Extending Mental Health Support to the Survivors of Ebola Virus Disease by Overcoming Challenges

Introduction

Ebola virus disease (EVD) is a rare infectious tropical disease, which is a serious illness among humans, and is often fatal [1]. Since its first detection in 1976, multiple outbreaks of the disease have been reported, with case fatality rates ranging between 25% and 90% depending on the sociocultural practices and readiness of the healthcare delivery system [1]. As the disease spreads via close contact (direct or through contaminated fomites and surfaces), many people living in the outbreak-affected region, including healthcare providers acquired the infection and lost their lives to the disease-associated complications [1,2]. This created a sort of stigma against the people who were infected with the virus in the local community, while many people needed mental health support during EVD outbreaks [3].

Necessity of Mental Health Support

EVD outbreaks have often been associated with the development of multiple psychological and mental health conditions like anxiety, depression, post-traumatic stress disorders (PTSD), intense grief, survivor’s grief, and sleep disorders [4,5]. The findings of a systematic review and meta-analysis indicated that 20% of the affected persons were diagnosed with depression [4]. The findings of a cross-sectional survey conducted among survivors of the disease in a district of Sierra Leone reported that six years after the occurrence of the epidemic, there was a high probability of development of mental health symptoms, like panic attacks, insomnia, and difficulty in falling asleep [5]. In addition, survivors of the affected families often face stigma, which propels them to withdraw and socially isolate from community life [3]. This was reinforced from the findings of a qualitative study done in Sierra Leone, where participants of key informant interviews and focus group discussions reported that isolation from the community and stigma related to infection proved to be a major reason of stress [3].

The healthcare providers also face these psychological conditions, and due to the highstress environment during the outbreak they often present with emotional and physical exhaustion that can impact their mental wellbeing and ability to work effectively and efficiently [6]. In fact, according to the findings from a mixed-methods study, wherein 200 healthcare professionals from Uganda were interviewed, almost 60% were found to be in psychological distress and anxiety [6]. In a crosssectional survey done among the general population, the prevalence of anxiety-depression and post-traumatic stress disorder was 48% and 76% respectively [7]. Mental health support helps survivors to come out of the trauma of losing their family members, friends, and community members [5]. This support provides coping mechanisms for the fear of acquiring infection or losing their loved ones and restores a sense of safety [7].

In addition, mental health support encourages community reintegration and develops resilience against discrimination for the survivors. Acknowledging the fact that mental and physical dimensions of health are interconnected, any efforts to improve mental wellbeing can improve the overall health condition and expedite the recovery process [6,8]. Based on the findings of a scoping review in which 25 studies were included, it was eventually concluded that there was shortage in resilience of mental health services [8]. These interventions play a big role in preventing substance abuse, as many affected individuals might turn to alcohol or drugs to cope with the loss and emotional stress [9]. It was reported in a cross-sectional study done in Sierra Leone using different validated mental health screening tools that 9.8% of the survivors and 2.2% of the close contacts of these survivors reported harmful level of alcohol use post the disease outbreak [9]. Moreover, the provision of timely support helps in mitigating long-term mental health consequences, including PTSD, and helps communities to rebuild social structures and return to daily life [5].

Identified Challenges and Potential Solutions

The above discussion justifies the need to extend mental health support to patients and healthcare providers during EVD outbreaks [8,9,10]. However, multiple challenges have been identified that essentially require integrated, culturally sensitive, and accessible mental health interventions to promote resilience and psychological wellbeing in affected communities [8,9,10,11,12,13,14,15,16]. The problem begins with the reality that the majority of reported outbreaks are in lowresource settings, which generally lack a sufficient number of mental health facilities, trained personnel, and resources, making it a difficult proposition to timely deliver psychological assistance [8,9]. In fact, the findings of a scoping review carried out with the purpose to assess the resilience of mental health services in Ebolaaffected African nations, revealed that none of these nations had metrics to support the inclusion of mental health in emergency plans, and a lack of pre-existing metrics to measure the extent of preparedness in emergency plans of the nations [8].

The solution could be training community health workers with basic mental health training to deliver initial assistance and identify those people who need further support [8,9]. The role of members of emergency medical teams in the training of 550 healthcare workers across different emergency locations in 38 nations was reported in the period between 2017-2020 [10]. There is a possibility to either deploy mobile clinics (community outreach teams) or use telehealth options to provide the desired counselling and mental health support to the affected individuals [10]. The findings of a case study in South Sudan highlighted the role of emergency multidisciplinary medical mobile teams in dealing with different humanitarian crises like investigations of disease outbreaks (such as cholera, measles, coronavirus disease2019, etc.), improving measles vaccination coverage in seven nations, and oral cholera vaccine drives in four nations [10]. Another potential recommendation from a cross-sectional study is to always take into account long-term consequences following EVD infection while designing and implementing future epidemic responses [4].

