity to share and learn from each other’s experiences.

The emerging literature measures the impact of various traumatic stressors related to COVID-19, as well as the effects of less severe types of stress exposures. COVID-19 has already led to diverse mental health problems, including anxiety, depression, posttraumatic stress disorder, and other trauma- and stress-related disorders. Different groups have met the qualifying criteria for posttraumatic stress disorder (PTSD) according to DSM-5 as a result of the pandemic: those who have themselves suffered from serious COVID-19 illness and potential death; individuals who, as family members and health care workers, have witnessed others’ suffering and death; individuals who have learned about the death or risk of death of a family member or friend due to the virus; and individuals who have experienced extreme exposure to aversive details (eg, journalists, first responders, medical examiners, and hospital personnel).

Moreover, studies have explored other stressors adding to individuals’ emotional burdens, such as social isolation, unemployment and economic losses, and working from home while caring for children and other family members. Among health care workers, strains include lack of personal protective equipment (PPE), fears of virus exposure, burnout, patients perishing despite heroic efforts to save them, and difficult decisions about which patients should receive limited resources. A few studies have examined posttraumatic stress symptoms (PTSS), as well as anxiety, depression and other symptoms, and substance use in the general population during the pandemic.

More time is needed, of course, to conduct and publish systematic investigations on mental health sequelae, such as formal psychiatric diagnoses. Studies generally have been conducted through diverse internet platforms, which may affect generalizability. Methods and validated rating scales vary.

At the same time, it is not too soon for clinicians to read the emerging literature and base treatments on the latest research. We will explore some representative international studies of various groups affected by COVID-19, as well as protective factors and suggested interventions to help those in need (Figure).

Much of the current research emerges from China, the first country confronted by the pandemic. A 

 in China exposed to COVID-19 found a PTSD incidence of 16.8%, with highest scores in avoidance symptoms.

 Job satisfaction was associated with lower PTSD symptom scores and positive coping. The authors recommended supporting nurses who are having difficulty coping with their work by providing counseling.

A web-based, cross-sectional survey of more than 7000 Chinese individuals in February 2020 found that health care workers had the highest rate of poor sleep, and those aged 35 years or younger had more mood and anxiety symptoms.

 Overall, 35.1% of respondents reported anxiety symptoms, 20.0% depressive symptoms, and 18.2% poor sleep quality.

Other international studies have examined stress responses in health care workers treating patients with COVID-19. A study of 900 health professionals caring for hospitalized patients with COVID-19 in Singapore and India found relatively low symptoms of anxiety (15.7%), depression (10.6%), and stress (5.2%).

 However, among health care workers reporting these issues, more than half had symptoms in the moderate to extremely severe range. In addition, 67% of respondents reported physical symptoms, especially headache, lethargy, anxiety, and insomnia, suggesting somatic expressions of distress. United Kingdom military health care workers were assessed for the effects of inadequate safety equipment on their mental health during the COVID-19 medical response. Those with inadequate equipment had greater odds of having common mental health disorders (2.49), PTSD (2.99), poorer global health (2.09), and emotional problems (1.69).

Only a few studies of mental health problems among patients hospitalized with COVID-19 have been published, with more to come. A study of hospitalized but stable patients found a high prevalence of PTSS (96.2%).

 A chart review of hospitalized patients with COVID-19 in Spain found more than half of the 841 patients hospitalized with COVID-19 had a neurological symptom. Of these, nonspecific neurological symptoms were identified, as well as disorders of consciousness (19.6%), mostly in elderly patients and in those with severe COVID-19 disease; myopathy (3.1%); dysautonomia (2.5%); and other less frequent symptoms.6

Neuropsychiatric symptoms were reported by 19.9% of these patients, including insomnia, anxiety, depression and psychosis; these were not associated with disease severity.

Some studies have drawn inferences based on other severe respiratory viruses. A meta-analysis of long-term clinical outcomes for survivors of adult severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) who were in the intensive care unit (ICU) revealed PTSD prevalence in 39%, depression in 33%, and anxiety in 30% beyond 6 months after discharge, as well as reduced lung function and reduced exercise capacity.

