When widespread fear and anxiety about the spread of an infectious disease stress our society, psychiatrists can play a variety of important roles in population health management.
TABLE: Roles of the psychiatrist in public health emergencies (eg, Ebola)
The Ebola outbreak has given reason for concern across the globe and most recently in the US. Recent media attention and ongoing coverage of the Ebola outbreaks in West Africa, as well as recent cases in the US, contribute to confusion among many. All this attention has also created fear and distress for our patients and their families and for health care workers. Individuals with preexisting psychiatric conditions may be particularly vulnerable to anxiety and mood symptoms as well as to the use of maladaptive coping, including substance use.
When widespread fear and anxiety about the spread of an infectious disease stress our society, psychiatrists can play a variety of important roles in population health management (Table). They can work directly with patients to encourage frank discussion of worries and distress, and they can identify symptoms such as sleep disturbances and exacerbation of underlying mental illness. Psychiatrists can also support primary care physicians and encourage them to address patients’ concerns.
In the community, psychiatrists can educate leaders about risk communication to decrease fear and anxiety. For psychiatrists who work in hospitals that may receive Ebola patients, additional consultation and work with the infectious disease teams and families of the patients (or those in quarantine) are needed. Ensuring optimal care for patients requires that psychiatrists understand the clinical aspects of Ebola and the principles of risk communication.
The Ebola virus
Ebola virus disease (EVD) is rare but potentially fatal; it is caused by infection with one of the Ebola virus strains. There are 5 identified Ebola virus species: 4 cause disease in humans; 1 causes disease only in non-human primates. Ebola was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo; it has now spread to several other African countries. Since its discovery, outbreaks of Ebola have appeared sporadically in Africa. The natural reservoir host of Ebola virus remains unknown, but researchers believe the most likely reservoir is bats.
The onset of symptoms is usually abrupt, generally starting 8 to 10 days after exposure. However, the incubation period can range from 2 to 21 days. People become contagious once they begin to show symptoms. Fever, anorexia, and weakness are common, along with chills, myalgia, and malaise. The nonspecific nature of these symptoms can be confused with other, more common diseases, such as influenza and meningococcemia, so a high degree of suspicion is needed.
Additional symptoms that may present around day 5 of the disease course include an erythematous maculopapular rash that can desquamate and a range of GI problems (eg, abdominal pain, profuse diarrhea, nausea, vomiting). Patients may also experience chest pain, shortness of breath, headache, confusion, conjunctival injection, hiccups, seizures, and frank bleeding. When early symptoms are severe, mortality is increased and generally results from multiorgan failure and septic shock. Mortality rates range from 55% to 75%; patients who receive early aggressive treatment fare better.
Transmission, detection, and treatment
Despite ongoing media coverage of the issue of Ebola being aerosolized, epidemiological evidence suggests this is not a mode of transmission. Ebola virus is spread by direct contact with blood and other body fluids, such as vomitus, urine, fecal matter, or breast milk, of an infected person or someone who has recently died of Ebola. Infection can also be transmitted by surfaces or objects contaminated by body fluids of an infected person. Persons who handle dirty linen, clean examination rooms, or perform other support tasks in hospitals are at increased risk and need to be educated about safety procedures.
The issues of sexual transmission can create family burdens and distress after a patient has survived an initial infection with Ebola. Ebola virus has been detected in semen up to 3 months following recovery from infection, and media reports suggest that women who have recovered from EVD may be capable of transmitting the disease through vaginal fluids. Thus, experts recommend abstaining from sex (including oral sex) for 3 months after recovery.
EVD can only be confirmed by laboratory testing. Treatment of EVD is supportive, with an emphasis on preventing dehydration through the use of intravenous fluids and oral rehydration. While there is currently no specific treatment or medication that cures EVD, case reports of patients who improved following a blood transfusion from a recovered patient are prompting additional research into mechanisms for enhancing or transferring immunity.
Managing fear, anxiety, and distress
Although many patients will be concerned about Ebola, it is expected that very few will actually contract the disease in the US. “Very few” for medical people (eg, tens, hundreds) does not necessarily translate to usual community language; most people want or expect zero risk and no cases. Fear is a normal response to threats that we do not fully understand.
Health care workers directly caring for Ebola patients need adequate training and protective equipment to reduce their anxiety and decrease the likelihood of making mistakes. Community education (schools, community leaders, stores/sales people, and your hospital and medical community) can be very helpful as well.
Psychiatrists can listen without judgment to a patient’s fears and concerns about Ebola. Avoid simple reassurances that are often experienced as dismissing patient concerns, such as, “There’s nothing to worry about,” or “Everything will be fine.” When patients are presenting for psychiatric care with an underlying concern about Ebola, a thorough medical screening is helpful. Patients also need to be evaluated for exacerbation of preexisting psychiatric illness. Stress often leads to the onset or worsening of maladaptive coping responses, such as use of alcohol, tobacco, and other drugs of abuse as well as social isolation and violence. A comprehensive risk assessment should be performed and emergency issues managed appropriately.
