key: cord-1019480-5520ckdr
authors: Maalouf, Fadi T.; Medawar, Bernadette; Meho, Lokman I.; Akl, Elie A.
title: Mental health research in response to the COVID-19, Ebola, and H1N1, outbreaks: a comparative bibliometric analysis
date: 2020-10-28
journal: J Psychiatr Res
DOI: 10.1016/j.jpsychires.2020.10.018
sha: 9ee29a6710abb90c0072d1a7d3d16d66df6a1768
doc_id: 1019480
cord_uid: 5520ckdr

INTRODUCTION: Both the COVID-19 pandemic and its management have had a negative impact on mental health worldwide. There is a growing body of research on mental health as it relates to the pandemic. The objective of this study is to use bibliometric analyses to assess the mental health research output related to the COVID-19 pandemic and compare it to that of the West Africa Ebola and H1N1 outbreaks. METHODOLOGY: We performed comprehensive searches in Embase, PubMed, and Scopus databases, and included all types of documents related to the three outbreaks published since the respective beginnings up to August 26, 2020. RESULTS: Despite the shorter time since the beginning of the COVID-19 pandemic, relative to Ebola and H1N1, we found a much greater number of mental health documents related to COVID-19 (n=3,070) compared to the two other outbreaks (127 for Ebola and 327 for H1N1). The proportion of documents in the top 10% journals was 31% for COVID-19, 24% for Ebola, and 40% for H1N1. Authors affiliated with institutions located in high-income countries published or contributed to 79% of all documents followed by authors from upper-middle-income countries (23%), lower-middle-income countries (10%), and low-income countries (2%). Approximately 19% of the documents reported receiving funding and 23% were the product of international collaboration. CONCLUSION: Mental health research output is already greater for COVID-19 compared to Ebola and H1N1 combined. A minority of documents reported funding, was the product of international collaboration, or was published by authors located in low-income countries during the three outbreaks in general, and the COVID-19 pandemic in particular.

After the emergence of pneumonia of unknown causes in late 2019 in Wuhan, China, a new coronavirus, SARS-COV2, was identified. On March 11, 2020, the World Health Organization (WHO) announced alarming concerns regarding the new virus and characterized it as the COVID-19 pandemic (Neilson, Woodward, Mosher, 2020; WHO, 2020c) .

As of August 26, 2020, 216 countries, areas, or territories were swept by the pandemic, 23,752,965 people have been infected, and 815,038 died as a result of the virus (WHO) (WHO, 2020a) . The death rate reached 15% in some countries (Worldmeter, 2020b) .

Distribution of confirmed cases varies by continent and countries, but the bulk extends over the Americas and Asia, with 13,885,026 and 7,365,080 infected individuals, respectively (Worldmeter, 2020d) . According to the Scopus database, on August 26, 2020, there were over 43,000 articles, letters, editorials, notes, reviews, and case reports published on COVID-19 and, per PubMed, thousands more were accepted for publication.

The impact of the COVID-19 pandemic on mental health has been of immense interest to international health organizations (WHO, 2020b), national health agencies (CDC, 2020) , and psychiatric and other mental health researchers. Recently published studies reported an increasing rate of psychological distress, traumatization, and suicide in relation to COVID-19 (Reger et al., 2020) . For example, in an online survey in China, 29% of respondents reported moderate to severe anxiety symptoms, while 17% reported depressive symptoms .

Research has also found a negative impact of COVID-19 public health interventions on mental health. For example, the strictly implemented measures of social distancing led to various negative psychological consequences associated with a prolonged quarantine duration, fear of catching the infection, disturbed routine, and lack of adequate supplies and J o u r n a l P r e -p r o o f information about the virus (Brooks et al., 2020) . The post-pandemic phase is even more unsettling due to the increasing rates of post-traumatic stress disorder (PTSD) and other mental health sequelae (Dutheil et al., 2020) .

Mental health researchers have also been interested in the impact of other infectious disease outbreaks on mental health and the mental health response to those outbreaks. Two prominent examples are the H1N1 influenza outbreak in 2009 and the Ebola virus disease (EVD) outbreak in 2014. For example, one study reported on fear and anxiety as common reactions during the H1N1 pandemic (Taha et al., 2014) and another study related to EVD reported that the burden of the disease on mental health continued to linger in the aftermath (Reardon, 2015) . Interestingly, while a high level of H1N1-related anxiety was associated with compliance to preventive measures (Bults et al., 2011) , fear of exposure or stigmatization during the EVD epidemic prevented individuals from seeking help and thus hastened viral transmission (O'Leary et al., 2018) .

