Mental health and psychosocial support strategies in highly contagious emerging disease outbreaks of substantial public concern: A systematic scoping review

Background Acute disease outbreaks such as the COVID-19 pandemic cause a high burden of psychological distress in people worldwide. Interventions to enable people to better cope with such distress should be based on the best available evidence. We therefore performed a scoping review to systematically identify and summarize the available literature of interventions that target the distress of people in the face of highly contagious disease outbreaks. Methods MEDLINE, Cochrane CENTRAL, Web of Science (January 2000 to May 7, 2020), and reference lists were systematically searched and screened by two independent reviewers. Quantitative and qualitative studies investigating the effects of psychological interventions before, during, and after outbreaks of highly contagious emerging infectious diseases, such as SARS, MERS, Ebola, or COVID-19 were included. Study effects were grouped (e.g. for healthcare professionals, community members, people at risk) and intervention contents at the individual and organizational level summarized. We assessed the level of evidence using a modified scheme from the Oxford Centre for Evidence-based Medicine and the Australian National Health and Medical Research Council. Results Of 4030 records found, 19 studies were included (two RCTs). Most interventions were delivered during-exposure and face-to-face, focused on healthcare workers and crisis personnel, and combined psychoeducation with training of coping strategies. Based on two high-quality studies, beneficial effects were reported for resilience factors (e.g. positive cognitive appraisal) and professional attitudes of healthcare workers, with mixed findings for mental health (e.g. depression). Across all studies, there was positive qualitative feedback from participants and facilitators. We identified seven ongoing studies mostly using online- and mobile-based deliveries. Conclusions There is preliminary evidence for beneficial effects of interventions to enable people to better cope with the distress of highly contagious emerging disease outbreaks. Besides the need for more high-quality studies, the summarized evidence may inform decision makers to plan interventions during the current pandemic and to develop pandemic preparedness plans.


Introduction
The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1], has an enormous impact on healthcare and economic systems, but also on public mental health. On 30 January 2020, the WHO Director-General declared the novel coronavirus (2019-nCoV) outbreak a public health emergency of international concern [1].
Emerging new infections such as COVID-19 and pandemic outbreaks in general exert a significant psychological impact on healthcare staff and the community at large. Several recent reports have shown that especially healthcare workers are at risk of developing psychological distress and other mental health symptoms during the SARS-CoV-2 pandemic [2][3][4][5][6]. Possible causes may be overwhelming workload, lack of personal protection equipment, lack of intensive care unit beds and triage situations, lack of specific treatments, and feelings of not getting enough support from their superiors. A recent survey of healthcare workers in Wuhan and other regions in China demonstrated high levels of depression, anxiety, insomnia, and distress, with exceptionally high burden in healthcare workers who are directly in charge of patients with COVID-19 [4]. Surveys of the general population, mostly from China, where the pandemic started [1], have also shown that people show high amounts of anxiety, depressive, and stress symptoms [7][8][9]. Such distress may be caused by disease-related fears, social distancing and quarantine measures [10], and the potential long-term impact of pandemics (e.g. economic disruption) [11].
Fostering mental health and psychological adjustment (i.e. resilience) to the challenges of pandemics appears to be an important approach to prevent the development of mental disorders in both healthcare workers and the general population [12,13]. The call for psychological interventions to cope with the immediate and long-term stress of pandemics had already been prompted after the SARS pandemic in 2003 and local Ebola epidemic outbreaks (e.g. 2014/2015 in West Africa) [14], but is becoming louder as the current pandemic is ongoing [15][16][17]. Epidemic and pandemic response plans also point to the need for measures of psychosocial support [18][19][20], and respective interventions have already been developed for SARS, influenza pandemics, and Ebola epidemics [21][22][23]. Since the WHO announced the COVID-19 outbreak a pandemic by March 2020, first interventions (e.g. online mental health services) to cope with the psychological impact of this disease were already initiated [24][25][26]. However, the currently available evidence of psychological interventions and potential benefits of training remain unclear.
In this scoping review, we intended to systematically examine relevant research in the field investigating strategies that have been implemented and evaluated to promote mental health and psychosocial support in people who are or were involved in the outbreak management of highly contagious infectious diseases, or are expected to be. In order to provide a reference point for policy makers and other deciders in clinical and public settings, we aimed to assess the appropriateness, meaningfulness and feasibility of such interventions as well as their effects on mental health outcomes. Furthermore, we aimed to identify key concepts of such interventions which may serve as a starting point for the planning of crisis plans and future intervention studies.

