Stating what was then known of the spread of the SARS-CoV-2 virus in relation to the 2020-2023 COVID-19 pandemic, an article published in Nature on 29 January 2021 [1] indicated that transmission was through airborne aerosolized droplets directly inhaled by contacts [2]. This was in contrast to earlier modeling and epidemiological observations that had implicated the spread of the virus through large respiratory droplets settled on surfaces and transferred to contacts' mucosal membranes (fomite transmission) [3]. Although there is evidence that the COVID-19 virus persists on certain surfaces for up to 72 hours [4], according to the Nature article, this viral RNA “is the equivalent of the corpse of the virus—It’s not infectious.” Furthermore, the article also stressed, “Fomite transmission is possible, but it just seems to be rare” [1].

The initial predictions regarding how the COVID-19 virus was spread were based on expectations comparing its transmission to that of other common respiratory viruses [3]. However, each virus type has a different interaction mechanism with fomites, and this is affected by several variables [5]. Continuing research reinforced the rarity of fomite transmission regarding COVID-19 [6-9], recognizing that fomite transmission was still possible in the spread of the COVID-19 virus [1].

Yet, the problem remained that cleansing surfaces and hands to control COVID-19 was stressed in a manner equivalent to improving ventilation [10]—although, in reducing aerosolized droplets, enhancing ventilation was the superior method to cleansing in controlling the spread of the virus [11]. Nevertheless, the call from the World Health Organization (WHO) for frequent and better handwashing along with other cleansing was maintained as an excellent method to reduce the incidence of COVID-19 [12].

Handwashing has been demonstrated to be potent in killing viruses if properly completed [13]. For this reason, handwashing is an easy precaution to take and might be effective [14]. What has not been taken into consideration by authorities who have continued their support of persistent handwashing among the measures to reduce the spread of the virus is those who obsess regarding handwashing, diagnosed with Obsessive-Compulsive Disorder (OCD), and those who became newly diagnosed as a result of this health directive—producing negative mental health in those affected [15].

OCD is defined by the American Psychiatric Association as patterns of unwanted and intrusive thoughts, images, or urges and repetitive behaviors that are intended to decrease the resulting distress from the compulsions [16]. OCD symptoms often include a fear of contamination which then triggers ritualized handwashing and other cleaning behaviors to neutralize the thought [14]. The widespread public health demands for increased and “proper” handwashing, cleaning, and use of disinfectants as a result COVID-19 may have been especially problematic for these patients with OCD, putting them at risk for developing excessive pandemic-related fears [17] leading to negative mental health.

This is the first paper to consider the role of handwashing alone in a limited review of both those previously diagnosed with OCD and those who developed OCD during COVID-19, with respect to the negative mental health they experienced as a result of the health directive to increase handwashing to protect against the transmission of the COVID-19 virus. As such, this paper aims to examine the extent of those with OCD whose mental health was negatively affected as a result of the directive to increase the amount they wash their hands during the COVID-19 pandemic.

The main conclusions are that the majority of those previously diagnosed with OCD before the pandemic—and all of those diagnosed during COVID-19—experienced negative mental health. Therefore, it is advised that information by health officials regarding the transmission of COVID-19 and future pandemic-related viruses be reconsidered as additional information becomes available regarding transmission.  Furthermore, also suggested is that this updated information include sufficient details concerning the type of handwashing required. In doing so, those susceptible to OCD are informed that it is unnecessary for them to increase their already thorough and persistent handwashing behavior in protecting themselves from COVID-19 and future pandemic virus transmission. The effect of doing so is anticipated to aid in maintaining their mental health. As OCD patients who demonstrated resilience—as well as a seemingly small percentage of those on stable medication—did not experience negative mental health, additional conclusions are that research investigate both (1) ways to teach resilience to those diagnosed with OCD to protect their mental health, and (2) the types of stable medication with the potential to support mental health regarding OCD during COVID-19, and future pandemics.

Study design

This examination is a limited review of a parameter with the following keywords, “handwashing, mental health, COVID-19, OCD.” The databases searched include OVID, PubMed, ProQuest, Scopus, Web of Science, and Google Scholar.

