Since its re-emergence in West Africa in the summer of 2014, the Ebola virus has ravaged communities, killed thousands, and sparked widespread fear, anxiety, distrust and, in some instances, violence. The Ebola outbreak has now been largely contained and a number of major advances achieved in prevention, treatment and vaccine development. However, the consequences of this sustained period of heightened stress on the mental health of the affected populations have been largely overlooked.
To date, only few, and largely uncoordinated, efforts have been made to address the mental health needs of victims, their families, and treatment teams, and none have resulted in systematic or coordinated projects. Consequently, efforts to devise and to test scientifically sound interventions and prevention programs and, if effective, to use them to help the general public, are yet to materialize.
Addressing mental health needs in trauma-exposed populations
Exposure to extreme traumatic events such as mass mortality, orphaning of children, loss of healthcare workers and inadequate supplies of medicine, food and resources, as well as discrimination against affected families due to stigma, are highly potent risk factors for mental health problems. People who experience these events have higher rates of trauma-related psychological conditions, including anxiety, depression, complicated grief and post-traumatic stress disorder (PTSD). A lack of mental health care and poverty further exacerbate these risks.
The WHO has made recommendations for mental health counseling in Ebola-stricken areas, but a more proactive, research-informed, mental health response is desperately needed to mitigate the magnitude of the mental health consequences.
The Ebola outbreak has affected large populations who are at high risk of developing mental health problems, including those who have survived the outbreak but have been stigmatized, bereaved family members, and ostracized orphans. According to a February 2015 UNICEF report, at least 16,000 children in Liberia, Sierra Leone and Guinea lost one or both of their parents, and an estimated 3,600 have been orphaned. “For many of the nine million children living in affected areas, Ebola has been terrifying,” the agency said. “These children have seen death and suffering beyond their comprehension.” Healthcare and burial workers, who have consistently witnessed the horror unfold, are also among those at high risk of lasting psychological trauma.
Children may be particularly vulnerable to psychological distress in the aftermath of Ebola, as many of them witnessed the gruesome effects of the disease firsthand.
Healing this trauma will be a long-term process that should start with evidence-based measures to evaluate and then address the population’s acute mental health needs, which will include the delivery of trauma-focused therapies such as prolonged exposure – which lowers distress through careful, repeated exposure to trauma-related thoughts, feelings and situations they have been avoiding – interpersonal treatment, or appropriate medication with or without psychotherapy. In cases of prolonged and clinically significant grief, a number of existing evidence-based treatments are recommended.
Limiting exposure
The Ebola outbreak provoked widespread fear behaviors among the public and families of victims, leading to dangerous incidents in which contagious patients fled from hospitals and desperate family members attempted to conceal sick relatives at home. Many victims’ families also performed secret burials, personally preparing the bodies of deceased victims and then becoming infected themselves. These behaviors were due to poverty, a lack of knowledge and a lack of access to treatment, alongside the daily painful exposure to the hemorrhagic symptoms of infected patients and dead bodies. Dr. Margaret Chan, the director-general of the WHO, said these behaviors propelled Ebola virus transmission.
Healthcare systems were also challenged by rumors and misinformation, often driven by flawed media reports and inadequate public health messaging. Dealing with the aftermath of a pandemic is one thing, but in the future we will need to prevent or limit the factors leading to such fear behaviors during a large-scale pandemic. This calls for well-coordinated programs to effectively address cultural barriers, educational gaps and mistrust among family members, caregivers and health systems.
In order to mitigate irrational fears and mishandling of victims’ health needs, efforts should address under-resourced treatment facilities and lack of well-trained, well-equipped and protected health teams who, in addition to providing evidence-based education and treatment, could also deliver mental health counseling.
Disseminating the wrong messages
Distress from indirect exposure to trauma via electronic and digital media during disasters is common and is also a risk factor for mental health problems. While there has to be public health information on disaster threats, media exposure may also exacerbate fear behaviors and mental health problems, as a group of researchers from the University of California found. To mitigate such risk, while not harming the delivery and dissemination of important news and education materials, the development of a science-based risk communications strategy is critical to offset a tendency for fear messaging.
Sensationalist reporting and misinformation in the media contribute greatly to fear behaviors among the public, making it difficult to mount an effective response during outbreaks.
Effective public health messaging should include information about behaviors that promote safety, the likelihood of recovery among well-treated patients, successful medical interventions, mental health support and information about protection and safety measures including how to avoid contact with victims – alive and deceased – and educating the public about ways to avoid risk in public spaces and mass transit.
As we witnessed here in the U.S., irresponsible reporting and fear mongering in the media can have serious, detrimental effects on our ability to respond effectively in such a crisis. At the height of the Ebola outbreak — when aid workers were needed the most — some state governors began imposing mandatory quarantines on healthcare workers returning from West Africa, a move that defied the recommendations of the world’s leading medical institutions and made it harder for trained personnel to reach the affected area. As the head of the U.N.’s Ebola response team reminded us in October, decisions like this “should be based on science and fact and not hype and hysteria.”
While pandemic-related fear reactions are expected, such emotional responses may play a pervasive role in disease spread in pandemic areas. Efforts to develop treatments and vaccines should be coupled with well-targeted public health messaging via the media, and well-coordinated mental health response to mitigate fear behaviors, and address the long-term psychological needs of patients, family members, and healthcare workers.