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“Trauma eventually affects everyone on the planet,” says Randall Bell, PhD, who has worked on disaster recovery around the globe. But after the disaster, it is time to figure out how to survive, and then thrive.

In this Mental Health Minute, Bell discusses his latest book, 

Post-Traumatic Thriving: The Art, Science, & Stories of Resilience

. Marshalling a combination of scientific studies and personal stories, he lays out a 3-stage journey from trauma to recovery.

holds a PhD in socioeconomics from the University of California, Los Angeles. He is the Chief Executive Officer of Landmark Research Group, LLC.

Is unresolved trauma the number one problem on planet earth? An economist with expertise in disaster-related distress makes the case. 

The Global Burden of Trauma

 and traumas have the potential for long-term mental health implications, noted 

 National Institute of Mental Health (NIMH) Director, so it is no surprise that the simultaneous nationwide crises of 2020 posed significant threats to mental health. Fortunately, lessons learned from previous events and preliminary research point to a relatively positive outlook, he told attendees of the 

2021 American Psychiatric Association Annual Meeting

The past year presented a dangerous pandemic, with unprecedented morbidity and mortality numbers and mitigation strategies that resulted in isolation and economic strife. On top of that, the United States saw natural disasters and a reckoning around the systemic racial injustice that has plagued this country for years. Individually, each crisis had the possibility of a negative impact on mental health; together, they had the potential to be catastrophic.

Fortunately, lessons from previous traumas have found most individuals (90%) who are exposed to trauma improve within a year or so. However, there is a significant minority who may have long-term or chronic experiences with mental illness, Gordon explained. Specifically, studies have shown there are 

 The first group consists of individuals whose levels of symptomology following the trauma are low and remain low; they generally do not require clinical attention. The second and third groups have either immediate (within 1 to 3 months following trauma) or delayed (between 3 and 6 months post-trauma) increased symptomology, but usually recover. The final group has a sustained or chronic time course, and symptoms last beyond 6 months.

Although improvement is often due to treatment, Gordon noted other factors often predict recovery versus negative outcomes. Risk factors for long-term or chronic experiences include: few social supports, a history of trauma or mental illness, direct exposure to death or injuries, severe acute reactions to disaster, and ongoing stressors such occupational and financial strain. Having these risk factors does not equate to long-term issues, Gordon explained, but increases the risk of such. He added that having multiple factors further increases the risk of chronic symptoms.

Study after study has indicated that meeting immediate needs after a trauma helps to reduce the long-term impact, Gordon explained. For instance, after a hurricane, it is important to make sure victims have a safe place to stay and food. Similarly, treating new or worsening mental illness is very important, he said. After Hurricane Katrina, half the residents met criteria for a diagnosable DSM condition, Gordon shared, but only half received treatment and even less received evidence-based treatment. “We put people at risk when we don’t identify that they have symptoms, and don’t help them cope or get them treatment,” Gordon explained.

There is already data on the COVID-19 pandemic, Gordon reported. Building on previous traumas and risk factors, it was not a surprise that contracting COVID-19 increased the risk for long-term mental health issues. Individuals with 

, especially schizophrenia, were found at higher risk for developing trauma-related mental health issues.

 The same study found the likelihood of new onset psychiatric disorders following COVID-19 infection was 6%, which is 2 to 3 times the rate as that with the flu. The incidence of any psychiatric diagnosis within the first 3 months after infection rose to 18% when including those with previous psychiatric disorders. The majority of the new onset symptoms were mood or anxiety-related. Gordon said the NIMH is embarking on a multi-institute study to further explore these data.

Similarly, the pandemic affected individuals who did not contract the virus, Gordon added. Data from the 

Centers for Disease Control and Prevention

 indicated that most adults had some symptoms, including mood, substance use, and suicide ideation. Rates of suicidal ideation was disturbingly high among young adults, he said, with about 18% noting they seriously considered suicide in the previous 30 days, double the number than would be normally expected.

 Gordon cautioned, however, that this data is a result of self-reports of mental illness, not diagnosed illnesses. Still, he said he would not be surprised if future studies found an increased rate of psychiatric diagnoses during the pandemic.

Yet, the picture is not all bleak, Gordon said. He referred to unpublished data from the 

, which consists of a number of managed care organizations, that looked at electronic health records. In each system, the number of visits for self-harm diagnosis (including self-injurious behavior and suicide attempt) remained steady over time, even through the pandemic.

The pandemic also illuminated the inequities of health care in the United States, with certain minorities at increased risk of adverse events associated with COVID-19, Gordon said. Of great concern was the shift to telehealth in the early days of the pandemic, and the possibility of telehealth exacerbating access to care issues for vulnerable populations. 