 Italian experts also concluded that we might anticipate similar outcomes in survivors of COVID-19.8

Acute respiratory distress syndrome (ARDS) in ICU survivors of COVID-19 may occur, with an expected survival rate of approximately 25%. Survivors of ARDS may experience persistent fatigue and poor exercise tolerance, pain and weakness, neurological sequelae, and the psychological effects of prolonged ICU stays, as noted in patients with MERS and SARS. Stressors included immobility, separation from family and friends, prolonged sedation, anxiety about health conditions and survival, and subsequent job loss. The authors emphasized the need to identify PTSD (anticipated in up to 30% of ARDS survivors) and other mental health problems, and to provide appropriate and timely multidisciplinary therapy that should continue after discharge.

 A literature review of studies linking panic disorder with patients who had SARS suggested that aggravation of panic attacks is highly likely in survivors of COVID-19 in the face of prominent respiratory symptoms, as panic may be triggered by fear conditioning to abnormal breathing problems.

 The authors urged monitoring for panic as well as obsessive compulsive disorder, PTSD, and generalized anxiety disorder.

Some mental health care advocates believe the general population may be suffering from various levels of vicarious traumatization, although strictly speaking this would not qualify for PTSD’s Criterion A for trauma exposure. Along these lines, in August 2020 the CDC published results of a large US web-based survey of more than 5000 adults (

 in which 40.9% endorsed at least 1 adverse mental or behavioral health problem related to the pandemic. Symptoms of a trauma- and stressor-related disorder were reported by 26.3%, symptoms of anxiety or depression by 30.9%, substance use to cope by 13.3%, and serious consideration of suicide in the prior days by 10.7%. Suicidal ideation was significantly higher for younger respondents aged 18 to 24 years (25.5%), minority groups (Hispanic individuals, 18.6%; Black individuals, 15.1%), nonpaid caregivers for adults (30.7%), and essential workers (21.7%). The authors stressed the need to identify at-risk individuals to develop policies to address health inequities, and to increase resources for identifying mental health problems and offering new treatment options, including telehealth treatments.

In a study of home-quarantined youth in China during the first month of the COVID-19 outbreak, 12.8% had PTSS levels consistent with PTSD, with PTSS and distress associated with negative coping styles.

 Symptom levels were expected to increase with time as quarantine continued. This is important since a formal diagnosis of PTSD requires symptoms to persist for more than a month.

In another online survey conducted early during the Wuhan outbreak, researchers looked at anxiety and depression symptoms (rather than specific PTSS) in relation to social media exposure (SME) to COVID-19 news. The study, which included approximately 5000 adults in China, found high SME was positively associated with higher odds of anxiety and a combination of depression and anxiety, compared with low SME.

 A longitudinal survey of the general population in China during the initial outbreak, and again 4 weeks later, found the mean Impact of Events Scores to be above the cutoff scores for PTSD symptoms at both times, with moderate to severe stress, anxiety, and depression levels.

Results of an Italian cross-sectional, web-based 

 showed a relatively high percentage (29.5%) of PTSS related to the pandemic, suggesting that the pandemic itself could be considered a traumatic event.

 Similarly, an online survey of almost 3500 people in Spain found symptoms of PTSD (15.8%), depression (18.7%), and anxiety (21.6%), with loneliness the strongest predictor of symptoms.

 Other factors associated with these problems were female gender, previous mental health or neurological problems, having physical symptoms similar to those of COVID-19, or having a close relative infected.

Nursing home residents have been particularly vulnerable to poor health outcomes; early in the COVID-19 pandemic many facilities adopted strict lockdown policies. However, social isolation is particularly detrimental to the elderly, who may have increased risk for depression, anxiety, worsening dementia, and even earlier death.

 Given these issues, the Centers for Medicare and Medicaid Services (CMS) recommended safe communal activities for locked-down nursing homes.

In Canada, researchers explored prenatal maternal distress before and during the COVID-19 pandemic.

 Women assessed during the pandemic had higher levels of depression and anxiety, with levels more likely to be clinically significant, compared with women assessed before COVID-19. During the pandemic, dissociative and PTSD symptoms and negative affectivity were also greater, underscoring the need to carefully assess pregnant women to help prevent negative, stress-related outcomes in mothers and infants.

