COVID-19, Stigma and Mental Health: Roots and Solutions

To the Editor,

Pandemics are not only medical experiences; they could also cause interference in the lives of individuals and society by affecting their behaviour, physical and mental health. The novel 2019 coronavirus disease (COVID-19) is the worst pandemic of this era, which loomed in China and gradually stretched to all parts of the world. The unknown nature of the disease has raised concerns about its clinical diagnostics, and management.¹ Pandemic leads to public health crises with immediate and late psychological impact, seen as fear of the unknown and anxiety, leading to prejudices against people and communities, social isolation, stigma, and xenophobia. These behaviours may culminate in chaos, hostility, and disruption of social life.² People with infectious diseases have been stigmatized in the past. A similar trend is observed in patients with mental health disorders. It is because of the heightened fear and spread of false information about the disease due to which patients and people face discrimination.³

In COVID-19 patients and survivors, the level of stigma associated based on three key factors — it is an illness that's recent and about which there are several unknowns; individuals are always scared of the unknown, and it is easy to equate the discomfort with one another’. The entities include infodemic, fear, and stigma itself are the most significant rival in this current crisis. From the past few months, the source of information is social and electronic media responsible for the spread of social stigma.⁴ There is a positive association between high fear of COVID-19 and stigma towards the disease.⁵ It has driven people to hide the illness to avoid discrimination, which could lead to delay in seeking immediate healthcare and it could also discourage them from adopting healthy behaviour practices.⁴ It has also instilled fear and avoidance among individuals due to its contagious nature and unavailability of vaccines.

The impact of social stigma is far worse than the clinical manifestations despite it being curable in almost 97% of patients affected. This has been in patients who have recovered from COVID-19 or were released from home isolation or quarantine.⁶ Also, patients with previous mental health disorders are at stake and might worsen their condition. The stigma among patients with mental health who are or have been infected by COVID-19 may double the overwhelming feeling of getting sick and social discrimination attitude. To minimize the spread of infectious disease, the province-wide lockdown has also created psychological distress. In a recent longitudinal study with 2-month follow-up period, self-stigma and personal control both significantly moderated the association, but those with higher self-stigma and lower personal control are impacted during the quarantine.⁷

Multiple reasons have attribute to cause stigma in the COVID-19 pandemic, like improper information about the spread of disease along with increased fear and anxiety, which have endorsed further aggravated by measures like self-isolation and social distancing for prevention.¹ On occasion, the danger of losing can extrapolate to social and moral circumstances, which can further lead to development of social stigma. However, the actual origin is very complex and may extend beyond concepts such as a social disability or moral transgressions. Along with isolation measures, social stigma can act as catalysts for many psychological issues, especially in people who are at risk.⁸ The adverse impact on mental health does not simply stop after the quarantine period, but continues to aggravate the condition putting a negative impact on health control measures. Secondly, patients with mental health issues are often discriminated and stigmatized, and these patients may not have timely access to health care.³ Health care providers must be, therefore, aware of risk factors and the potential psychological consequences of stigmatization and prolonged quarantine in these patients too.^8,9

Along with the rapid vaccine development, the anticipation of widespread vaccine hesitancy and resistance has led to various concerns. Therefore, the choice of being vaccinated against COVID-19 or even participate in vaccine trials could be also important sources of social stigma, and vice versa: the perceived COVID-19 societal stigma have found to be a drive to accept vaccination.¹⁰

Despite mental health practitioners calling attention to the need to prioritise COVID-19 vaccination for people with mental illness, the community seems to distinguish between different vulnerable populations and present the highest stigma against those people who use drugs. The community was much less likely to endorse providing prevention resources, including vaccine to people with substance abuse.¹¹ The desire to be vaccinated can have potential financial implications as well. Patients with anxiety disorder and depression in China were more willing to pay for the COVID-19 vaccine than healthy controls; moreover, the severity of their symptoms was the most important influencing factor. The results also showed that the greater the internalised stigma of COVID-19 infection is, the stronger the motivation is to pay for the vaccine in the control group.¹²

Based on previous polio vaccine work experiences, community-centric strategies might have a place in alleviating the widespread vaccine hesitancy and non-compliance during the COVID-19 pandemic through facilitating inclusive community engagement, leveraging existing networks by trained and supported volunteers, and establishing relationships with community leaders, who could act as gatekeepers.¹³ In this perspective, community-centric strategies should also focus on addressing discrimination and intersecting vulnerabilities, as well as the conditions that promote or perpetuate stigma.

We also need to address this stigmatization towards COVID-19 patients after recovery.¹⁴ In a Chinese study, it was illustrated that acceptance of COVID-19 vaccinations statistically significantly reduced COVID-19 discrimination against recovered patients; however, discrimination rates still overall remained high.¹⁵ An urgent need to control such prejudices and rise as a community that is empowered with health literacy, and responds appropriately in the face of this adversity as the risk of re-infection is quite evident.⁴ By minimizing stigma and stereotypical behaviour is required in making all community members safer and healthier physically and mentally. Everyone can help prevent this discrimination by knowing the facts right and sharing them with other community members. The usage of credible information from official sources such as the Ministry of Health, the World Health Organization, and the UNICEF should be ensured. It is recommended that the privacy and confidentiality of those seeking health care should also be preserved. Speaking out against negative statements and stereotyping groups on social media, news channels and other media group is in need. At the same time, creating virtual resources and other social support services for patients with mental health disorders who have experienced stigma and discrimination should be supported by all means to avoid post-pandemic mental health problems and aggravation.

Conflicts of Interest

The author has no conflicts of interest to declare