CSTS | Department of Psychiatry | Uniformed Services University | 4301 Jones Bridge Road, Bethesda, MD 20814-4799 | www.CSTSonline.org

Mental Health and Behavioral Guidelines
for Preparedness and Response toCoronavirus and other Emerging
Infectious Outbreaks
Several global infectious disease
members typically come together toCommunity response to outbreaks isoutbreaks, such as Coronavirus
help with rescue efforts and bond
(COVID-19), can help informover the shared adversity caused bygoverned by perception of risk (not actual
psychological and behavioral
the catastrophe. This “honeymoon”risk) with a variety of factors impacting
responses to these events as well asphase is often helpful for people
appropriate interventions. Since theto begin the process of recovery.
community distress...
highly lethal pandemic outbreak ofIn contrast, recommendations
influenza in 1918, there have been few
during infectious outbreaks include
global threats from infectious agents. SARS outbreaks in Asia
avoiding public places, social distancing, limiting contact
and Canada, as well as H1N1, MERS, Ebola virus, and Zika
with potentially infected individuals and other measures thatvirus have provided important lessons to inform preparedness diminish social connections and amplify feelings of isolation.
and response.
In some cases, the requirement for quarantine furthers
Like many crisis and disaster events, pandemics result
feelings of isolation for individuals directly affected as well as
in a predictable range of distress reactions (insomnia,
their families, friends, and community members.
decreased perceptions of safety, anxiety), health risk behaviors
Front-line health workers are particularly vulnerable to(increased use of alcohol and tobacco, work/life imbalance
negative mental health effects of treating outbreak victims,
manifested by extreme over-dedication in the workplace toand may experience high levels of traumatic stress reactions,
alleviate distress), and may also result in psychiatric disorders, including depression, anxiety, hostility, and somatizationsuch as PTSD, depression, and anxiety.
symptoms. They are directly exposed to the illness andInfectious outbreaks have unique characteristics that
resultant community distress, typically working long hours
increase fear and uncertainty, due to the imperceptibility of
due to high rates of patients presenting compounded by
the infectious agent, uncertainty about infection, and early
illness in some providers, and the need to balance the duty
stage symptoms that are often easily mistaken for more wellto care for patients with concerns about their own well-being
known, benign illnesses. As a result, pandemics manifest
and that of their family and friends.
unique individual and community responses, including
Effective public mental health measures will address
scapegoating and blaming, fear of infection, and high levels ofnumerous areas of potential distress, health risk behaviors,
somatic (physical) symptoms.
and psychiatric disease. In anticipation of significant
Community response to outbreaks is governed bydisruption and loss, promoting health protective behaviors
perception of risk (not actual risk) with a variety of factors
and health response behaviors will be imperative. Areas ofimpacting community distress.
special attention include: (1) the role of risk communication;
These factors include: fear of infection, concerns about(2) the role of safety communication through public/private
adequate supplies, efficacy of prophylactic and treatment
collaboration; (3) psychological, emotional, and behavioral
medications. and the emergence of pathogens.
responses to public education, public health surveillance,
In particular, new pathogens may be difficult to detect orand early detection efforts; (4) psychological responses totreat, can spread in novel ways, or can cause unfamiliar orcommunity containment strategies (quarantine, movement
extreme symptoms. All of which will increase community
restrictions, school/work/other community closures);
distress.
(5) health care service surge and continuity; and (6) responses
Most large-scale community disasters result in predictableto mass prophylaxis strategies using vaccines and antiviralphases of community behavior that unfold over time. Aftermedication.
an event such as an earthquake or hurricane, community
The first step in preventing undesirable psychological,