Perhaps not surprisingly, when compared with a control population, psychiatric inpatients in China had more PTSD, anxiety, and depression symptoms; more anger, impulsivity, and worries about health; and intense suicidal ideation.18 Hospitalized psychiatric patients and their mental health caregivers are at high risk for COVID-19 infection, compounding their existing stress. This was noted early in February 2020 in Wuhan, when the virus was diagnosed in at least 50 inpatients with psychiatric disorders and 30 mental health professionals. Factors included lack of protective gear and difficulties isolating.

 Outpatients with psychiatric disorders are also vulnerable to emotional distress during a pandemic. An online survey of more than 2000 outpatients in China discovered that 20.9% of patients with preexisting psychiatric disorders had seen their symptoms get worse during the pandemic.

How can we help individuals whose mental health has been harmed by COVID-19?

To support medical caregivers assigned to the front line during the pandemic, experts advise addressing burnout, as prolonged problems may overlap and lead to acute stress disorder and PTSD.

 Suggestions have ranged from practical measures (such as ensuring adequate PPE, handwashing, and decontamination of surfaces) to developing personnel policies that reassign at-risk medical personnel away from high-risk sites, ensure the safety of their family members, and stress the importance of self-care.

 Also recommended is providing health care workers access to child care services during expanded work hours and school closures. Workers should have adequate rest and breaks, be excused from less-essential tasks, and have regular information and feedback sessions with managers and the community. In many areas, hospitals provide telephone hotline teams trained to provide psychological assistance. Professional organizations offer physician wellness programs to provide free, confidential sessions to deal with burnout, adjustment problems, family issues, and other mental health sequelae.

The increasing numbers of people who were seriously ill with COVID-19 should be assessed for physical symptoms of chronic pain,

 with physical therapy and medications adjusted to avoid opioid dependence. Survivors of ARDS should receive evidence-based medications, cognitive behavioral therapy, and other psychotherapies for PTSD, panic, depression, and other mental disorders.

To combat isolation among locked-down nursing home residents, CMS recommends safe communal activities such as book clubs, movies, bingo, and outdoor family visits (ie, on lawns or in parking lots) with precautions of social distancing and PPE. Some nursing homes have provided live music, parades, therapy animals, recordings and photos of loved ones, physical contact with loved ones through plastic protective barriers, and even physical and occupational therapy sessions held outdoors.

Psychological first aid provided by trained community personnel might help the general population as they experience distress during the COVID-19 pandemic.

 For individuals enduring fallout from personal stressors, experts have recommended expanded use of telehealth to identify and treat mental health conditions, including depression, PTSD and other trauma-related disorders, substance use disorders, and suicidal ideation. Self-help groups, 12-step programs, spiritual and religious services, interest groups, and employee groups working from home are all increasingly using interactive internet-based platforms. And it is essential for societies to provide citizens with assistance for jobs, housing, food, medical care, education, internet connections, and many other basic survival needs.

The current international pandemic and possibly future ones will challenge us and give us the chance to continue to learn and share with other nations, hopefully linking us cooperatively rather than polarizing us.

 is professor and vice chair of education, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. 

is assistant professor and residency training director, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. Authors have no relevant financial conflicts of interest. This article was originally posted on October 5, 2020, and has since been updated.

 Factors associated with post-traumatic stress disorder of nurses exposed to corona virus disease 2019 in China

2. Huang Y, Zhao N. Mental health burden for the public affected by the COVID-19 outbreak in China: Who will be the high-risk group? 

3. Chew NWS, Lee GKH, Tan BYQ, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. 

4. Simms A, Fear NT, Greenberg N. The impact of having inadequate safety equipment on mental health. 

5. Bo HX, Li W, Yang Y, et al. Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. 

6. Romero-Sánchez CM, Díaz-Maroto I, Fernández-Díaz E, et al. Neurologic manifestations in hospitalized patients with COVID-19: The ALBACOVID registry. 

7. Ahmed H, Patel K, Greenwood DC, et al. Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalization or ICU admission: A systematic review and meta-analysis. 

8. Vittori A, Lerman J, Cascella M, et al. COVID-19 Pandemic acute respiratory distress syndrome survivors: pain after the storm? 