The Mental Health Research Network looked at the number of mental health visits in person, via phone, and via video both before and during the pandemic, and the data revealed some promising news. The numbers of visits among White non-Hispanic patients, African-American patients, and Hispanic patients were similar, with a huge drop in in-person visits at the beginning of the pandemic, when a slow upward shift was found for voice and video visits, Gordon reported. Although there were fewer visits during the pandemic, the rates were similar among all groups. Gordon said more research is needed across wider swaths of populations to confirm these findings, but he believes the increased popularity and availability of smartphones helped forestall access issues.

Unfortunately, Gordon noted not all the news was good: There was a dramatic increase in suicide rates among Black youth. Blacks have been relatively protected against suicide when compared with Whites in the United States, he noted, although it is not quite certain why. For some reason, he added, that is changing in Black youth, especially males, and that is troubling.

Gordon added that the NIMH is addressing the growing awareness of broad systemic racism on 2 fronts: an increase in diversity in the workforce and an increase focus in disparity research. For instance, Gordon discussed the April 21, 2020, webinar cohosted with SAMHSA, “

Responding to the Alarm Addressing Black Youth Suicide

On a broader scale, the NIMH has taken the lead with a number of NIH organizations to further explore, measure, and address the social and economic impacts of COVID-19 on mental health, especially among vulnerable populations (eg, older adults, frontline workers, racial and ethnic minorities, etc). To date, the NIMH and working group members have funded 28 longitudinal studies, 15 digital health studies, and 9 community health studies looking at substance use and other mental health outcomes as well as public health mitigation impact and adherence. Gordon expects the information learned from these studies will not only help address issues from the pandemic, but also inform future disaster response.

In terms of the pandemic, there are still many uncertainties, which continues the risk of new and exacerbated mental health issues, Gordon warned. “We don’t know when it will end, there is increased exposure to morbidity and mortality (at this point we all know someone who has had COVID-19), there is continued social economic vulnerability, and preexisting mental health problems,” all of which are risk factors for poor outcomes, he explained.

Still, research shows there are ways to foster resiliency and prevent negative outcomes, and Gordon encouraged attendees to focus on those endeavors. Psychiatrists can help patients focus on the hope for the future and remind patients they have some control over their situations. They can encourage patients to find ways to meet their immediate needs. And, they can inspire healthy coping habits.

1. deRoon-Cassini TA, Mancini AD, Rusch MD, Bonanno GA. 

Psychopathology and resilience following traumatic injury: a latent growth mixture model analysis.

2. Taquet M, Luciano S, Geddes JR, Harrison PJ. 

Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA

3. 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

Joshua A. Gordon, MD, PhD, National Institute of Mental Health Director, leverages lessons from past natural disasters and traumas to foster resiliency and inform future research endeavors.

Amidst Multiple Crises, NIMH Pursues Research to Improve Outcomes

, Colleen McCullough’s 1977 blockbuster novel, you will know that Australia is not all panoramic vistas and rural dynasties, but also a nation that contends with, absorbs, and bounces back from occasional disasters: bushfires, floods, and droughts. But our recent experiences have been very different.

Over the last few years, Australia has been afflicted by an overlapping sequence of unusually prolonged droughts,

 that cast persistent heavy and potentially deadly smoke over urban as well as rural 

 pandemic-induced lockdowns, with its isolation and uncertainties, and most recently, devastating storms and widespread flooding. All of these caused deaths, grieving, and trauma, to say nothing of the vast loss of wildlife and habitat.

 They also have been punctuated by additional plagues of dust storms, locusts, and mice.

Studies suggest that it may be more difficult to recover resilience from recurrent knocks than from a single event. Taken together, adverse events are sometimes called “domino crises.” The more dominos over a shorter period, the more difficult it is to recover.

In the Australian countryside, more than 60% of communities that bore the brunt of the floods were also still recovering from the extreme fires a year earlier, followed by the pandemic. Climate change-related disasters increasingly overlap both temporally and geographically, and occur with greater frequency, intensity, and duration. Such a staccato volley of climate crises may be “threat multipliers, compounding harms” from vector-borne diseases, stressful secondary life events, and compromised mental health.

 Historically, societies that fail to develop buffers and strategic resilience against the domino effects of climate change and other disasters may be more 

With the recent flooding, many rural landscapes became temporary inland seas. To provide some idea of comparative scale, the affected areas are reported to have been about the area of Alaska. On a brighter note, floods have likely broken the years of drought in some rural regions, but not all of the worst affected. The intensity of these extreme droughts, fires, storms, and floods indicates that they are likely to cause a cascading sequence of severe climate change related events.