Searched records returned

In total, 2,467 individual records were returned from six different database searches of the keywords “handwashing, mental health, COVID-19, OCD.” The databases searched and the number of records returned were as follows: OVID (n = 4), PubMed (n = 4), ProQuest (n = 201), Scopus (n = 1), Web of Science (n = 7), and Google Scholar (n = 2250). There were no registers searched. Of these records, those removed included duplicates (n = 41), not in English (n = 0), not peer reviewed (n = 158), not published between 2020-2024 (n = 330), and missing one keyword per page in the Google Scholar search returns (n = 1580). Of the remainder, there were 358 records to be screened with none excluded for lacking COVID-19. Consequently, all 358 reports were sought for retrieval, and all were retrieved. The result was 358 reports to be assessed for eligibility. Excluded were those lacking: handwashing (n = 53), mental health (n = 7), and OCD (n = 6). Thus, 292 studies were included (see Figure 1).

Studies included

A total of 50 articles were investigated from all databases searched with 20 articles provided by the primary database searches, and 30 articles included from the Google Scholar search. The total number of reports included from each of the six databases is represented in Table 1.

Of the 50 articles included from all databases searched, 45 mentioned negative mental health. Of the 46 reports that concerned those diagnosed with OCD before the pandemic, 41 of them found negative mental health in those diagnosed. Of the 15 reports investigating OCD in those who developed symptoms during COVID-19, all 15 reported negative mental health in these individuals. In contrast, negative mental health was not found in only 5 of the 50 reports included. Of these, all 5 were identified with those who were diagnosed with OCD before COVID-19—0 for those diagnosed during the pandemic.

With the results of the 50 included reports, a table can be constructed indicating the articles that concern those diagnosed with OCD before COVID-19, those diagnosed during COVID-19, and whether, for either of these, their negative mental health was indicated. Table 2 represents this compilation. What is evident from the table is that although most articles (39 or 78%) focused on either those diagnosed with OCD before or after, there were 11 (22%) that concerned both [18-28]. Interesting to recognize is, of these 11 articles—where their authors looked at both those previously diagnosed with OCD and those whose OCD symptoms were newly identified during COVID-19—each of them considered that the directive by health authorities to increase handwashing had a detrimental effect on the mental health of those studied, producing negative mental health. Furthermore, of the studies that concerned only those with new symptoms of OCD during COVID-19 brought on by increased handwashing, all also found negative mental health [29-32] (4 or 8%). Therefore, the only articles that did not detect negative mental health were some that investigated those diagnosed with OCD before the pandemic. There were 34 articles that discussed only those previously diagnosed with OCD. Of these, 5 or 14.7% of them [33-37] stated that there was no negative mental health in those diagnosed with OCD, equaling 10% of the total articles.

The vast majority of the included reports found negative mental health in those previously diagnosed with OCD. If the report investigated only those who developed symptoms during COVID-19—or both groups—then the view was unanimous that the health directive to increase handwashing during COVID-19 exacerbated negative mental health. Consequently, it is pertinent to discuss in detail those five articles that found there to be no negative mental health in those already displaying OCD symptoms before COVID-19, concerning the directive to increase handwashing. The articles to be discussed include: “Resilience Predicts Positive Mental Health Outcomes” [33], “Contamination Compulsions” [34], “Impact of COVID-19” [35], “Experiences of Mental Distress during COVID-19” [36], and “Impact of the COVID-19 Pandemic” [37]. The purpose of this discussion will be to determine why the authors of these papers judged that there was no negative mental health and if this judgment can be considered to be based on the evidence presented in the studies performed for these reports.

Five articles not finding negative mental health in those diagnosed with OCD

Presented here will be the five articles that did not find negative mental health in those who had been diagnosed with OCD pre-COVID-19 of the articles included in this review.