Search strategy
A protocol of this review was drafted according to the standards delineated in the Preferred Reporting Items for Systematic Reviews and Meta-analysis-scoping reviews extension (PRIS-MA-ScR) [27] and was registered at OSF registries in parallel (osf.io/5fevy). We searched three bibliographic databases from January 2000 to May 7, 2020: MEDLINE, Cochrane CENTRAL, and Web of Science. The search strategy combined three key sets of terms: functional ways of dealing with stress (e.g. resilience, psychological adjustment, coping), interventions (e.g. stress management), and disease outbreaks (e.g. SARS, pandemic). Various terms for each of the concepts were entered, as appropriate for each database (e.g. as MeSH terms, keywords, text words). The full search string for all databases is outlined in the S1 Appendix. The search was limited to studies of humans. There were no restrictions concerning language, publication status, date, or format. The reference lists of eligible studies and of relevant sources (e.g. reviews) were hand searched to identify any additional relevant studies.

Eligibility criteria
We included individuals in anticipation of, during, or in the aftermath of an outbreak of a highly contagious emerging disease, irrespective of age and health. Eligible interventions were any psychological interventions to foster the adjustment of individuals (possibly) exposed to pandemics or hazardous infectious disease outbreaks and/or to promote their mental health and psychosocial support. We included quantitative and qualitative studies (for detailed eligibility criteria see S1 Table).

Study selection and data analysis
After de-duplication, the screening and study selection process were performed in duplicate by two independent reviewers (AMK and MS, ALM, MB, SW, respectively). Titles and abstracts were screened to exclude evidently irrelevant records, then full-text records of relevant studies were inspected to determine eligible studies. Any disagreements were resolved by discussion or by consulting a third reviewer (KL). If necessary, study authors were contacted. Discrepancies were resolved at each stage and consensus was achieved with excellent interrater reliability (κ = 0.84). Two independent reviewers (AMK, KL) extracted relevant information for each included study using a customized spreadsheet. Intervention contents at the individual and organizational level across eligible studies were also extracted by two reviewers (SW, KL) working independently. Discrepancies in data extraction were resolved through discussion or by a third reviewer (JSW, DG, IH).
The quality of the evidence of completed and published studies was assessed by two independent reviewers (AK, KL) using a rating scheme that was modified from the Oxford Centre for Evidence-based Medicine (EBM) for ratings of individual studies [28] and the Australian National Health and Medical Research Council (NHMRC) evidence hierarchy [29]. Given the status of this work as a scoping review, which do not require a formal assessment of the methodological quality of included studies [30], we used a rating scheme with four levels in order to assess the level of evidence (level 1: randomized controlled trial; level 2: controlled trial without randomization, case-control study or controlled time series design; level 3: single-group study with either posttest or pretest/posttest assessment; level 4: case study/report with either posttest or pretest/posttest assessment).
We did not quantitatively integrate research findings because of the variety of included interventions, settings, and outcomes. Instead, we aimed at giving a comprehensive overview of intervention concepts based on the available quantitative and qualitative evidence. To do so, we first grouped the publications by target populations (healthcare professionals and crisis personnel; children and adolescents, community members, patients with highly contagious infectious disease, and people at elevated risk due to somatic conditions), and the time point of implementation (pre-exposure, during-exposure, after-exposure), respectively. We summarized the quantitative and qualitative findings for these interventions, if available. Second, we examined the intervention contents of eligible studies and additional observations described by the publications (e.g. feedback from participants) in order to give an overview of key concepts used in the respective interventions relating to the individual and organizational level. Overall, this systematic scoping review adheres to the PRISMA-ScR statement [27] (see S2 Table).