COVID-19, H1N1, and EVD vary in their epidemiological characteristics and general prevalence of associated mental distress and disorders. We have summarized these differences in Table 1 . (Lau et al., 2010) Depression 12 -75 %, Anxiety 27.5 -83.3 %, PTSD 40% (Cénat et al., 2020) Depression 17%,-28%, Anxiety 21 -32 %, Insomnia 7 -24% (Rossi et al., 2020; Shi et al., 2020) J o u r n a l P r e -p r o o f Before the COVID-19 outbreak, humanity faced two other coronavirus epidemics; namely, SARS in 2002 and MERS in 2012. Out of the five outbreaks that occurred during the past two decades, COVID-19, EVD, and H1N1 have infected more people worldwide as compared to SARS and MERS which were associated with elevated case fatality rates of 11% and 35%, respectively (Sarukhan, 2016) .

The current study focuses on the most recent coronavirus outbreak (i.e., COVID-19), and EVD and H1N1. Our objective is to use bibliometric analyses to assess the mental health research output related to the COVID-19 pandemic and compare it to that of EVD and H1N1 outbreaks. We specifically aimed to identify the publications' numbers, types, venues, origins, levels of funding, and levels of collaboration.

We used Embase, PubMed, and Scopus databases to identify relevant documents. 

To be as inclusive as possible, we carried out comprehensive searches for documents that included in the title, abstract, or keywords fields both terms and phrases related to 

For each of the three infectious diseases, we extracted the following data:

1-Number of documents by disease; 2-Number of documents published in Open Access format, as a measure of accessibility;

3-Number of documents by country, based on affiliation information provided for each document. We gave equal full credit for each country represented in each document.

We also specified the number of documents by country for each outbreak alone as well as the total number of documents by country for the three outbreaks together; 4-Number of documents by countries' income. We categorized countries into four groups according to the World Bank classification: high-income countries, upper-middle-income countries, lower-middle-income countries, and low-income countries. We then calculated for each outbreak, the total number of documents in each of the four income categories;

5-Proportion of documents in high impact journals, defined as the top 10% journals in their respective fields per Scopus's CiteScore; J o u r n a l P r e -p r o o f 6-Proportion of documents with authors from more than one country, as a measure of international collaboration; and 7-Percentage of documents receiving internal or external funding as recorded by the Scopus database.

We exported the data and analyzed them using Microsoft Excel and Access 2016. We analyzed all indicators using frequency analysis and cross-tabulations where necessary. We compared findings for the three outbreaks, then compared them by country income level and funding, and finally assessed the patterns of collaboration between countries. The assessment of international collaboration included the proportion of documents with authors from more than one country and social network analyses using the VOSviewer software. Where necessary, we supported our claims by comparing results of outbreakrelated mental health research against those of the larger fields of "psychiatry and mental health" and "medicine" as defined by Scopus. In Scopus, the field of "psychiatry and mental health" is composed of 501 active journals and "medicine" of 6,452 such journals.

The number of documents published on mental health aspects of the three outbreaks was as follows: 3,070 on COVID-19 in less than a year since the first case was officially reported, 127 on West African Ebola since late 2013, and 327 documents on H1N1 since 2009. When examining research productivity by country ( Leone, Liberia, and Uganda and no LMIC country is among the topmost published on any outbreak (see Table 2 ).

We should emphasize here that about 12% of the total publication on the mental health aspects of COVID-19 were about health care workers as compared to 25% of the EVD publications and 2% of publications on H1N1 (see Figure 1 ). The proportion of outbreak-related mental health documents published in the top 10% journals per Scopus's CiteScore was 31% for COVID-19, 24% for EVD, and 40% for H1N1. These percentages for outbreak-related mental health were, in the cases of COVID-19 and H1N1, considerably higher than the percentages for "psychiatry and mental health" and "medicine" overall research fields (see Table 3 ). Concerning research accessibility, the proportion of outbreak-related mental health documents published in Open Access format was 81% for COVID-19, 57% for Ebola, and 32% for H1N1. These percentages for outbreak-related mental health were remarkably larger than the proportions for psychiatry, mental health, and medicine research fields in general (see Table 4 ). Source: Scopus (August 2020).

As shown in Table 5 , of all published documents, the proportion of outbreak-related mental health documents reporting funding was 18% for COVID-19, 20% for EVD, and 22%

for H1N1. During COVID-19 particularly, the percentage of funded "outbreak-related mental J o u r n a l P r e -p r o o f health research" was remarkably lower than the funding received for "psychiatry and mental health" research (35%) and "medicine" research (32%). 