Article 1. “Resilience Predicts Positive Mental Health Outcomes” [33] is the first of the five articles of those already diagnosed with OCD before the pandemic that did not find negative mental health in response to the health directive to increase handwashing. The reason for this finding among these New York City psychiatric patients is that some patients demonstrated resilience with respect to their OCD symptoms. For those who were resilient, these authors found that there was no resulting negative mental health. That said, the authors also point out that, “less resilience was associated with worsening obsessive-compulsive symptoms.” In effect, it was not that this study did not find negative mental health in those already diagnosed with OCD during COVID-19. It was only for those with OCD who were resilient that there was no negative mental health. Why these authors concentrated on the resilience demonstrated by only some of those with OCD seems to be that their original hypothesis was that all those with OCD would suffer from negative mental health. They were then surprised to find that not all those with OCD had negative mental health in response to the handwashing directive.

The authors speculated that the reasons for some expressing high resilience could be (1) those affected used the pandemic as motivation to confront their OCD symptoms, (2) lockdowns may have permitted those with OCD to avoid situations that would otherwise exacerbate their symptoms, and (3) those with higher resilience were better able to manage their symptoms and persist with treatment regardless of the pandemic. The quantitative data that were gathered seemed to support both the first two possibilities. Yet, there were few of those with OCD studied for this report who fit into this category of resilience. As such, the conclusion of the authors that negative mental health was not found oversteps the information provided throughout the majority of the article. Most likely the authors directed their attention to those demonstrating resilience because, as they note, resilience can be taught. However, that resilience can be taught does not mean it can be taught to those with negative mental health who have OCD symptoms related to handwashing. Although the resilience of some patients is a hopeful finding, further research is needed in this area to determine if resilience can be taught to OCD patients with negative mental health.

Article 2. The second article that found no negative mental health in those with OCD confronting the directive to increase handwashing during COVID-19 is one regarding patients seen by Australian psychiatrists. The article is “Contamination Compulsions” [34]. Although this one-page letter to the editor admits that some patients with OCD had increased anxiety during the pandemic, others with OCD reported feeling reassured and validated by the strict guidelines about handwashing. The authors conclude, “Our early anecdotal evidence appears to suggest that COVID-19 has had an unexpected positive impact on the mental health of some, but not all, people with OCD.” Although these authors admit that there is no universal finding regarding the mental health of those with OCD with respect to handwashing during the pandemic, with no controlled-study evidence to present, these authors have made it appear in their conclusion that a positive impact of the handwashing directive for COVID-19 is to be expected in patients with OCD. This conclusion goes beyond the evidence presented.

Article 3. “Impact of COVID-19” [35] is a paper regarding those with OCD in West Bengal based on phone interviews with psychiatric patients who had each been prescribed drug treatment for their OCD symptoms. During the time the survey was undertaken to determine if their symptoms had been exacerbated by the handwashing directive, 57 were continuing to take their medication during the pandemic, 13 took them irregularly due to fear of possible unavailability, and 14 had stopped taking their medicines due to unavailability at nearby drug stores. Of this group, only 5 (6%) of the patients reported any negative change in their mental health as a result of the pandemic directive to increase handwashing and, of those 5 patients, all of them were those who had stopped taking their medication. Consequently, it might be concluded what is necessary to keep mental health from being negative in this regard is to have the patients on the right medication and ensure that they are continuing to take them.

However, although all of the 5 patients who experienced negative mental health were those who had stopped taking their medication, this left 9 of those who had stopped taking their medication who claimed they did not experience negative mental health. If being on medication was the reason for not experiencing negative mental health, these 9 patients who stopped their medication should have reported negative mental health as well. Furthermore, the educational background of the patients is unclear, but it can be assumed to be low if the educational background is reported as the reason the authors chose a phone interview rather than an online survey. As such, if these patients lacked the education to access the internet, they may have felt that if an official contacts them to ask questions about the medication they are receiving for their OCD—and they are afraid that they may lose their prescription if they don’t answer the survey to say they feel fine with their medication—it can be supposed this fear may have been a reason why only those who weren’t taking their medication because it wasn't available felt safe in saying that their symptoms had got worse, indicating negative mental health. Given that these results are an anomaly in the research conducted on those with OCD in response to the health directive to increase handwashing during COVID-19, the lack of negative mental health in these patients is unexpected and requires further details that are unavailable to confirm the result.