emotional, and behavioral response is an effective publichealth program of risk assessment and communication,
public health prevention, and consequence management.
These are necessarily premised on having effective
political and community leadership, appropriate pre-event
organization, staffing, and funding.
Being alert to the interrelationship between psychological,
emotional, and behavioral responses and their effect on otherelements of the response plan must also be emphasized.
While planning can be based on assumptions that publichealth efforts to stop an outbreak will be successful, ability
to manage consequences of failure, including subsequent
behavioral response(s) to failure, is crucial. This can extend
from failure to deliver support and services, to failure of a
vaccine to prevent illness, to failure of therapies to work.
Recommended steps in response to a pandemic or
infectious disease outbreak are divided into four phases:
preparedness, early outbreak response, later response andrecovery, and mental health intervention planning.
PREPAREDNESS
1. Education. Public education must begin immediately,
before a pandemic occurs, and be embed into existingdisaster public education campaigns, resources, andinitiatives (e.g. HLS’s www.ready.gov, Red Cross, CDC
public education and preparedness https://www.cdc.gov/
flu/pandemic-resources/planning-preparedness/nationalstrategy-planning.html, and HHS https://www.cdc.gov/
flu/pandemic-resources/index.htm). This should focus onfacts, include what is known, what is not known, and how
individuals, communities, and organizations can prepare
for a potential outbreak. As we know from the SARS
and other outbreaks, public education impacts threatawareness, threat assessment, and preparedness behaviors
in every phase of an event. Public education in advance ofan outbreak should be inclusive of the varying degree of
threats, to include those of reasonably low threat potential
to those with the highest potential.
2. Leadership preparation. Leadership preparation includes
ensuring that public officials understand which membersof the population will be most vulnerable and who willneed the highest level of health services, including mental
health services. This includes identification of thosegroups who may be at greatest risk for problems related
to contagion, such as those with psychiatric illness,children, elderly, homeless, and those dealing with griefor loss. Ongoing negative life events also increase one’s
risk for mental health problems and may place certain
people at higher risk for negative mental health impactof an outbreak. In addition, health risk behaviors such as
smoking, drug use, and alcohol use may increase in timesof stress, putting some people at increased risk.
3. Sustaining preparedness measures. Maintenance of
motivation, capital assets, equipment, and funding tocontinue preparedness efforts over the long term must
be considered, not just to focus on immediate needs. It isalso important to remember that if responses are undersupported and fail, the community anger and lowered
morale may complicate the ability of a community torespond to an outbreak, as well as the recovery process
once an outbreak has ended.
4. Leadership functions. Leadership functions require
identification of community leaders, spokespersons,and natural emergent leaders who can affect community
and individual behaviors and who can endorse andmodel protective health behaviors. Special attention to
the workplace is imperative as corporations have public
education resources to potentially reach large populations.
The media and celebrity groups constitute importantleaders in most modern societies and have a critical role inproviding leadership in communication.
EARLY PANDEMIC RESPONSE
1. Communication. Wide dissemination of uncomplicated,
empathically informed information on normal stress
reactions can serve to normalize reactions and emphasize
hope, resilience, and natural recovery. Recommendations
to prevent exposure, infection, or halt disease transmission
will be met with skepticism, hope, and fear. These
responses will vary based on the individuals’ and the
local community’s past experiences with government
agencies. In addition, compliance with recommendations
for vaccination or medication treatment or prophylaxis
will vary greatly and will not be complete. The media
can either amplify skepticism or promote a collaborative
approach. Interactions with the media will be bothchallenging and critical. The public must clearly andrepeatedly be informed about the rationale and mechanism
for distribution of limited supplies (e.g., prophylactic
or treatment medications). Leadership must adhere topolicies regarding such distribution, as abuses of policy
will undercut public safety and public adherence to othergovernment risk reduction recommendations.
2. Tipping points. Certain events, known as ‘tipping points’,will occur that can dramatically increase or decrease fear
and helpful or health risk behaviors. Deaths of importantor particularly vulnerable individuals (e.g., children),new unexpected and unknown risk factors, and shortagesof treatments are typical tipping points. The behavioral
importance of community rituals (e.g. speeches, memorialservices, funerals, collection campaigns, television
specials) are important tools for managing the community
wide distress and loss.
3. Surges in demands for health care. Those who believe
they have been exposed (but have not actually been) may
outnumber those exposed and may quickly overwhelm
a community’s medical response capacity. Planning forthe psychological and behavioral responses of the healthdemand surge, the community responses to shortages,
and the early behavioral interventions after identificationof the pandemic and prior to availability of vaccines areimportant public health preparedness activities.

