COVID‐19 under the SARS Cloud: Mental Health Nursing during the Pandemic in Hong Kong

1. INTRODUCTION

This editorial presents a commentary on COVID‐19 and mental health in Hong Kong. We outline the current measures being used to contain the outbreak and how the experience of the SARS epidemic may have influenced the response in Hong Kong. We also discuss the potential mental health ill‐effects of the pandemic and its impact on mental health nursing locally.

2. RELEVANCE STATEMENT

This editorial provides an overview of the impact of COVID‐19 on mental health and mental health nursing in Hong Kong. The discussion shares our experiences and briefly summarizes the limited evidence to date. The potential consequences of the pandemic for mental health nurses and future research are outlined.

3. COVID‐19 AND THE CURRENT SITUATION IN HONG KONG

At the time of writing (mid‐April 2020), the current number of people in Hong Kong diagnosed as infected by the virus (SARS‐CoV‐2) that causes COVID‐19 stands at 1,011. Despite Hong Kong's proximity to mainland China, the huge numbers of Chinese tourists and business visitors, and Hong Kong's position as a major international transport hub, to date, only four people have lost their lives to COVID‐19. Concerns about Hong Kong becoming an epicentre for the COVID‐19 outbreak were compounded by the fact that Hong Kong is an extremely densely populated region, with a total population of 7.48 million residing in an area of 1,004 km² and hence is particularly conducive to the spread of a highly contagious virus.

Despite the numbers of infections and COVID‐19 deaths being relatively low, people in Hong Kong have been facing prolonged fear and restrictions on their daily lives since mid‐January 2020. While some governments were minimizing the risk of the virus, the HK government began to provide social distancing advice and implementing border restriction measures on 26 January 2020 (Information Services Department, 2020a). Due to the rapidly growing number of COVID‐19 patients in Hong Kong, the Hospital Authority (HA) activated the Emergency Response Level on 25 January 2020 (Hospital Authority, 2020a). All hospital visiting was suspended, and non‐urgent outpatient specialist appointments/surgery was re‐scheduled. These preventive measures aimed to reduce COVID‐19 infection rates and reduce the risk of the healthcare system becoming overwhelmed.

Initially, the measures put in place by the local government to control the spread of the virus were far less restrictive than many other areas of the world, consisting of social distancing, border restrictions, school/university closures, encouraging working from home, promoting frequent hand washing and encouraging wearing masks in public (CHP, 2020). However, due to a rapid increase in confirmed COVID‐19 cases, the government decided to impose Prevention and Control of Disease Regulations from 28 March 2020 to 23 April 2020. Although a total “lockdown” was not imposed, restaurants were required to run at half‐capacity, group gatherings were limited to four people, and bars, beauty parlours, and other leisure venues were closed. Anyone contravening these regulations is subject to fines and imprisonment, but generally, the majority of local people have been complying with regulations and advice.

These more stringent preventive measures seem to have been effective to reduce the transmission of COVID‐19 because new infections have been declining for two weeks at the time of writing. However, the government are warning the population not to become complacent due to the risk of a third wave of local infection due to imported cases. This is a real concern given that Hong Kong has experienced restrictions for almost three months, resulting in some people becoming frustrated by the lack of social contact.

It is likely that the Severe Acute Respiratory Syndrome (SARS) epidemic of 2003 influenced the government's and the public's response to COVID‐19. In 2003, Hong Kong was the epicentre of SARS outbreak with a total of 1,750 confirmed cases and 286 deaths, eight of these fatalities were healthcare professionals (Lee, 2003). The SARS epidemic also resulted in severe financial decline locally, which harmed mental health (Liu et al., 2012). The impact of SARS resulted in profound changes in the way Hong Kong people maintained self‐hygiene, such as the routine wearing of face masks when unwell. The wearing of masks during COVID‐19 has become so entrenched in daily life that virtually everyone will use one when leaving home and the few people who do not comply with this social norm are sometimes chastised and ostracized. Despite the damaging aspects of the SARS cloud sitting over Hong Kong for 17 years, it is possible there was a silver lining, as these past experiences seem to have increased perceptions of COVID‐19 severity and susceptibility, and thus, the Hong Kong population may have been better prepared for the outbreak.

4. COVID‐19 MENTAL HEALTH CHALLENGES

Hong Kong may face a range of mental health challenges resulting from COVID‐19. The emerging issues are expected to be similar to those experienced in other countries. It is becoming apparent that stringent preventive measures, especially the social distancing and prolonged quarantines, may have a negative impact on the general population's physical and mental well‐being, inter‐familial relationships and social/emotional support networks. Whether these COVID‐19 preventive measures will increase the likelihood of psychiatric morbidity requires further investigation. Limited local evidence suggests that anxiety levels are rising, a recent cross‐sectional study involving 1,168 Hong Kong citizens reported that respondents had a high perceived susceptibility (88%) of contracting COVID‐19 and the mean anxiety level was 8.82 (borderline abnormal) using the Hospital Anxiety and Depression Scale (CUHK, 2020).