9. Javelot H, Weiner L. Panique et pandémie: revue de la littérature sur les liens entre le trouble panique et l’épidémie à SARS-CoV-2 [Panic and pandemic: Review of the literature on the links between panic disorder and the SARS-CoV-2 epidemic]. 

10. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. 

11. Liang L, Gao T, Ren H et al. Post-traumatic stress disorder and psychological distress in Chinese youths following the COVID-19 emergency. 

12. Gao J, Zheng P, Jia Y et al. Mental health problems and social media exposure during COVID-19 outbreak. 

13. Wang C, Pan R, Wan X, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. 

14. Forte G, Favieri F, Tambelli R, Casagrande M. 

COVID-19 Pandemic in the Italian Population: Validation of a Post-Traumatic Stress Disorder Questionnaire and Prevalence of PTSD Symptomatology

15. González-Sanguino C, Ausín B, Castellanos MÁ, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. 

16. Abbasi J. Social isolation—the other COVID-19 threat in nursing homes. 

17. Berthelot N, Lemieux R, Garon‐Bissonnette J, et al. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. 

18. Hao F, Tan W, Jiang L, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. 

. 2020;87:100-106.19. Xiang YT, Zhao YJ, Liu ZH, et al. The COVID-19 outbreak and psychiatric hospitals in China: managing challenges through mental health service reform. 

. 2020;16(10):1741-1744. Published 2020 Mar 15.

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21. Restauri N, Sheridan AD. Burnout and Posttraumatic Stress Disorder in the Coronavirus Disease 2019 (COVID-19) Pandemic: Intersection, Impact, and Interventions. 

22. Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. 

The pandemic has triggered an array of emotional, physical, and economic issues but in the midst of this crisis, nations have shared and learned from each other’s experiences.

Post-COVID Stress Disorder: Another Emerging Consequence of the Global Pandemic

“Alone we can do so little; together we can do so much.”--Helen Keller

The climate crisis presents unique and complex challenges to the mental health and wellness of individuals and communities.

 The need for interventions at a global scale increasingly leads mental health providers to look toward large group interventions. This article outlines a number of the more popular group approaches. It informs psychiatrists about the climate distress groups that our patients may access and advances our understanding of these groups’ methods, which may help psychiatry’s own public health response.

We can anticipate an increasing number of population-wide climate events, from disasters and social disruptions to existential concerns. Within disaster psychiatry, it is now suggested that

Beyond contemporary approaches of diagnosing and treating illness...there should be a transition to early screening and delivery of public health interventions that are evidence-based, cost-effective, readily accessible and community-focused with the goal of reducing distress, enhancing well-being and functioning, reducing the rate of progression to psychological disorders and, ultimately, improving the overall trajectory….

This is no small challenge, given the complexity of the problem and the wide range of individual responses.

 An objective exploration of the novel programs that have been developed to address eco-distress will help us offer better clinical approaches and guidance for these new types of distress.

In one approach, Climate Cafés (CC), were developed with the idea that diverse individuals will benefit from discussing their concerns about climate change in an informal supportive space, free of charge. There are several models of CC, some led by mental health professionals and others by non-specialists. One clinician-led model was developed by the 

Climate Psychology Alliance (CPA)/United Kingdom

 It is not a closed therapeutic group. The general structure of the CC is for group members to share what is on their minds about climate change, what prompted them to attend the group, and reactions to what others say. Leaders are there to listen for emotions and reflect them back, focus group process, and protect the emotional safety of the space. The leaders do not suggest any course of action, nor is there expectation that group members will take action regarding climate.

 has posted a suggested template for a CC discussion group, modeled loosely off the Death Café project and led by a non-clinician. (Death Cafés are gatherings aimed at increasing awareness of death and mortality as a means to becoming more engaged and fully alive within our finite lives.)

strives to “include equal doses of hope and action. If at all possible, participants should leave feeling empowered and energized, rather than hopeless and depressed.”

 There is, to date, no published information or research on the experience of CC participants.