One of the practical challenges during outbreaks is that the healthcare systems’ topmost priority is to control the spread of the infection and thus there are not many resources available, including manpower to offer mental health support [1,8]. The best approach is to include mental health professionals as an integral member of the response team who can simultaneously address the psychological needs along with the outbreak management [11]. This was clearly highlighted in a participatory qualitative study wherein the focus was on how to integrate mental health and psychological support into outbreak response, especially in low- and middleincome nations [11]. The consensus study concluded that mental health professionals can be integrated into different aspects (e.g., case management, collaboration with different sectors, promoting infection prevention and control, promoting well-being of staff members, risk communication, and community engagement) of outbreak preparedness and response plans [11]. Another option could be to liaise with nongovernmental agencies or welfare agencies to mobilize additional resources to ensure psychological support [1,9].

The next challenge is that even if people think they need some form of psychological assistance, they avoid visiting healthcare facilities due to the fear of contracting the infection [12]. This is a practical concern and hospital administration must set up designated areas (safe zones) within or near the facility where infection risk is minimal and people can avail of mental health services [13]. In a study to improve infection prevention and control measures in hard to reach areas in Liberia, 180 healthcare professionals were trained and were also exposed to mentorship [13]. This significantly brough an increase in the infection prevention and control, as evidenced by the increase from 75% to 90% in the minimum standard tool for safe care [13]. Finally, we can also explore the possibility of offering mental health support through home visits to avoid exposure to healthcare environments [8].

The next set of challenges are social, where stigma is often linked with mental health issues, which often prevent seeking help, and in the case of EVD, there is an added fear of acquiring the disease [3,4]. In fact, depending on the results obtained in a qualitative study, the need for a coordinated response was advocated to minimize the extent of stigma resulting because of infection and isolation subsequently [3]. This calls for the need to create awareness in the community with the help of local leaders and celebrities to reduce the stigma and promote acceptance among people about mental health services [3,14]. In a mixed-methods study done in two provinces of the Democratic Republic of Congo among 800 randomly selected adults (quantitative) and selected community leaders, religious leaders, survivors, etc., using the in-depth interviews (qualitative), the extent of community involvement was variable, with the majority being involved in information dissemination [14]. Nevertheless, the participants did mention that they could have contributed more in improving the overall public health response[14].

Moreover, these awareness activities should be utilized to clear myths and motivate people to come forward to seek help [14]. All mental health interventions must bear cultural relevance and sensitivity, as it will ensure better acceptance [1,14]. In fact, the findings of a systematic review clearly justified the need to plan and implement culturally sensitive preventive strategies to improve the overall experiences of the communities affected by EVD [4]. However, the long-term solution will be to integrate mental health with other health services and make it an integral component of overall health [8,9]. The final challenge is about inability to afford mental health care, even if it is available, as many people lose their source of revenue during such outbreaks [15]. The solution to this could be offering psychological support at no cost or low cost to ensure that monetary factors do not prevent access to essential care [1,15].

Another feasible solution would be to provide low-cost, community-based support groups to enable people to access mental health care within their economic means [16]. The findings obtained from a research work done across 15 communities in two counties of Liberia proposed multiple models for community-based management of the Ebola outbreak and the need for community-based psychosocial support [16]. The community members adapted to the epidemic using different coping approaches, in the absence of adequate health and infrastructural support [16]. Based on the above discussion it is quite essential that mental health plans must be integrated into emergency response plans, including training of healthcare professionals plus outreach workers, formulation of preparedness metrics in outbreakprone areas, expansion of telehealth and mobile mental health clinics, designation of safe zones within healthcare facilities, strengthening of public awareness campaigns, and liaisons with private sector for better resource mobilizations and reach of the services. However, the successful implementation of these policy-level decisions will require a thorough assessment for feasibility for the availability of adequate number of trained professionals, supervision of trained outreach workers, internet connectivity in remote regions, lack of space in overcrowded healthcare institutions, the presence of deep-rooted cultural beliefs, and lack of coordination between different stakeholders.

Conclusions

In conclusion, the Ebola virus disease outbreaks have accounted for a wide spectrum of direct and indirect psychological effects, highlighting the need for mental health support. The need of the hour is to extend timely mental health support to reduce the burden of emotional stress, expedite the process of individual recovery, and strengthen societal resilience.