In addition to COVID‐19 infection‐related anxiety, it is foreseeable that Hong Kong and many other countries will be confronted with a major economic recession, which will have a direct detrimental impact on mental health. The financial impact of the pandemic locally is already evidenced by the highest unemployment rates for seven years (Information Services Department, 2020b) and the infamously high average home rental costs reducing by 4% over the last two months (Li, 2020). Although the local government has offered some short‐term financial assistance to reduce the financial burden of COVID‐19, the long‐term economic damage should not be underestimated. These financial challenges in Hong Kong are also compounded by the huge reductions in tourist visitors due to the social movement and associated anti‐government protests that have been apparent since June 2019.

The mental health of mental health nurses and other healthcare professionals may also be an area that requires additional resources and attention. It is reasonable to assume that the anxiety and stress levels among health professionals are proportionally higher than that of the general population due to direct contact with infected patients. Without any disease epidemic, the healthcare system in Hong Kong is already struggling with shortages of hospital beds, a lack of staff and scant resources in both general and psychiatric clinical settings (Cheung & Yip, 2015). This may explain why frontline nurses are exceptionally vulnerable to fatigue, burnout (Wang, Okoli, et al., 2020), mental exhaustion, poor staff morale, decision control/autonomy, lower quality of life and poor job satisfaction (Cheung & Yip, 2015). Also, nurses caring for COVID‐19 cases may have a higher risk of developing burnout, anxiety and depression than other allied health professionals (Lai et al., 2020). Recent research conducted in mainland China also highlights the negative impact of COVID‐19 pandemic on frontline healthcare workers including increased levels of anxiety (Shanafelt, Ripp, & Trockel, 2020), depression (Xiang et al., 2020), post‐traumatic stress symptoms, loneliness and powerlessness (Xiang et al., 2020). Based on experience with SARS, many frontline healthcare professionals will experience psychological damage due to COVID‐19. Studies showed that 90% of the frontline medical personnel who worked in high‐risk clinical settings reported psychological symptoms (Chua et al., 2004) and some nurses who experienced SARS still required mental health treatment for their depressive/post‐traumatic stress symptoms after several years (Liu et al., 2012).

5. IMPACT ON MENTAL HEALTH SERVICES, EDUCATION AND RESEARCH

Local mental health services are now inevitably affected by the COVID‐19 pandemic. Psychiatric Day Hospitals are currently only operated for a half‐day, restricted to a small number of day patients or temporarily closed. Charity‐funded drop‐in centres have also closed, resulting in a lack of non‐statutory community support services. Besides, community mental health clinical services have also been impacted, for example outreach visits were suspended in mid‐February 2020 (Hospital Authority, 2020b) and replaced by telephone contacts by community psychiatric nurses (except for crisis interventions).

Measures put in place to reduce the risk of infection within inpatient units consisted of closing wards to all visitors, provision of face masks for all staff and patients, and newly admitted patients being isolated on selected admission wards for 14 days before being transferred to other units. Due to the suspension of visiting, psychiatric patients were allowed to maintain social contact with their family members online to reduce perceived loneliness and abandonment and maintain bonds between patients’ and their families. The consequences of a temporary reduction in clinical and supportive services remain to be seen, but it is logical to assume that recovery rates may be damaged, particularly for those people with a severe mental illness who require regular and consistent community‐based support.

Hong Kong mental health nursing academics and students have also experienced disruption and stress due to COVID‐19. Nursing students have been withdrawn from clinical placements since the end of January 2020 and all face‐to‐face classes have been replaced with online learning. Students are understandably very anxious about how and when their clinical placement hours will be made up. Academics have needed to learn how to conduct online lessons, set up remote meetings and supervise research students online. Mental health nurse researchers are facing mounting stressors as all data collection and participant recruitment have been suspended since late January, resulting in financial concerns associated with paying full‐time research staff who have no work to do on suspended clinical trials.

6. THE FUTURE

The real‐world impact of COVID‐19 on the mental health of the public, nursing staff, students and academics is currently unclear. However, based on the experience of SARS and the limited empirical and anecdotal evidence, we may be facing the possibility of a mental health epidemic in Hong Kong. We hope that the COVID‐19 crisis may provide the impetus for the local government to place more emphasis on the allocation of financial resources to mental health services and staff support programmes. Any additional funding should be informed by robust mental health‐related research on COVID‐19; hence, increases in research funding will also be required. However, the degree of mental health research evidence is currently inadequate to inform a measured response. For example, recent research conducted in China has focused on psychological responses towards COVID‐19 in the general population (Wang, Okoli, et al., 2020), the levels of depression and quality of life in suspected COVID‐19 cases (Nguyen et al., 2020) and the importance of wearing masks to combat COVID‐19 infection (Lam et al., 2020). There seems to be a paucity of local studies examining the impact of COVID‐19 on mental well‐being (Sjöberg et al., 2020); therefore, timely research examining the mental health status of health professionals, mental health service users and the general population in Hong Kong is urgently needed (Xiang et al., 2020).

7. CONCLUSION

Based on earlier experiences of SARS and the limited recent evidence, the direct impact of COVID‐19 on the mental health of the population, mental health service users and nurses is predicted to be a major issue in Hong Kong. Thankfully, the preventative measures seem to have been relatively effective and the infection rate curve has downturned in Hong Kong; however, the potential for a major economic recession and the resulting long‐lasting damage on mental well‐being should not be underestimated.