Results
The literature search yielded 4030 records (Fig 1).
After de-duplication, 3872 records were retained for title/abstract screening. Of these records, 149 were assessed at full-text level. The full-text screening resulted in 19 completed studies (from 21 reports) that were included in the review. The study characteristics of these studies are given in Table 1. We also identified seven eligible registered studies (see Currently registered, yet unpublished intervention studies).

Studies in healthcare professionals and crisis personnel
Healthcare professionals and crisis personnel (e.g. local hospital or treatment center staff, deployed individuals providing help on-site)-that is, individuals directly exposed to acute disease outbreaks-were most frequently addressed by interventions, with 12 studies performed in this target group.
In four studies that aimed to prepare healthcare staff and crisis personnel for an anticipated pandemic, participants were reported to feel better able to cope compared to before the training [21]. The randomized study of Maunder and colleagues [31], who compared different doses of resilience training, suggested evidence of increases in resilience factors (e.g. pandemic self-efficacy), the confidence in training, and interpersonal problems. For two pre-deployment trainings focusing on resilience (e.g. coping, resilience factors like problem-solving), combined with virtual reality, Klomp and colleagues [34,35] reported improvements in resilience and self-efficacy.
Five interventions were offered during a pandemic, with one crisis intervention also referring to quarantined medical staff during the current COVID-19 pandemic [26]. Regarding the effectiveness of Psychological First Aid (PFA) to equip volunteers to provide psychosocial support, the results of another study were mixed [47]. In a safety training also containing psychological elements (e.g. stress management), participants reported to benefit most from handson aspects [37]. In a qualitative study, emergency hotline workers reported to find a support group helpful for, for example, stress management and self-efficacy [33]. A pre-incident stress inoculation training (e.g. personal resilience plan, monitoring of own stressors) resulted in 90% participants under the clinical cut-off for a posttraumatic stress disorder in a self-triage encounter system [23].
The only cluster-RCT comparing PFA to wait-list control for healthcare staff after the 2014 Ebola outbreak found mixed results, with small effects on professional attitude versus no effects on, for example, professional quality of life [32]. Waterman and colleagues [39] examined the only stepped care approach in this review. For a three-phase intervention (e.g. CBT group intervention), developed to be implemented during or after an Ebola outbreak, the authors reported evidence of positive training effects for several mental health outcomes (e.g. depression, posttraumatic stress symptoms). In a qualitative study [48] with facilitators of the CBT group, the emerging social networks and the novelty of CBT were highlighted as key enablers, while different cultural concepts of mental health problems presented key barriers. Finally, when evaluating the same CBT group in former Ebola Treatment Center (ETC) staff, positive effects on anxiety, depression and functional impairment were reported, with the effects being independent of the exposure to risk of infection during the ETC work [41].