 (GGN) is a nonprofit support group organization aiming to help people build resilience for living with climate change, as well as other systemic issues such as racism, classism, sexism and homophobia. The co-founders, Laura Schmidt, MS, and Aimee Lewis Reau, MFA, anchor their program in a 10-step model, similar to Alcoholics Anonymous (

). The purpose of the meetings is to gather with others in order to build community and to enhance one’s ability to accept and sit with climate uncertainty, pain, loss, and grief. They propose that personal resilience is built as a result of this process. The group meets for 10 consecutive weeks and is led by lay people who have received training from The Good Grief Network staff. Neither Schmidt nor Lewis-Reau are certified mental health providers.

Readings by climate change authors such as Joanna Macy, PhD, and Jem Bendell, and trauma experts such as Bessel Van der Kolk, MD, are recommended, as are meditation and yoga exercises. Group leaders do not prescribe any specific climate related action, but they do support members in personal discovery of meaningful climate action. Schmidt and Lewis-Reau do not discourage group members from discussing and processing past non-climate related traumatic events during group meetings, believing that processing past traumatic events can “free you from the extra weights that are tethering you from being a nimble actor” in dealing with 

 There is, to date, no published information or research on the experience of GGN participants.

The Work That Reconnects (TWTR) is an approach developed by Joanna Macy, PhD, and is described as a “transformative learning process.”

 TWTR incorporates aspects of deep ecology, systems theory, eco-psychology, Buddhism, and activism. It was initially developed for adults, but it is also being applied to the late adolescent and young adult populations. A key premise of TWTR is that for humanity to respond adaptively to the problem of climate change, individuals must learn to shift from an automatic psychological response of withdrawal and defensiveness towards an active, creative, and collective response, termed “Active Hope.” TWTR workshops (conducted over 1 to several days) involve a 

, designed for exploring and tolerating emotional reactions to catastrophic world problems (

Instead of turning away from the problem, group members reframe and honor their feelings, and then develop fresh perspectives intended to bring about “The Great Turning,” a societal transformation from an industrial, growth, and consumer-based society to a more equitable and sustainable one. In 

, there has been an emphasis within TWTR on “revisioning the Work with the aims of decolonization, integrating a deeper anti-oppression framing and analysis, embracing marginalized perspectives and considerations, and generally making the Work safer and more relevant for non-dominant groups.”

 This effort is referred to within TWTR literature as the “Evolving Edge.” There are guidelines for individuals who want to become group facilitators, but no specific training or degree requirements. There is a variable fee to attend. To date there is no published information or research on the experience of TWTR participants.

The Deep Adaptation Forum was developed by Jem Bendell, PhD, after the publication of 

 “Deep Adaptation: A Map for Navigating Climate Tragedy,”

 which went viral. Deep Adaptation (DA) positions itself outside of mainstream work on climate adaptation in that it assumes inevitable societal breakdown and collapse due to climate change and intentionally challenges the idea that hope should be part of climate change adaptation.

An international DA online forum has subgroups: a Professions Network for professional collaborations exploring climate collapse; a Groups Network aimed at cross-pollination between groups focused on related topics; and Positive Deep Adaptation, a Facebook group for sharing the psycho-social-spiritual implications of climate collapse and practical knowledge to support individual, local, national and international wellbeing before and during social breakdown. The addition of “Positive” to the Facebook group’s name is intentional, as the group’s focus is not to detail and recount the collapse, but to support personal and community adaptation mechanisms to best live with collapse (

 (ie, creating an equitable system for distribution of life essentials such as food, water, energy, and health care) and 

 (fostering psycho-social-spiritual-cultural shifts to accept and live through collapse with some composure and stability).

There are no workshops or intervention templates in DA work. Rather, online forums promote international discussion and sharing action plans for societal collapse. There is an emphasis on the collective, in terms of both leadership and actions. There is to date no published information or research on the experience of DA participants. There are, however, comments on the 

 written by participants who describe the collapse-readiness and collapse-transcendence changes they have made in their lives as a result of engagement with DA.

Transformational Resilience (TR) is an approach developed by Bob Doppelt, who is trained in both counseling psychology and environmental science. This workshop approach focuses on building individual and community psycho-social-spiritual resilience to prevent or minimize harmful impacts of climate changes.

