Treating Ebola has focused on the physical – but there will be mental scars too

Since its re-emergence in the summer of 2014, the Ebola outbreak in West Africa has ravaged communities, killed thousands, created fear, anxiety and 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 on the mental health of the populations has 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 programmes and, if effective, to use them to help the general public, are yet to materialise.

Addressing mental health needs

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. These include anxiety, depression, complicated grief and post-traumatic stress disorder (PTSD). A lack of mental health systems and poverty further exacerbate these risks.

The WHO has made recommendations for mental health counselling 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 stigmatised, bereaved family members, and ostracised orphans. Healthcare and burial workers, who have consistently witnessed the horror unfold, are also among them.

Orphaned children, bereaved families and stigma.Ahmed Jallanzo/EPA

Programmes should now include evidence-based measures to assess mental health needs and 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, existing evidence-based treatments are recommended.

Limiting exposure

Ebola virus provoked large-scale fear behaviours among the public and families of victims. These included patients with symptoms escaping from hospitals and desperate family members attempting 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 behaviours 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. Margaret Chan, the director-general of the WHO, said these behaviours propelled Ebola virus transmission.

Healthcare systems were also challenged by rumours 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 behaviours during a large-scale pandemic. This calls for well-coordinated programmes to effectively address cultural barriers, educational gaps and mistrust among family members, caregivers and health systems.

Health workers on the frontline.DFID, CC BY

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 counselling.

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 behaviours 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.

Effective public health messaging should include information about behaviours 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.

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 behaviours, and address the long-term psychological needs of patients, family members, and healthcare workers.

Yuval Neria receives funding from: NIMH, NHLBI, NIDA, Stand the Troops, Grand Challenges Canada, and Cambridge University Press He is affiliated with Columbia University Medical Center, and the New York State Psychiatric Institute