Studies in community members and other groups
Four studies focused on community members (e.g. people in quarantine). Based on qualitative data, a Social Reconnections Group helped participants to overcome grief and return to normal life [36]. From two studies in quarantined individuals [38,42], Pan and colleagues made mixed observations from a support group during the SARS outbreak (e.g. sense of connection is important, self-disclosure difficult). Yoon and colleagues [42] described the implementation of a mental health service system for people in quarantine and families of patients, with 2% of quarantined individuals receiving continued services. For one intervention implemented during the current coronavirus outbreak [26], no data are available yet. For both interventions focusing on children and adolescents during and after SARS and Ebola outbreaks (e.g. strength-focused and meaning-oriented resilience training) [40,[44][45][46], positive quantitative findings were reported (e.g. reduction of psychological stress, increase of sense of social commitment and resilience factors), in part supported by positive qualitative feedback.
One study focused on patients with a highly contagious infectious disease by investigating patients during the 2014 Ebola outbreak [43]. For psychosocial support measures in Ebola treatment units, including, for example, measures to minimize distress and enhance wellbeing as well as stress management, the authors found mixed effects with a decline of low mood compared to no effects on other measures (e.g. anxiety).
People at elevated health risk due to somatic conditions-a frequently named risk group during the current COVID-19 pandemic-were subject to one study. Ng and colleagues [22] compared a resilience training (same intervention as Yau and colleagues [40]) to no-intervention control. While there was evidence in favor of training for depression and cognitive appraisal of the SARS outbreak, the study found no effects on other mental health outcomes (e.g. anxiety).

Contents of intervention studies
The 19 studies qualitatively described important contents that should be addressed in interventions to cope with the psychological challenges of a pandemic. These were immediately focused in the trainings or resulted from the observations made during the implementation. The recommended targets on the individual and organizational level are summarized in Tables  2 and 3, respectively.

Discussion
With this systematic scoping review, we identified interventions to provide psychosocial and mental health support in different target groups in the face of highly contagious infectious disease outbreaks. Evidence of positive effects on psychological outcomes was mostly reported by