As well as stress, anxiety, depression, and trauma responses, distinct mental health conditions relating to climate change are now increasingly recognized internationally (eg, eco-anxiety: the chronic fear of ecological doom

; and solastalgia: the existential distress and grief due to the loss of familiar habitat

). The latter condition may have been familiar to indigenous peoples, who lost familiar environments, custodial roles, and sovereignty over their lands and waters due to colonization. Perhaps our wider societies may now be catching up and beginning to understand indigenous concerns better, especially in Australia. Indigenous quests to have their expertise in communal, land, fire, and water management more widely valued and re-established are crucial not only for the continued existence of indigenous societies, but also arguably for the survival of our species and our planet.

It is important to acknowledge the well-documented risks and existential threats of the pandemic and other climate change-related events to all vulnerable individuals, especially those in indigenous communities. Indigenous communities are particularly concerned about the effects of climate change on their elders, who have a life expectancy more than a decade lower than wider populations.

At the same time, there is also a glimmer of hope. Australasian indigenous communities effectively prepared their communities to for COVID-19, demonstrating their ability to act with self-determination and full community consultation. National and regional Aboriginal organizations rapidly mobilized local networks to take preventative action, invoking prompt government support for community-controlled strategies. These included: Aboriginal health and community workers proactively assisting with contact tracing and deterring overcrowding; ensuring food and medicine supplies; and immediate lockdowns with exclusion of visiting strangers.

Nationally, over the first year of the pandemic, the per capita rate of COVID-19 cases among the indigenous population was only one-sixth of the per capita rate among the general population, with 22 hospital admissions, 1 intensive care unit admission, and 0 deaths.

 Maori individuals in New Zealand have a similar story to tell. Despite constructive attempts by Aboriginal groups to bring these encouraging outcomes to national and international attention, it has been difficult to do so. Is this due perhaps to our media attention being attuned mostly to bad news? Or have the pervasive expectations and dire warnings poor outcomes for indigenous peoples (due to the pandemic and other climate change related events) led too many governments to accept the inevitability of a dismal fate?

There have been lessons for and from Aboriginal and Torres Strait Islander communities and other indigenous communities on ameliorating the impacts of climate change. How can the wider medical community learn and benefit from this traditional knowledge and wisdom, so both practical application and modern technology can be integrated?

There is a strong parallel here with working “2 ways” or in “2 worlds” in mental health, as advocated by indigenous leadership.

 Working in 2 worlds means using traditional cultural “healing in combination with (evidence based) clinical approaches when working to restore the wellbeing and mental health of Aboriginal and Torres Strait Islander peoples,” and training an Aboriginal mental health workforce in both traditional and modern methods.

 It is crucial to build synergies between traditional cultural healing practices and evidence-based clinical interventions. They can both optimize transgenerational resilience and outcomes for mental health sequelae of complex psychiatric disorders caused by climate-related and other severe trauma. Similar synergies could be applied fruitfully to land, water, fire, and pandemic management.

 got the story right, but the headline a bit wrong. It trumpeted: “Australia made a plan to protect Indigenous elders from covid. It worked.”

 Australia did not make a plan. The headline should have read: “Australian Aboriginal national networks and local communities collectively prepared with a community-controlled plan for COVID-19, and for once, persuaded government to back them promptly. It worked.” Hopefully we are all learning the value of this for managing the climate change phenomena that we have yet to face. 

All future mental health and wellbeing strategies should include participatory, collaborative, hyperlocal work that permeates, mobilizes, and 

 all communities and societies as whole ecosystems.

Learnings from Professors Alexander MacFarlane, Pat Dudgeon and Fiona Stanley, Mr Tom Brideson and Ms Vivienne Miller.

is an officer of the Order of Australia, a Fellow of the Royal Australian and New Zealand College of Psychiatrists, is affiliated with the Brain & Mind Centre at University of Sydney and the Institute of Mental Health at the University of Wollongong (Australia), and is

Chair of Transforming Australia’s Mental Health Service System (TAMHSS).He has been a psychiatrist serving Aboriginal communities in a remote region of New South Wales for 35+ years. Dr Rosen has no conflicts of interest.

To see more on Earth & Psychiatry, please see

The Power and Potential of Earth Week and Psychiatry

1. Rigby CW, Rosen A, Berry HL, Hart CR. If the land’s sick, we’re sick:* the impact of prolonged drought on the social and emotional well-being of Aboriginal communities in rural New South Wales. 

