During any outbreak of an infectious disease, the population’s psychological reactions play a critical role in shaping both spread of the disease and the occurrence of emotional distress and social disorder during and after the outbreak. Despite this fact, sufficient resources are typically not provided to manage or attenuate pandemics’ effects on mental health and wellbeing. 1 While this might be understandable in the acute phase of an outbreak, when health systems prioritize testing, reducing transmission and critical patient care, psychological and psychiatric needs should not be overlooked during any phase of pandemic management. There are many reasons for this. It is known that psychological factors play an important role in adherence to public health measures (such as vaccination) and in how people cope with the threat of infection and consequent losses. 1 These are clearly crucial issues to consider in the management of any infectious disease, including COVID-19. Psychological reactions to pandemics include maladaptive behaviours, emotional distress and defensive responses. 1 People who are prone to psychological problems are especially vulnerable. All of these features are in clear evidence during the current COVID-19 pandemic. One study of 1210 respondents from 194 cities in China in January and February 2020 found that 54% of respondents rated the psychological impact of the COVID-19 outbreak as moderate or severe; 29% reported moderate to severe anxiety symptoms; and 17% reported moderate to severe depressive symptoms. 2 Notwithstanding possible response bias, these are very high proportions—and it is likely that some people are at even greater risk. During the 2009 H1N1 influenza outbreak (‘swine flu’), a study of mental health patients found that children and patients with neurotic and somatoform disorders were significantly over-represented among those expressing moderate or severe concerns. 3 Against this background, and as the COVID-19 pandemic continues to spread around the world, we hypothesize a number of psychological impacts that merit consideration now rather than later.

In the first instance, it should be recognized that, even in the normal course of events, people with established mental illness have a lower life expectancy and poorer physical health outcomes than the general population. 4 As a result, people with pre-existing mental health and substance use disorders will be at increased risk of infection with COVID-19, increased risk of having problems accessing testing and treatment and increased risk of negative physical and psychological effects stemming from the pandemic.