General health care information
Health and hygiene information, help system; clinical/site structure studies that included a mix of providing information (e.g. pandemic-related knowledge, stress) and teaching psychological strategies (e.g. training of resilience factors and coping strategies) [21,22,26,31,32,35,38,40]. Besides, relaxation and mindfulness techniques (e.g. meditation) were often included [22, 26, 31, 33-36, 40, 43, 46, 47]. Several studies [22,39,40,48] indicate that psychological interventions such as CBT, or trainings including Eastern spiritual techniques like in the SMART approach [22,40,46], need to be adapted to the cultural context of the target group and respective concepts of mental health. As pointed out by several studies [39,[43][44][45], train the trainer concepts and the provision of interventions by trained peers (e.g. other healthcare professionals) or para professionals (e.g. survivors) can be beneficial. Consistently, PFA (see Table 2) was often (partly) included in the interventions [32,34,35,39,43,47]. However, the efficacy of PFA in general is critically discussed and was rarely examined in RCTs, especially during pandemics [32,56]. Horn and colleagues [47] also concluded advantages of training non-specialists to provide psychosocial support during emergencies. However, participants might only benefit from short-term trainings if they already have certain skills before the training.
Highly contagious disease outbreaks and the associated changes (e.g. quarantine) as major stressors can have considerable psychosocial impacts on individuals, including short-term (e.g. stigma, anxiety) and long-term effects (e.g. trauma, grief) [e.g. 10,57]. Since not all individuals exposed will develop mental health problems, stepped care approaches [e.g. 39] might be especially useful for mental health services during disease outbreaks.  The reviewed literature provides preliminary evidence that individuals deployed to disease outbreaks might benefit from psychological interventions, such as resilience training, offered in the pre-incident period [23,34,35,37]. For example, a pre-event stress inoculation training that requires participants to create personalized resilience plans before deployment might improve the coping on-site and reduce (long-term) mental health effects of the deployment, such as posttraumatic distress. In addition to several trainings to foster the resilience of individuals in deployment situations, the Centers for Disease Control and Prevention (CDC) has implemented a pre-deployment screening process, which aims to reduce the likelihood of deploying people at risk of mental health problems [34,35].
While the contents of nearly all included studies referred to the individual level (e.g. coping skills training, strengthening of resilience factors, relaxation training), especially the interventions targeting healthcare workers and crisis personnel also included elements at the organizational level (e.g. supportive leadership, supervision). In resilience research, a reciprocal association between individual and organizational resilience [58] has been suggested [59]. Organizational resilience (e.g. at the level of hospitals) might facilitate individual resilience in response to a stressor and vice versa. Thus, in the face of highly contagious infectious disease outbreaks, a combination of individual-and organizational-level training elements could also be important to better reach individuals and to provide them with comprehensive psychosocial and mental health support. In the context of a global pandemic like the current COVID-19 crisis, which can affect societies across different countries and regions at large, especially community interventions might benefit of organizational-level contents (e.g. fostering social support and connectedness in a community). Given the still limited number of training programs for children and adolescents, school-based interventions would be desirable (e.g. pandemic preparedness courses at class level). Finally, psychosocial and mental health support for patient populations or people at risk (e.g. due to underlying chronic diseases) might be also provided with the help of organizational structures in healthcare services, such as hospitals or general practitioners.
The findings of this scoping review, especially regarding during-and after-exposure interventions, might be of use with respect to the COVID-19 pandemic. The general public and specific risk groups, like healthcare workers and various patient populations, were mostly addressed during previous epidemic and pandemic disease outbreaks, with positive quantitative and qualitative findings reported by the respective studies. Thus, these population groups could also benefit from COVID-19 related interventions. This is in line with recent systematic reviews and meta-analyses which also found increased psychological distress and (stressrelated) mental symptoms in these groups caused by the current pandemic and the associated measures of containment (e.g. quarantine) [10,[60][61][62][63][64][65][66][67][68]. Another practical implication of the reviewed literature refers to the intervention contents and methods used in the included studies. As discussed above, the provision of information (e.g. on infectious disease) and the strengthening of psychological coping strategies (e.g. resilience factors) were valuable approaches to provide mental health and psychosocial support in the timeline of different disease outbreaks. Given that the satisfaction with COVID-19 related knowledge [69][70][71][72][73][74] and certain resilience factors (e.g. social support) [71,75,76] have also been shown as protective factors during the current pandemic, these contents might serve as a first starting point or guidance for the development of health-promoting interventions in view of the COVID-19 pandemic.
Despite the positive effects of interventions that were reported in several included studies, this review reveals several evidence gaps to be addressed, with respect to specific target groups, the time point, delivery, and content of training programs (e.g. combination of individualand organizational-level contents), and the design of intervention studies. Based on these findings, Table 4 summarizes suggested topics for further research in the field which might also be of benefit for the COVID-19 related (intervention) research.
Regarding participants, only a minority of studies assessed interventions to cope with the potential negative impact of quarantine measures [26,38,42] on mental health. During disease outbreaks, people with elevated health risks are confronted with worries concerning their health as well as social stigma [22], making them an important target group of psychological interventions, which was, however, hardly represented in the literature. The same applies to older adults as well as to children and adolescents who are also exposed to various outbreakrelated stressors (e.g. social isolation, homeschooling) and should be addressed-with programs adapted to their needs-in more interventions. Other system-relevant professions (e.g. grocery workers), who provide essential services for the general population, even during quarantine, were neglected in the studies. Furthermore, individuals with mental disorders deserve special attention during disease outbreaks, especially the ones who struggle to understand what is happening to them or who do not adhere to required procedures [43]. Finally, the review indicates the urgent need for more interventions to be conducted before the exposure to disease outbreaks in order to prepare communities and institutions (e.g. hospitals) for the various stressors and prevent negative mental health outcomes. Some studies particularly point to the need of trials under "real-world pandemic conditions" which would allow to measure the participants' actual response instead of proxy measures of resilience and mental health [31]. Therefore, virtual reality methods, used in two included studies [34,35], might be a good supplement for pre-outbreak trainings. Finally, more interventions that are implemented after the exposure to disease outbreaks, such as the current pandemic, would be desirable in order to mitigate potential negative psychosocial and mental health effects. Table 4. Recommended research topics based on the findings of this review.