In terms of the proportion of documents with authors from more than one country, 23% of mental health research related to all three diseases had multinational co-authorship.

While 41% of EVD mental health publications were the product of international collaboration, only 22% of the total COVID-19 mental health research and 24% H1N1 mental health-related publications resulted from such collaboration. The bibliometric approach used in the current study is comprehensive as we included all types of documents available in any language from three distinct, comprehensive databases: Embase, PubMed, and Scopus. Additionally, the choice of phrases and terms related to mental health and each of the outbreaks was exhaustive.

Unlike prior analyses of the scientific literature on coronaviruses, ours did not limit to records in English Nowakowska et al., 2020; Tao et al., 2020; Zhai et al., 2020) or English and Chinese only (Yu et al., 2020) . We additionally extracted records from more than two databases (Haghani et al., 2020; Liu et al., 2020) and included editorials, commentaries, letters, case reports, news, and narrative reviews Yu et al., 2020) . In addition to looking at the number and countries of origin of publications, we also examined indicators related to international collaboration, funding, and research quality. , namely, the trend in mental health research, and compared the findings with two prior distinct viral outbreaks.

Our study, however, has a couple of limitations. Although we tried to be as inclusive as possible using three different databases, there may be publications that are not captured by Embase, PubMed, and Scopus. Also, since the COVID-19 pandemic is still evolving, our results do not represent the complete course of the fast-growing literature of the current pandemic.

It was not surprising that the number of publications on COVID-19 related mental health publications was much higher than that of the other two outbreaks combined. These results are explained by the relative magnitude of the different outbreaks. For example, the death toll registered for COVID-19 during the first six months of the outbreak exceeded the total deaths during the first two years of the EVD epidemic and is close to the estimated death toll during 18 months of the H1N1 pandemic (CDC, , 2010 (CDC, , 2019a (CDC, , 2019b Worldmeter, 2020c) . Furthermore, unlike the more localized EVD epidemic (CDC, 2019b), the transcontinental spread of the current COVID-19 pandemic (Worldmeter, 2020b) , although similar in its geographical distribution to the H1N1 pandemic (CDC, 2010), has precipitated an unusual global economic, social, and geopolitical crises (Nicola et al., 2020) .

These have resulted in mental health distress among the general public (Alradhawi et al., 2020) . The proportion of publications about health care workers was higher for EVD as compared to the other two outbreaks. This may be due to the high fatality rate of EVD and the stigma associated with it as compared to COVID-19 which puts health care workers at higher risk for mental health disorders (Cénat et al., 2020; Rossi et al., 2020; Shi et al., 2020) .

We also found a gradual increase in Open Access publications in mental health research during infectious outbreaks from 32% during H1N1 up to 81% during the COVID-19

pandemic. Although a similar trend was observed for publications in medicine and mental health in general, the proportion of Open Access publications in mental health aspects of COVID-19 was double that observed for mental health in general (Piwowar et al., 2018) .

Besides seeking higher citations associated with Open Access articles (Piwowar et al., 2018) , researchers likely aimed at making their research results as widely accessible as possible during outbreaks in general and COVID-19 pandemic in particular (Eysenbach, 2006 This is also in-line with our findings that only a small minority (12%) of research about mental health in any of the three outbreaks included authors from low and low-middleincome countries. Indeed, it has been previously reported that only 6% of the mental health literature is published from regions of the world that account for over 90% of the global population (Helal et al., 2011; Patel and Kim, 2007; Zeinoun et al., 2020) . Acceptance bias, low submission rate, and low quality of submitted research are likely reasons for these geographical disparities (Patel and Sumathipala, 2001) .

The proportion of publications on mental health-related to the outbreaks that reported receiving funding was lower than the proportion of publications on general mental health that reported receiving funding. This difference may be because, amid an outbreak, investigators do not have time to seek funding and seem to prioritize getting much-needed J o u r n a l P r e -p r o o f evidence out to the scientific community over waiting for projects to get funded. In addition, in many parts of the world, mental health is still not a research priority for major funding agencies (Maalouf et al., 2019) . Interestingly, however, despite receiving less funding, the proportion of publications on mental health aspects of the outbreaks published in the top 10% journals was remarkably higher than that of medicine and mental health overall.

Despite the time lag between the first studies on all three outbreaks in general and the first studies on mental health aspects of the outbreaks in particular, research output in the latter area follows an upward trend similar to that of other research areas. Indeed, previous bibliometric analyses found increased output in microbiological, epidemiological, and clinical research of coronaviruses that peaked one to two years following SARS and MERS outbreaks (Haghani et al., 2020; Nowakowska et al., 2020; Tao et al., 2020) . The gradual increase in mental health research over time is important for all pandemics, particularly COVID-19, given the dire need for generating evidence to guide best practices.

