We thank Drs Orlu & Olumoroti for their kind and thoughtful response to our paper on ‘Psychological distress after the Great East Japan Earthquake’.^{Reference Goodwin, Sugiyama, Sun, Aida and Ben-Ezra1} We agree that a focus on the psychological sequela of major societal stressors is a timely subject for study for psychiatrists, particularly given the mental health burden already evident as a consequence of coronavirus disease 2019 (COVID-19). Indeed, this novel coronavirus might be expected to place particular burdens on a wide range of the populace, worldwide. The data seems to support this. While in our study of the 2011 Japanese earthquake 10.2% of Miyagi refugees reported risk of severe mental illness (SMI) later during that year, data from COVID-19 suggests higher prevalence of SMI. Using the same measure and cut-off for psychological distress (the Kessler K6) national online surveys during March 2020 found 19.1% of Chinese at risk of SMI.^{Reference Ben-Ezra, Hou, Sun and Goodwin2} In April 2020 13.6% of US adults reported SMI, compared with 3.9% during 2018.^{Reference McGinty, Presskreischer, Han and Barry3} Using a national UK longitudinal survey and the General Health Questionnaire, the number of adults experiencing mental health problems (indicated by the 12-item General Health Questionnaire ≥ 3) rose from 23.4% (2017–2019) to 37.1% (April 2020).^{Reference Daly, Sutin and Robinson4}

The main reason for this may be that COVID-19 is no ‘normal’ disaster. Unlike other novel zoonoses (such as the 2009 AH1N1 ‘swine flu’) there can be a prolonged period of symptomatic or pre-symptomatic transmission, an ambiguity that can rapidly lead to the blame and stigmatisation described by Drs Orlu & Olumoroti. More than 12 months after the first case, exact transmission pathways are still unclear (viz: the current debate over aerosolisation), creating further uncertainty over effective preventive measures (for example ‘safe’ physical distancing, a requirement for masks with particular designs). There remains an additional risk that this coronavirus may continue to further mutate, potentially undermining vaccine efficacy. Subsequent risks cannot be readily limited to one exclusion zone (as, for example, is the case after a nuclear accident). COVID-19 infection (and subsequent mortality and morbidity) may well be seasonal and occurs in waves, with the novel challenge of national and local lockdowns that are released then re-imposed, making it difficult for both individuals and communities to plan their activities. Indeed, this changing landscape can seriously disrupt regular daily routines, incurring a further burden on mental health.^{Reference Hou, Lai, Ben-Ezra and Goodwin5}

Following major disasters only around a tenth of effected populations are chronically distressed.^{Reference Galatzer-Levy, Huang and Bonanno6} Even for those who are initially distressed psychological health returns to pre-disaster levels within a relatively short period. Yet, unlike an earthquake or terror attack, COVID-19 threatens to pose a particularly sustained threat, with enduring health and economic consequences. During ‘usual’ disasters particular groups are especially vulnerable (such as women, the unemployed, those with pre-existing psychological disorders, those who have to relocate). With COVID-19 it is the young that seem particularly at risk of mental illness,^{Reference Daly, Sutin and Robinson4} as well as those who have to spend time in isolation/quarantine.^{Reference Ben-Ezra, Hou, Sun and Goodwin2} Practitioners may need to be particularly mindful of their particular needs as the pandemic unfolds.