Article 4. The fourth article, “Experiences of Mental Distress during COVID-19” [36], investigated the experiences of those with OCD seeking peer support in discussion forums of a popular social networking discussion forum platform (Reddit) during the COVID-19 pandemic. What is unique about this study as compared to others is its focus on discussions those with OCD had with others diagnosed with the same disorder. Their comments recorded for the study include statements such as, “Being advised to do all the things that I did anyway almost gives me a sense of normality. I haven’t felt normal in years,” and “It’s funny how the same people that made fun of me for not touching doorknobs, only eating off paper or plastic plates and silverware, and washing my hands till they bleed are becoming more and more ‘like me’.” To this extent, this study did not find negative mental health in these Reddit forum users.

However, others provided comments to the forum that were less self-assured, demonstrating negative mental health, “Being more conscious about germs and washing hands more regularly isn't necessarily a bad thing at the moment. Arguably we are positioned better than most of the population in terms of protecting ourselves because we already are thinking so much about germs and contamination. But I'm at that point where my increased caution is no longer useful and has begun to hinder my daily functioning again,” or “The last week COVID has made me worse again. I feel I need to wash my hands or sanitize everything after I touch things, and I'm only in my house. It's driving me crazy, I'm obviously wiping surfaces, taps, door handles etc. down regularly but I still feel as if I need to wash and feel clean otherwise I can't relax.”

Although Reddit permitted users with OCD the opportunity to express a new feeling of normalcy, this was insufficient for the authors to ignore the increase in negative mental health of those Reddit users brought on by the handwashing directive of the pandemic.

Article 5. The final article that did not find negative mental health in those diagnosed with OCD before the pandemic as a result of the health directive to increase handwashing is “Impact of the COVID-19 Pandemic” [37]. This is a report of a study of 240 psychiatric patients who attended an OCD clinic at a hospital in India and were later followed up with two telephone interviews several months apart. All patients were on OCD medication. Similar to the other telephone study of OCD psychiatric patients in India, only 6% of patients reported negative mental health. This was an unexpected result by the investigators, given previous studies in the literature reporting negative mental health. Also similar to the other Indian study, most of the patients were on stable doses of medications, implying that continued treatment with medication may have prevented negative mental health. However, unlike the other study in India, this study did not collect information on the education level of the participants. Furthermore, the information was again collected by telephone and the questions asked are not included in the methods section of the report. It can again be queried if the patients did not mention negative changes in their mental health to those conducting the survey for fear that the purpose of the survey was to find a reason to stop medication. As such, there is insufficient information provided on the demographics of the patients and the questions asked of them to determine why the investigators recognized so few instances of negative mental health.

Each of the five articles that did not find negative mental health in OCD patients who had been diagnosed previous to COVID-19 therefore has made this assessment for questionable reasons. The first paper [33] actually did find negative mental health in OCD patients; however, the concentration of the article was on those patients who were resilient, and it was those who did not have negative mental health. The second article [34] by Australian psychiatrists is a one-page letter based on anecdotal evidence alone. As such, the results are not scientifically sound. The third report [35] and the fifth [37] were both conducted in India under similar circumstances that may have put indirect pressure on the respondents to say that they did not experience negative mental health in case they might lose their right to medication as a result. The fourth report [36], similar to the first, actually did find negative mental health in some of the Reddit users, the paper’s authors chose to focus on those who did not experience negative mental health. As a final appraisal, it remains unclear whether these five papers that differed in their assessment of the effect of the handwashing directive on OCD patients diagnosed before the pandemic actually did have results that differed substantially from the other reports included that found negative mental health.