The impact of the COVID-19 pandemic extends beyond infected individuals and healthcare workers. While quarantine is a common denominator for all infectious outbreaks (Tognotti, 2013) , widespread lockdown and social distancing were essential public health tools used in the COVID 19 pandemic (News, 2020) . On the one hand, strict lockdown measures increased worries about physical health, anger, impulsivity, suicidal ideations as well as symptoms of anxiety, depression, insomnia, and PTSD among mentally ill patients.

On the other hand, access to direct emergency and outpatient psychiatric care was reduced (Hao et al., 2020) . Consequently, mental health practitioners and policymakers called for J o u r n a l P r e -p r o o f research on regulations and implementations of alternative clinical interventions, such as telepsychiatry (Kannarkat et al., 2020; Shore et al., 2020) .

This is the first bibliometric analysis of mental health research comparing research aspects of the three infectious disease outbreaks that took place over the last decade or so, namely H1N1, Ebola, and COVID-19. The analysis shows rapid exponential growth in the number of mental health research during outbreaks. Our study also highlights the paucity of funding, collaboration, and contribution of LIC to mental health research during all outbreaks in general but more importantly during the current COVID-19 pandemic. Albeit the increased awareness of the short-and long-term psychological impacts of infectious outbreaks that lead to better representation of mental health research in the top 10% journals, efforts need to be aggregated to fill the prevailing gaps in mental health research.

Anticipating a mental health pandemic, experts have called for action for mental health research (Hoffmann, 2020) . That research should prioritize key questions, produce highquality studies, and involve international multidisciplinary collaboration (Holmes et al., 2020) . The results of this study could help experts set a roadmap for future COVID-19 related mental health research and contribute to the international response to the current pandemic.

J o u r n a l P r e -p r o o f

Effects of the COVID-19 pandemic on mental wellbeing amongst individuals in society-A letter to the editor on "The socio-economic implications of the coronavirus and COVID-19 pandemic: A review

SARS-CoV, MERS-CoV and now the 2019-novel CoV: Have we investigated enough about coronaviruses? -A bibliometric analysis

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

Perceived risk, anxiety, and behavioural responses of the general public during the early phase of the Influenza A (H1N1) pandemic in the Netherlands: results of three consecutive online surveys

H1N1 Early Outbreak and Disease Characteristics

H1N1: Overview of a Pandemic impact of

H1N1 pandemic (H1N1 pdm09 virus

Ebola Outbreak in West Africa

CDC, 2020. Coronavirus Disease 2019 (COVID19) Stress and Coping

Prevalence of mental health problems in populations affected by the Ebola virus disease: A systematic review and meta-analysis

Coronavirus Disease (COVID-19): A Machine Learning Bibliometric Analysis

PTSD as the second tsunami of the SARS-Cov2 pandemic

R0: How Scientists Quantify the Intensity of an Outbreak Like Coronavirus and Its Pandemic Potential

The scientific literature on Coronaviruses, COVID-19 and its associated safety-related research dimensions: A scientometric analysis and scoping review

Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry

The representation of low-and middle-income countries in the psychiatric research literature

Covid-19: Be Ready for The Coming Mental Health Pandemic

Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

Mobilization of Telepsychiatry in Response to COVID-19-Moving Toward 21(st) Century Access to Care

Avoidance behaviors and negative psychological responses in the general population in the initial stage of the H1N1 pandemic in Hong Kong

Coronavirus disease 2019 (COVID-19): an evidence map of medical literature

Mental health research in the Arab region: challenges and call for action

Coronavirus: The world in lockdown in maps and charts

A comprehensive timeline of the coronavirus pandemic at 9 months, from China's first case to the present

The Socio-Economic Implications of the Coronavirus and COVID-19 Pandemic: A Review

When science goes viral: The research response during three months of the COVID-19 outbreak

Fear and culture: contextualising mental health impact of the 2014-2016 Ebola epidemic in West Africa

Contribution of low-and middle-income countries to research published in leading general psychiatry journals

International representation in psychiatric literature: survey of six leading journals

The state of OA: a large-scale analysis of the prevalence and impact of Open Access articles

Ebola's mental-health wounds linger in Africa

Suicide Mortality and Coronavirus Disease 2019-A Perfect Storm

COVID-19 Pandemic and Lockdown Measures Impact on Mental Health Among the General Population in Italy

