Novel influenza A (H1N1) advanced and receded in the United States this
past spring, but no one in the public health community expects it to stay
away. Whether the flu formerly known as swine will return this fall and winter
as a mild breeze or a storm of infection is unknown at press time.
Flu is usually not the concern of psychiatrists (unless they catch it
themselves), but some aspects of last spring's mini-pandemic have raised some
concerns in the disaster mental health community.
These include not only neuropsychiatric effects of the disease or the
medications used to treat it, but the community mental health issues that
follow any major disaster (see Flu Outbreak Could Lead to Community Stress).
According to the Centers for Disease Control and Prevention (CDC),"
seizures, encephalitis, encephalopathy, Reye's syndrome, and other
neurologic disorders" and "acute cognitive and behavioral
problems" have been seen in children with seasonal flu. In July the
agency reported on four cases in Dallas of neurologic complications in
children and adolescents with confirmed H1N1 flu. Those patients represented
about 1 percent of the H1N1 cases seen at the hospitals reporting. At various
times, one or more of these patients had seizures, were confused, and had
difficulty responding to questions. All were hospitalized, treated, and
released without long-term mental complications.
"Clinicians should consider influenza-associated encephalopathy in
the differential diagnosis of children with [influenza-like illness] and
seizures or mental status changes," wrote the CDC in the July 24 issue
of Morbidity and Mortality Weekly Report. Such symptoms are
manageable in normal caseloads but would presumably appear in greater absolute
numbers if tens of thousands of people came down with the flu in one city.
Treatment represents another potential area of concern. The CDC recommends
two neuraminidase inhibitors for the antiviral treatment and prophylaxis of
H1N1 influenza: zanamivir (Relenza) and oseltamivir (Tamiflu). Recent
prophylactic trials in Britain of the latter produced reports of side effects
in 21 percent to 33 percent of participants, mostly gastrointestinal or
headache, but the small number of participants and methodological problems
limit the trials' usefulness.
Occasional reports of "bizarre behavior" after taking these
drugs exist, but those effects may be attributable to the illness as much as
to the medication. Early reports from Japan of increased suicides among young
people taking oseltamivir were not confirmed after an FDA review, which said
the events may have been related to high levels of flu-induced encephalitis
there. A report last April from the drug's manufacturer (Hoffmann-La Roche)
said "no increase in the incidence of claims-based neuropsychiatric
events was detected" in users of the drug compared with those not taking
Nonpharmaceutical interventions could play a role in holding down infection
rates but might produce their own problems. "Social
distancing"—closing schools and businesses, staying home from work
when sick, and canceling concerts, sports events, and church
services—has proven effective in past epidemics but might be hard to
continue for more than short stretches of time.
"[M]aintaining the strict confinement of children during a pandemic
would raise significant problems for many families and may cause psychosocial
stress to children and adolescents," says the U.S. government flu Web
site. "These considerations must be weighed against the severity of a
given pandemic virus to the community at large and to children in
In the worst case, if schools and child care centers were closed, workplace
absenteeism could rise and incomes fall as parents stayed home to look after
their children. Economic disruption could become severe. Families with members
infected with the flu might be shunned by neighbors. Combined with high
mortality rates, all of this would inevitably raise stress levels, or worse,
as often occurs after floods and earthquakes.
Another problem might not show up for decades.
Last spring, pregnant women appeared to be at higher risk for severe
complications of H1N1 flu, including death, so the CDC placed them at the top
of its vaccine priority list.
Research looking at health records from the 1950s and 1960s has found that
influenza infection in pregnant women is associated with increased risk of
schizophrenia in their offspring. The spring 2009 outbreak struck people under
the age of 25 twice as frequently as older people, reversing the seasonal flu
pattern and making women of child-bearing age more vulnerable.
The H1N1 virus has some elements in its viral coat similar to that of
strains circulating half a century ago, said Alan Brown of Columbia
University, who has studied this question extensively. However, its viral
makeup may not make much difference.
"Based on our data, the effect on the risk of schizophrenia is
probably due not to the flu itself but to immune response, especially the
cytokine response produced by activated T-cells," said Brown in an
interview. "Infection is associated with a huge cytokine
Would the immune response generated by a flu vaccine cause the same
"The evidence is that the cytokine response to the flu shot is far
less than that from infection," said Brown. "Influenza is a
greater danger when weighing the risks against the benefits."
Brown would like to see the CDC extend its vaccine recommendation to all
women of childbearing age.
However, much uncertainty remains because no one has studied the effects of
flu vaccine on birth outcome to see the effects of the cytokine response on
the fetus, he said.
Finally, a major outbreak might also place enormous strain on health care
workers and first responders, if the outbreak of severe acute respiratory
syndrome (SARS) in Toronto in 2003 offers any lesson.
There, the mysteries accompanying an unknown pathogen and route of
transmission, along with a high fatality rate, raised stress levels in
hospital employees, reported Robert Maunder, M.D., an associate professor of
psychiatry at the Mount Sinai Hospital in Toronto, in 2004 in the
Philosophical Transactions of the Royal Society of London (B).
"[T]he SARS outbreak turned the modern world of health care on its
head in Toronto, in the sense that health care workers were seen as victims
and vectors of disease rather than healers, and hospitals were seen as
contaminated areas rather than places fostering health," wrote
Besides worrying about infection risk to themselves, their families, and
coworkers, health workers had to deal with the isolation enforced by
quarantine procedures. Access to hospitals was restricted, handshaking was
forbidden, and protective gear made everyone anonymous without repeated
introductions. Staff who followed orders and avoided colleagues reported
greater stress, according to a post-outbreak survey. Collectively, this social
isolation took its toll on workers, said Maunder.
Novel influenza A (H1N1) may return as a modest surge in the winter's usual
flu cases or it may roar back like wildfire across a dry prairie, but anyone
involved in caring for patients must be prepared for any of its
More information is posted at the CDC's flu Web site at<www.flu.gov/plan/community/commitigation.html#I>.▪