For patients without exacerbation of significant underlying psychiatric illness, Psychological First Aid (PFA) can be used to manage stress; it can also be used for those who have contracted EVD. The principles of PFA include optimizing safety, calming, connectedness to others, self-efficacy, and hopefulness. Teaching the patient (and his or her family) ways to maintain hopefulness and optimism are evidence-based interventions for acute trauma responses.
Help patients understand that it is essential to avoid contact with persons who are infected or traveling to areas with Ebola outbreaks. Regular hand washing is vital to infection control. Because influenza and EVD share common nonspecific symptoms during the course of illness, reducing the incidence of influenza may decrease the number of patients presenting for evaluation-encourage patients to get their flu shots.
To ensure that patients have the most accurate, up-to-date information, steer them toward well-established sources of information, such as the CDC. Suggest that patients and their families limit exposure to news and social media, which may exacerbate stress and anxiety. Episodes of excessive fear and anxiety can also be reduced by simple measures, such as diaphragmatic breathing and progressive muscle relaxation, both of which can be taught quickly and easily.
If your hospital has an Ebola case
EVD is not thought to produce neuropsychiatric symptoms directly; however, patients infected with the virus may experience a range of psychological responses. Those with underlying psychiatric illness may experience an exacerbation of symptoms, complicated by unique aspects of necessary treatment, such as the need for quarantine.
A particularly significant aspect of treatment for EVD is the need to quarantine, which can increase distress for both the patient and his family. Consultation-liaison psychiatrists can suggest ways to reduce isolation, such as addressing institutional barriers that limit visiting hours or using creative IT solutions (eg, webcam). Clinically significant symptoms among those who are exposed and quarantined may include depression, acute stress disorder, PTSD, sleep disturbances, and anxiety symptoms.
Helping health care providers and the family understand how the patient is affected by symptoms of Ebola and the various aspects of treatment can be beneficial in maintaining the health care provider’s working relationship with the patient and may decrease the family’s worries of separation.
The patient’s family and friends may also express concerns, including fear of the patient’s death and anxiety about contracting the illness themselves. Because family and friends are important for enhancing the patient’s social support, addressing ambivalence in family and friends can be particularly helpful. Patients with EVD also present unique challenges for physicians, nurses, technicians, and others who provide care. Working with members of the health care team to understand their particular fears and concerns can enhance their resilience and sustain them throughout the experience.
Helping the community
Psychiatrists may also be in a position to advise community leaders and policymakers on ways to communicate health information to larger populations or organizations. When providing this type of consultation, consider well-established principles of risk communication.1-3 Begin by recommending that messages be considered and planned in advance, including anticipating questions that will be asked. What an audience wants to know, as well as what the person speaking wants them to know, should be taken into consideration. Specifically, during acutely stressful situations, most people want to know if they and their loved ones are safe and what actions they can take. Accurate information about what is known as well as what is not known should be provided.
Those in leadership positions may believe that people do not want to hear “bad news” when in fact what people really want to hear is accurate and reliable information from trusted leaders. When there is a question for which an answer is not known, leaders can commit to finding out in a timely manner and reporting back. Accurate and reliable information and keeping a promise to follow up with answers builds trust and enhances rapport.
Psychiatrists have an important role to play in the evolving impact of Ebola in the US; that role is to support the well-being of individuals, enhance health, and provide a range of consultation services. An awareness of our own emotions regarding Ebola is a critical foundation for providing effective interventions.
Psychiatrists must have an appreciation for the pathogenesis, transmission, and treatment of Ebola as well as for the unique facets of the disease and its treatment and how these can affect patients, their loved ones, and their health care providers. An understanding of effective risk communication strategies allows psychiatrists to advise leaders and policymakers in relevant Ebola health messaging.
The views expressed are those of the authors and do not necessarily reflect the views of the Department of Defense, the Uniformed Services University, the Department of Health and Human Services, or the United States Public Health Service.
Dr Morganstein is a Commander in the United States Public Health Service; Assistant Professor and Assistant Chair, department of psychiatry, and Scientist, Center for the Study of Traumatic Stress at the Uniformed Services University School of Medicine in Bethesda, Md. Dr Ursano is Professor and Chair, department of psychiatry, and Director, Center for the Study of Traumatic Stress at the Uniformed Services University School of Medicine. They report no conflicts of interest concerning the subject matter of this article.
1. Covello VT. Best practices in public health risk and crisis communication. J Health Commun. 2003;8(suppl 1):5-8.
2. Vineburgh N, Ursano R, Hamaoka D, Fullerton C. Public health communication for disaster planning and response. Int J Public Pol. 2008;3:292-301.
3. Substance Abuse and Mental Health Services Administration (SAMHSA). Communicating in a Crisis: Risk Communication Guidelines for Public Officials. 2002. http://store.samhsa.gov/product/Risk-Communication-Guidelines-for-PublicOfficials/SMA02-3641. Accessed November 24, 2014.