Ebola: Two Years and 11,300 Deaths Later. Global Health Lessons From an Epidemic

Prevalence of and Risk Factors Associated With Mental Health Symptoms Among the General

Telepsychiatry and the Coronavirus Disease 2019 Pandemic-Current and Future Outcomes of the Rapid Virtualization of Psychiatric Care

Intolerance of uncertainty, appraisals, coping, and anxiety: The case of the 2009 H1N1 pandemic

COVID-19 will stimulate a new coronavirus research breakthrough: a 20-year bibliometric analysis

Lessons from the history of quarantine, from plague to influenza A

Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China

Emergencies preparedness, response: Pandemic (H1N1)

Coronavirus disease (COVID-19) pandemic

Mental health and psychosocial considerations during the COVID-19 outbreak

WHO, 2020c. WHO timeline -COVID-19

Estimating mortality from COVID-19

worldmeter, 2020a. Coronavirus Incubation Period

Countries where COVID-19 has spread

COVID-19 situation update worldwide, as of 4

Assessment of the quality of systematic reviews on COVID-19: A comparative study of previous coronavirus outbreaks

The Arab Region's Contribution to Global Mental Health Research (2009-2018): A Bibliometric Analysis

Research Progress of Coronavirus Based on Bibliometric Analysis

Mental Health'/exp/mj OR 'Mental Health Care'/exp/mj OR 'Mental Health Service'/exp/mj OR 'Mental Disease'/exp/mj OR 'Mental Health':ti,ab,kw OR 'Mental Disease*':ti,ab,kw OR 'Mental Disorder*':ti,ab,kw) AND: 1. ('2009 H1N1 Influenza'/exp OR 'Influenza A (H1N1)'/exp OR H1N1*:ti,kw OR 'Novel Influenza Virus*':ti,kw OR 'Pandemic Influenza':ti,kw OR

Ebola Hemorrhagic Fever'/exp/mj OR 'Ebolavirus'/exp/mj OR Ebola*:ti,ab,kw)

OR 'coronavirus disease-19' OR 'coronavirus-2019' OR 'covid19' OR 'covid-19' OR 'ncov2019' OR 'ncov-2019' OR 'novel coronavirus 2019' OR 'sars coronavirus 2'/exp OR 'sars coronavirus 2' OR 'sars-cov2' OR 'sars-cov-2' OR 'severe acute respiratory syndrome coronavirus 2'/exp OR 'severe acute respiratory syndrome coronavirus 2') OR (((coronavirus:ti OR 'corona virus':ti OR COVID*:ti,ab,kw OR (Wuhan:ti,ab,kw AND Coronavirus:ti,ab,kw) OR (Hubei:ti,ab,kw AND Coronavirus:ti,ab,kw)) NOT (229e*:ti OR 'avian coronavirus':ti OR bovine:ti OR 'bovine coronavirus':ti,ab,kw OR calves:ti,ab,kw OR camel*:ti OR 'canine coronavirus':ti OR Covidence:ti,ab,kw OR Covidien*:ti,ab,kw OR 'feline coronavirus':ti OR 'feline enteric coronavirus':ti OR 'hcov-229e':ti OR 'infectious bronchitis':ti OR 'mouse coronavirus':ti OR 'murine coronavirus':ti OR 'murine hepatitis virus':ti,ab,kw OR nl63:ti OR oc43:ti OR porcine:ti OR sads*:ti,ab,kw OR swine:ti OR 'turkey coronavirus':ti,ab,kw)) AND [2020-2030]/py)) NOT ispor:nc PUBMED (Mental Health[MeSH Major Topic] OR Mental Health Services

2019-Coronavirus" OR "2019-CoV" OR "2019-nCoV" OR "2019-New Coronavirus" OR "2019-Novel Coronavirus" OR "Corona Virus Disease-2019

Clinical Psychology" in the database, research and COVID-19, Ebola, and H1N1 26 and all documents that included in their titles keywords related to "Mental Disorders" and "Mental Health" regardless of the subject categories of journals in which they were published (34)) AND: 1. TITLE-ABS(H1N1*) OR AUTHKEY(H1N1) 2

Avian Coronavirus" OR Bovine OR Camel* OR "Canine Coronavirus" OR "Feline Coronavirus" OR "Feline Enteric Coronavirus" OR "HCoV-229E" OR "Infectious Bronchitis" OR "Murine Coronavirus" OR NL63 OR OC43 OR Porcine OR Swine) OR TITLE-ABS-KEY("Bovine Coronavirus" OR Calves OR Covidence OR Covidien* OR "Murine Hepatitis Virus

The authors declare no conflict of interest.J o u r n a l P r e -p r o o f