 The model is based on the premise of post-traumatic growth: that living through and with adversity can result in a more satisfying way of life. TR is tailored for diverse participants (different ages, demographics, communities, cultures and nationalities) and can also be tailored to specific occupational groups including mental health and social services workers, first responders, environmental scientists and policy makers, climate activists, businesses, and nonprofit organizations. A small number of highly trained and experienced clinicians lead the workshops, which involve a fee.

 are the 2 foundational skills taught in TR workshops. Attention is paid to presenting and teaching these skills in an age-appropriate, culturally-informed manner. Presencing involves integrating skills for self-regulation to decrease the fight/flight response. These skills include body-based techniques such as grounding and mindful breathing. Psychoeducation, reviewing the neurobiology of the acute and chronic stress response, is woven into the skill building. The maladaptive nature of the fight/flight response, when employed as the only go to response to climate stressors, is illustrated through its negative impacts on individual physical and mental health and harm to the social health of a community (eg, distrust, increased interpersonal aggression, and decreased concern for the other, which includes the environment.)

Purposing involves helping participants explore and consider their values and what matters most to them in life. Through the steps of Purposing, participants imagine and begin to create an intentionally meaningful life, in spite of unfavorable climate change conditions. The skills involved in Purposing include cultivating appreciation for insights of self and others in adversity, clarifying values to live by, and harvesting hope for the future by engaging creatively in relationships and activities that promote the wellbeing of self, others, and the environment. Purposing emphasizes the importance of nurturing and growing social support networks and developing more resilient core community infrastructure systems (eg, food, water, energy). Doppelt

 proposed that the TR approach can not only help individuals develop resilience, but also that the skills of Presencing and Purposing can help communities shift from being “trauma-organized” (fear-based, with rigid and punitive policies) to “resilience-enhancing” communities.

There are a number of TR workshop participant testimonials describing benefits of workshop participation. Survey results describing participants’ responses to a 2014 TR workshop are also available online. The majority of participants rated the workshop as 

, one which increased their “personal resilience skills and their ability to help other people develop resilience skills and practices.”

 To date, there is no other published information or research on the experience of TR participants.

 concludes, “The phenomenology of the effects of climate change differs greatly” between individuals and communities. Given the variety of timing and type of climate change insults, there is likely no 1 psychological method or intervention that fits the bill for eco-distress, and there is little specific data regarding the efficacy of these group approaches. They do, however, incorporate interventions that are based both on evidence and expert consensus. For example, some of the basic steps in Psychological First Aid, a widely used intervention that is 

 are incorporated in a number of the groups described. Some of the 6 recommended techniques for addressing climate distress advocated by Clayton et al

 are also utilized: confirming climate concern as normal stress response to a real threat; psychoeducation about the human stress response; cultivation of coping, self-regulation skills, and resilience; fostering meaningful behaviors in line with values; and promoting meaningful social connections. The benefits of the behavioral techniques promoted, such a diaphragmatic breathing, are well established,

 and there is growing evidence that yoga and mindfulness decrease stress responses and anxiety.

How participation in the groups may impact psychologically vulnerable people is of concern. Group members are likely to experience strong emotions while participating, and it is unclear what procedures would be taken if a group member deteriorates psychologically. Potential psychological vulnerability of attendees may be particularly considered in TR, which is designed to acknowledge and help decrease psychological activation. Other approaches encourage participants to more fully connect to and experience distressing emotions. These experiences may be psychologically destabilizing, and it falls to group leaders with varying degrees of training and no mental health degree to assist. Given the paucity of outcome data, we must use our experience as psychiatrists to determine whether it is appropriate to recommend these treatments for our more vulnerable patients.

For individuals and communities experiencing ongoing, chronic environmental disasters such as drought, crop failure, and sea level rise, we would want approaches that provide practical supports and hold space for grieving, reevaluation, and reimagining of the future. These are potentially provided by GGN, TWTR, DA, and TR. For individuals who are somewhat distant from feeling the physical impacts of climate change, we want programs that assist in processing and managing anticipatory anxiety, fear, grief, anger and distress. They are potentially provided by CC, GGN, TWTR, DA. For individuals most in need of specific coping techniques and self-regulation skills TR provides both psychoeducation about the stress response and the teaching of specific stress reduction and coping techniques. Cultivating resiliency, something we would wish for all our patients, is an explicit goal in GGN, TWR, DA, and TR, though the definition of resiliency is not consistent across approaches. Fostering meaningful behaviors in line with values, a therapeutic intervention well-known to us from ACT, is a stated goal in GGN, TWR, DA, and TR as well as some of the CC models. Promoting meaningful social connections is a key element of GGN, TWR, DA, and TR and is implicit in the shared, experiential nature of the CC.