2. Rosen A. Climate changes are leading to ‘eco-anxiety,’ trauma. 

https://www.mdedge.com/psychiatry/article/221163/anxiety-disorders/climate-changes-are-leading-eco-anxiety-trauma

3. McInerney M, MacKee N. Another catastrophe: back-to-back climate emergencies are taking their toll on our health. 

https://www.croakey.org/another-catastrophe-back-to-back-climate-emergencies-are-taking-their-toll-on-our-health/

4. Salas RN. The climate crisis and clinical practice. 

5. Kessler RC, McLaughlin KA, Koenen KC, et al; WHO World Mental Health Survey Consortium. The importance of secondary trauma exposure for post-disaster mental disorder. 

6. Feng Q, Yang L, Deo RC, et al. Domino effect of climate change over two millennia in ancient China’s Hexi Corridor. 

https://www.nature.com/articles/s41893-019-0397-9/

7. Usher K, Durkin J, Bhullar N. Eco‐anxiety: How thinking about climate change‐related environmental decline is affecting our mental health. 

8. Albrecht G, Sartore G-M, Connor L, et al. Solastalgia: The distress caused by environmental change. 

9. Rosen A. For Indigenous communities, climate crisis could prove calamitous. 

https://www.mdedge.com/psychiatry/article/222198/anxiety-disorders/indigenous-communities-climate-crisis-could-prove

10. Dudgeon P, Wright M, Derry K. 2020, A national COVID-19 pandemic issues paper on mental health and wellbeing for Aboriginal and Torres Strait Islander Peoples. The University of Western Australia Poche Centre for Indigenous Health. 2020. 

11. Eades S, Eades F, McCaullay D, et al. Australia’s First Nations response to the COVID-19 pandemic. 

12. Talley NJ, Stanley FJ, Lucas T, Horton RC. Health and climate change MJA-Lancet Countdown report: Australia gets another failing grade in 2020 but shows signs of progress. 

13. Durie M. Providing health services to indigenous peoples. 

14. NATSIMHL. National Aboriginal and Torres Strait Islander Leadership Mental Health. Gayaa Dhuwi-Proud Spirit Declaration. 2019. 

15. Coopes A. Relationships, stories and healing: Indigenous knowledges for mental health and wellbeing. 

https://www.croakey.org/relationships-stories-and-healing-indigenous-knowledges-for-mental-health-and-wellbeing/

16. Pannett R. Australia made a plan to protect Indigenous elders from covid-19. It worked. 

https://www.washingtonpost.com/world/asia_pacific/australia-coronavirus-aboriginal-indigenous/2021/04/09/7acd4d56-96a4-11eb-8f0a-3384cf4fb399_story.html

17. Belkin G, Appleton S, Langlois K. Reimagining mental health systems post COVID-19. 

18. Rosen A, Gill NS, Salvador-Carulla L. The future of community psychiatry and community mental health services. 

Australia’s cascading environmental crises are all likely effects of climate change. How can psychiatrists and other mental health stakeholders respond?

Dominos: Mental Health Impacts of Australia’s Environmental Crises

 will feature articles, video, and poetry related to its first-ever Earth & Psychiatry series. This year, Earth Week begins on April 16 and ends on Thursday, April 22, 

Beyond climate psychiatry, which in its own way underscores the clear and present danger of instability in our environment, the Earth & Psychiatry series, shepherded by Series Editor H. Steven Moffic, MD, details the massive potential for psychiatry to mitigate harms done on society, culture, Planet Earth, and the people and other living creatures inhabiting the world. 

The poem opens with, “Yearning soil succors the seeds saturated with intergenerational wisdom . . .”

Respect Mother Earth as Ancient China Did

Earth is a sacred concept in Chinese tradition. How can we continue respecting it today?

, by Andrew McLean, MD, MPH and Lavonne Fox, PhD, OTR/L

Themes of diving and returning anew are common in creation stories, as are themes of sacrifice and rebirth. These stories seem to touch something deep in the human psyche.

When things at home were volatile and school was demanding, the thought of entering The Woods seemed to settle his soul.

Dominos: Mental Health Impacts of Australia's Environmental Crises

Australia’s cascading environmental crises are all likely effects of climate change. How can psychiatrists and other stakeholders respond?

Ancient religious texts from India explain the deep connections between human beings and their environment.

A Call to Change in the Relationship Between Psychiatry and the Earth

In this video, Dr Moffic raises the alarm for psychiatrists to be at the forefront of efforts to save the earth.

The Series Editor concludes the collection with thanks to contributors from around the world and shares his passion for the climate.


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. 

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

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

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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.)

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. 

Disaster Psychiatry

The Global Burden of Trauma

Amidst Multiple Crises, NIMH Pursues Research to Improve Outcomes

Dominos: Mental Health Impacts of Australia’s Environmental Crises

The Power and Potential of Earth Week and 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