Target groups of interventions
• Individuals with elevated health risks (e.g. underlying chronic disease) • Individuals with pre-existing mental disorders (e.g. depression) • Employees in other critical infrastructure sectors [77] than the healthcare sector (e.g. food supply, energy, information technology and communications, transportations) • Children and adolescents • Older adults

More interventions
• before the exposure to disease outbreak (e.g. pandemic preparedness interventions) • during the exposure: • more training programs to deal with negative effects of quarantine and other measures of containment • more trainings at peak of a pandemic (e.g. acute pandemic wave) • after the exposure in order to mitigate potential long-term negative effects Only two of the eligible completed studies focused on computer-based or online and telephone interventions. Providing low-threshold interventions that are easy to implement during acute disease outbreaks and quarantine, this delivery format should be used more frequently in future studies. The findings of current registered trials to cope with the COVID-19 pandemic will provide important evidence regarding the efficacy of this delivery format to promote mental health and psychosocial support in highly contagious emerging disease outbreaks of substantial public concern.

Delivery of interventions
The overall quality of evidence found in this review was low with only two level-1 studies [22,32]. Due to weaknesses in study designs (e.g. no control groups), some positive results may only represent natural improvements over time rather than a response to the intervention [e.g. 31]. Therefore, controlled studies and RCTs are urgently needed. As long as no standards or clearly effective interventions are available, trainings should be contrasted with non-participation to allow fair comparisons, and more hard outcomes depending on the target group (e.g. absence from work, domestic violence, development of mental disorders, mortality) and extended follow-up assessments would be desirable. Because of the mix of interventions and training methods in the included studies, the "effective component" cannot be identified [31], making dismantling designs for future studies beneficial. Nevertheless, non-RCTs and other study designs can provide key lessons of relevance for the current COVID-19 outbreak as well as future disease outbreaks (see Tables 2 and 3).
As we performed this scoping review to respond to the needs of decision makers during the current coronavirus pandemic timely, the review has limitations: the protocol was only registered at OSF in parallel, and potentially relevant trial registers and grey literature were not explored. Based on the limited evidence base, we are not able to make reliable conclusions concerning the efficacy of recommended targets in Tables 2 and 3. Limitations of the reviewed studies often include small samples sizes, few RCTs, and short follow-ups. Some interventions were not provided within the peak of a pandemic [e.g. 39,41] but when the risk and thus psychosocial stressors had started to decrease, potentially leading to natural improvements of psychological outcomes. Conclusions made for a particular sample or disease outbreak might not apply to other target groups or disease outbreaks, and heterogeneity renders comparisons between studies difficult. Strengths of this scoping review include the hand-searching of reference lists, contacting study authors to ask for unavailable full-texts, and the inclusion of various study designs to provide the full picture of the current evidence.

Conclusions
To our knowledge, this scoping review is the first to systematically identify and summarize the available literature on psychological interventions to foster adjustment and/or to promote mental health and psychosocial support in individuals (possibly) exposed to outbreaks of highly contagious emerging infectious diseases. Although the quality of evidence is limited due to the small number of studies and their methodological limitations, the reviewed literature reports beneficial effects for mental health and resilience factors in various target groups, with overall positive qualitative feedback from participants and intervention providers. There is an urgent need for better-designed studies, pandemic preparedness interventions, focus on specific target groups (e.g. children, specific system-relevant professions), and low-threshold and easy-access (e.g. online) interventions to address large population groups. Given the psychological burden caused by disease outbreaks and associated changes like quarantine, more research is required to inform practice and policy in order to improve mental health and psychosocial support before, during, and after outbreaks. The findings may serve as a guide for researchers and policy makers during the current COVID-19 pandemic and future highly contagious disease outbreaks in order to plan and conduct interventions and to establish pandemic preparedness plans.
Supporting information S1 Appendix. Search strategies. Search strategies in three electronic databases. (PDF) S1 Table. Eligibility criteria. Detailed eligibility criteria of the systematic scoping review. (PDF) S2 Table. PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist. (PDF)