Despite our belief that these programs can be recommended at the current time, studies investigating participants’ experiences are needed. Does participation increase resilience and well-being? Are certain programs better suited for particular individuals or groups? The answers to these questions would assist mental health providers who are considering recommending a group to a patient, allowing for more precise risk-benefit analysis. Even though there may not yet be comprehensive research on eco-distress epidemiology or evidenced-based treatment, mental health providers have a responsibility to respond to distress within our shifting circumstances. Familiarizing ourselves with these various programs is an important step towards climate change competency for mental health providers.

 is a staff psychiatrist at the Counseling and Psychological Services of the University of Pennsylvania, and a student in the Masters of Environmental Studies Program at the University of Pennsylvania; she is on the Steering Committee of the Climate Psychiatry Alliance. 

is clinical assistant professor, Department of Psychiatry, University of Rochester, NY, and in private practice in Penn Yan and Ithaca, NY.

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From disasters and social disruptions to existential concerns, climate distress groups may not only provide much-needed support to patients but may also help psychiatry’s public health responses. 

Group Interventions for Climate Change Distress 

Coronavirus disease 2019 (COVID-19) blindsided the world. It exposed gaps in public health emergency planning at every level, including in the strategic planning to support mental health and wellness. Studies of the SARS and 

 epidemics as well as natural disasters have taught us 

 about the importance of planning for and responding to the mental health needs of health care and frontline workers.

 Thus, this is a pivotal moment, a chance to implement systems and structures for staff support in every organization and advance staff wellness and resilience initiatives.

The literature on disasters and public health emergencies describes pervasive emotional distress, feelings of extreme vulnerability, uncertainty, and threats to life, particularly during the rapid spread of an outbreak.

 A recent COVID-19 web-based survey supports this finding. More than 40% of respondents reported symptoms of depression, anxiety, traumatic stress, substance use, and suicidal ideation. Symptoms were notably elevated in black and Hispanic individuals, essential workers, unpaid adult caregivers, and those with psychiatric conditions.

 research has shown that, ultimately, most people are resilient even after the most severe traumatic event.

 In the immediate aftermath of large-scale catastrophes, a majority of negative mental health symptoms are recognized as distress reactions to intense and overwhelming events. They are not pathologized or labeled psychiatric disorders. The disaster literature emphasizes the importance of acknowledging the normality of distress reactions, identifying high-risk populations, promoting effective coping and adaptation strategies, and encouraging overall wellness and resilience.

 Disaster mental health assistance during the acute phase is often more practical than psychological in nature. In this case, such assistance includes Centers for Disease Control information and updates, access to food and cleaning supplies, access to COVID-19 testing, protective equipment, financial assistance, and links to community resources.

After the acute phase of the disaster, long-term stress responses can emerge. Lancee et al.

 that 2 years after the SARS outbreak, health care workers who treated these patients had elevated rates of smoking and drinking, absenteeism due to stress or illness, decreased face-to-face contact with patients, and decreased work hours.Yet rates of depression, posttraumatic stress disorder, and other mental illness were not elevated. This is consistent with existing research, which has found that the long-term impact of massive 

 is predominantly in the range of subsyndromal stress responses rather than an increase in psychiatric morbidity. Limited long-term studies suggest that post-disaster symptomatology peaks in the first year and then declines, but the course of recovery is variable.

 The challenge for mental health clinicians is to distinguish normal distress reactions to catastrophes from exacerbation of existing mental health susceptibilities or new-onset disaster-related pathology.