LATER RESPONSE AND RECOVERY
1. Community structure. Maintenance of community
is important. Community social supports — formaland informal — will remain important. In-personsocial supports may be hampered by the need to limit
movement or contact due to concerns of contagion.
Virtual contact — via phone, web, and other remoteresources — will be particularly important at these times.
At other times local gathering places — places of worship,
schools, post offices, and grocery stores — could be pointsof access for education, training, and distribution. In as
much as allowed, instilling a sense of normalcy could beeffective in fostering resiliency. In addition, observing
rituals and engaging in regular activities (such as schooland work) might manage community and organizationaldistress and untoward behaviors. Providing tasks
for community action can supplement needed work
resources, decrease helplessness, and instill optimism.
Maintenance and organization in order to keep families
and members of a community together is important(especially in event of relocation).
2. Stigma and discrimination. Under conditions ofcontinuing threat, the management of ongoing racialand social conflicts in the immediate response period
and during recovery takes on added significance. Stigmaand discrimination may marginalize and isolate certain
groups, thereby impeding recovery.
3. Management of fatalities. Mass fatality and managementof bodies, as well as community responses to this, must beplanned for. Containment measures related to bodies may
also be in conflict with religious beliefs, rituals of burial,
and the usual process of grieving. Local officials should
be aware of the potential negative impact of disrupting
normal funeral rituals and processes of grieving in orderto take safety precautions. Public health announcements
should include (if known) how long the virus remains in
the corpse and what should be done with the bodies. Ina pandemic, funeral resources can be overwhelmed andmortuaries may not want to handle contaminated bodies.
Careful identification of bodies must be ensured andappropriate, and accurate records maintained.
MENTAL HEALTH INTERVENTION PLANNING
1. Efforts to increase health protective behaviors andresponse behaviors. Individuals under stress will needreminders to take care of their own health and limit
potentially harmful behaviors. This will include taking
medication, giving medications to elderly and children,
infection prevention measures, and when to go for
vaccination.
2. Good risk communication following risk

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communication principles. The media can either
amplify skepticism or promote a collaborative approach.
Interactions with the media will be both critical andchallenging.
Good safety communication. Promoting clear, simple,
and easy-to-do measures can be effective in helping
individuals protect themselves and their families.
Public education. Educating the public not only informs
and prepares, it enlists them as partners in the process andplan. Education and communications will need to address
fears of contagion, danger to family and pets, and mistrustof authority and government. The tendency to expect oract as if these are not present can delay community-wide
health protective behaviors.
Facilitating community directed efforts. Organizing
communal needs and directing action toward tangible
goals will help foster the inherent community resiliency
toward recovery.
Utilizing evidence-informed principles of psychologicalfirst aid. These basic principles include:
x Establish safety and identify safe areas and behaviors.
Provide accurate and updated information.
x Maximize individuals’ ability to care for self andfamily and provide measures that allow individuals
and families to be successful in their efforts.
x Teach calming skills and maintenance of natural bodyrhythms (e.g., nutrition, sleep, rest, exercise). Limit
exposure to traditional and social media as increased
use enhances distress.
x Maximize and facilitate connectedness to family andother social supports to the extent possible (this may
require electronic rather than physical presence).
x Foster hope and optimism while not denying risk.
Encourage activities that restore a sense of normalcy.
Care for responders and healthcare workers to maintaintheir function and workplace presence. This will requireassistance to ensure the safety and care of their families.
First responders will be comprised of a diverse population,
to include medically trained personnel to bystanders
with no experience. Healthcare personnel will experience
increased stress while having to manage concerns about
their own safety and, potentially, stigma from family,friends, and neighbors.
Mental health surveillance. Ongoing population-level
estimates of mental health problems in order to direct
services and funding. Surveillance should addressPTSD, depression, and altered substance use as well as
psychosocial needs (e.g., housing, transportation, schools,employment) and loss of critical infrastructure necessary
to sustaining community function.

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University
4301 Jones Bridge Road, Bethesda, MD 20814-4799
www.CSTSonline.org