Implications

What can be identified from three of these papers [33,34,36] is that resilience matters to the mental health experience of those with OCD in relation to the handwashing directive. Resilience was displayed by some New Yorkers with OCD, most OCD patients of Australian psychiatrists, and some of those who used Reddit to communicate with others diagnosed with OCD. That resilience may be effective in reducing symptoms of OCD during COVID-19 has been recognized in other studies [39,40]. Furthermore, it is those with low resilience who are most likely to have demonstrated negative mental health [23]. In that resilience can be taught [41], this provides a potential way in which those diagnosed with OCD who experienced negative mental health as a result of the directive to increase handwashing might be able to overcome their symptoms to some degree with improved resilience. Such resilience generally has been recognized as necessary for all those demonstrating negative mental health as a result of the pandemic [42]. However, whether OCD patients who were negatively affected by the directive to increase their handwashing during COVID-19 are the type of patients who can be expected to gain from being taught resilience is uncertain. One method that seems to have been effective in this regard is reported in relation to a study of 8 OCD patients conducted early in the pandemic [43]. However, as it has been noted that OCD is linked with anger experience and expression from an incohesive and unempathetic family life [44,45], these more fundamental problems likely require attention for the teaching of resilience to be effective in OCD patients.

In considering the two reports from India [35,37] demonstrating little negative mental health in OCD patients who were on stable medication, it needs to be considered if maintaining stable medication during COVID-19 was sufficient to protect against negative mental health concerning the directive to increase handwashing during the pandemic for this group. Yet, apart from these two Indian articles, there appears to be no additional research to support the claim that stable medication is enough in this regard. Other research studies considering the adequacy of stable OCD medication regarding protecting against negative mental health during the pandemic found instead that negative mental health developed to the extent that previously stable medication had to be adjusted to affect regaining mental health in these patients [46,47]. In one survey group, 73% of OCD patients on stable selective serotonin reuptake inhibitor medication saw a worsening of their symptoms during COVID-19 [48]. Nevertheless, in a study that reported most OCD patients on stable medication experienced negative mental health [49], one survey respondent provided this positive comment, “I am very fortunate that my medication has been keeping my OCD under very good control,” demonstrating that, although rare, stable medication was able to maintain the mental health in at least some OCD patients, concurring with the findings of the two Indian articles.

The following represents the significance of this limited review conducted of the parameter containing the keywords “handwashing, mental health, COVID-19, OCD.”

Limitations

A limitation of this study is that the author did not provide a detailed account of the 45 reports that found negative mental health in those who had both been diagnosed with OCD before COVID-19 and those diagnosed during the pandemic. Given that the point of this examination is to present a limited review regarding “handwashing, mental health, COVID-19, OCD”—researchers who would like to check the accuracy of the author’s assessment have been provided with the type of transparency to make such an examination possible [50-76].

To this point, an additional limitation is that the evaluation of the articles for their authors’ points of view regarding negative mental health and OCD was contingent on the reading done by this author. Although this author undertook the present study with the aim of objectivity, it is possible that the author had a cognitive bias that was unrecognized [77]. Although various frameworks have been developed to debias research, there remains little research on the efficacy of these models and, as such, how to recognize and reduce cognitive bias is identified as an area in need of additional research [77].

Main outcomes

This limited review has demonstrated that the great majority of those diagnosed with OCD both before COVID-19, and those diagnosed after, sustained negative mental health based on the directive regarding handwashing during COVID-19. However, it was also noted that it was those with the least resilience who experienced the greatest negative mental health, and negative mental health was not a factor for those OCD patients who demonstrated resilience. Nevertheless, resilience generally is not present in those experiencing OCD, especially during the pandemic. Furthermore, it was found that stable medication might be a protective factor for those who were diagnosed with OCD pre-pandemic, although this finding is generally not supported.

Given these results, for this particular pandemic that was not fueled by fomite transmission, health officials might have supported the mental health of those with OCD if they had reconsidered and been more specific regarding their directive regarding handwashing when the information became available that airborne aerosol droplets were the cause of transmission.

Future perspectives

For future pandemics, an early effort should be made to determine the method of transmission of these viruses so that health directives can match what is likely to protect populations, including the most vulnerable to particular directives, thus reducing the possibility that negative mental health will result in those with OCD if increased handwashing is the directive. Moreover, given the importance of resilience in maintaining mental health, research should continue regarding how resilience might be increased in those with OCD symptoms experiencing negative mental health so that they might be able to mitigate their negative mental health under future pandemic conditions. Additionally, further studies are required to determine whether stable medication is actually a protective factor for OCD patients during pandemics in response to handwashing directives.

The author declares no conflict of interest.

This research received no external funding.