Disaster trauma is characterized by exposure to personal loss and community disruption. Cultural, political, and socioeconomic factors all influence the shared 

 Looking through a disaster trauma lens, a better understanding of the emotional stages of public reaction can help: anticipate community responses to large-scale catastrophic events (

), identify the changing goals of recovery at different phases (

), and inform mitigation strategies. It is important to note that the timing of the phases is fluid. They do not occur in an exact sequence. Phases can overlap and move forward or back across a timeline, depending on the type of disaster.

 depicts the stages of public reactions to natural disasters like 2012’s Hurricane Sandy and even the 9/11 terrorist attacks in 2001, but the community response to a pandemic seems more unpredictable. The immediate COVID-19 experience in New York state in the spring of 2020 was marked by safety concerns, deaths in the thousands, food and job insecurity, financial hardships, and anger at government response. We do, however, see a heroic phaseexemplified by the emergence of heroes, such as Anthony Fauci, MD, on the national level and Governor Andrew Cuomo in New York state. We then witnessed community cohesion typical of the honeymoon phase as New Yorkers connected with each other from stoops, windows, terraces, and rooftops, all cheering for frontline workers at 7:00 PM each night to show gratitude and appreciation.

New York successfully flattened the curve by the summer. The number of daily deaths fell dramatically, from a high of nearly 800 per day across the state down to none in New York City by June. Now the focus is shifting to economic recovery, while keeping community viral transmission low and bracing for a potential second wave. This could be the beginning of the reconstruction phase: figuring out a new normal and how to live with a persisting virus. Disillusionment is certainly felt when other states are unable to control the virus, in spite of the availability of immense resources and clear and concrete directions from world-class health experts to wear 

, avoid crowds, maintain social distance, and wash hands.

 that during an infectious disease outbreak, the operational response of an organization is likely the single most important factor influencing staff perception of both stress and safety.

 Traumatic events can disrupt feelings of safety, trust, control, esteem, and intimacy. As a result, staff can exhibit maladaptive behaviors or experience traumatic stress symptoms.

 Best practices to mitigate the disruptions and support staff during a pandemic involve 4 key elements: leadership, communication, education, and social support.

 Strong leadership and supportive teams influenced the resilience of health care workers during the SARS and Ebola outbreaks.

 Capable and effective leadership over the course of a major disaster makes staff feel safe and supported by the organization. Best practices include:

Visible and prepared leaders at organizational, departmental, and team levels.

Setting the tone for a positive and supportive organizational culture.

Skilled assessment of team strengths and weaknesses.

Proactive outreach and crisis support from all levels of leadership.

Creativity and innovation in increasing staff resilience and reducing stress.

Role modeling infection control and safety practices—wear masks, practice physical distancing, and wash your hands.

 is communication, coordination, and collaboration.

 Delivery of clear, transparent, timely, trustworthy information in a rapidly evolving situation is essential. Organizations should be prepared to:

Communicate timely and trustworthy COVID-19-specific guidance.

Acknowledge and normalize feelings of anxiety related to the pandemic.

Communicate efforts to address the negative impacts of the pandemic, including financial concerns.

Communicate supportive organizational practices (eg, working from home, flexible work schedule, reduced hours, job rotation, location rotation, availability of PPE, testing).

Widely disseminate available self-care and wellness information and resources.

Training and education on the issues of infection control, disaster mental health, and the disaster response system increases confidence and moderates the risk of stress. Just as Federal Emergency Management Agency (FEMA) provides appropriate resources and training for disaster responders before deployment, organizations have a responsibility to provide education and training to better prepare for and respond to a pandemic. Organizations should be prepared to offer staff:

We have learned that in order to provide much-needed social support during difficult times, organizations should prepare to take certain steps.

Disaster Psychiatry

Post-COVID Stress Disorder: Another Emerging Consequence of the Global Pandemic

Group Interventions for Climate Change Distress

Managing Distress in Health Care Workers During COVID-19: Lessons From a Disaster Trauma Lens

Surviving 9/11

Dear Mental Health Innovators: The COVID-19 Honeymoon Is Almost Over

From Tragedy to Realism: The Role of Optimism in Pandemic Recovery

25 Years After the Oklahoma City Bombing

Resilience, Not Panic, in a Time of Pandemic

PsychPearls: Battling Loneliness During the COVID-19 Pandemic

Exploring the Role of Psychiatrists in Disasters