The "primary emotional reaction" during the COVID-19 outbreak in Korea may be considered the fear or anxiety of the physical disease itself, or the “contagion” myth, directly related to infectious diseases. On the basis of our knowledge of pandemics throughout history, the presumption is that the primary emotional reaction may be shared worldwide during pandemic events. With respect to the primary emotional reaction, mental health care should focus on patients in isolation, individuals in quarantine, and healthcare workers who treat COVID-19 cases. Thus, care for the primary emotional reaction to COVID-19 has been relatively well prepared and provided in Korea.4 First, national hospitals and mental health welfare centers across the country have prepared to provide mental healthcare services for individuals in isolation or quarantine because of the COVID-19 outbreak. Second, the leaflets promoting mental healthcare related to the distress due to the infectious disease outbreak have been distributed by the National Center for Disaster Trauma. The "secondary emotional reaction", beyond the anxiety of the physical disease itself, or the contagion myth, may be considered the other psychological consequence of the COVID-19 outbreak. The secondary emotional reaction may involve an indirect psychological response to the COVID-19 outbreak, which reveals the public psyche's repressed emotional problems and may be deeply influenced by specific sociocultural factors in Korea. Although mental health care for secondary emotional reactions to COVID-19 is also urgently needed, it may be poorly prepared for and supported in Korea compared to that for primary emotional reactions.3 Consequently, we introduce herein two groups who should urgently be considered for care in Korea due to secondary emotional reactions prompted by the COVID-19 outbreak. In addition, as requested, potential therapeutic approaches for the two groups are proposed below.

The critical outbreak of COVID-19 has been closely linked to the recent massive-scale rallies of the Shincheonji religious group which occurred on February 9 and 16, 2020, in Daegu, Korea. Based on epidemiological survey reports from the Korea Centers for Disease Control and Prevention (KCDC), approximately two-thirds of the accumulated COVID-19 cases may be directly related to the Shincheonji Church of Jesus. The Shincheonji is a newly coined Korean word that designates a new heaven and a new earth in the Book of Revelation of John. As a result, this religious group believes from the viewpoint of eschatology that “the end of this world is at hand, and the new world is about to begin.” Because Shincheonji congregants are convinced that only 144,000 individuals worldwide can go to heaven, they usually abandon all social relationships, including family and occupation, under the direction of charismatic totalitarian religious leaders. Thus, before the COVID-19 outbreak, the Shincheonji Church of Jesus has been usually regarded as an unacceptable religious group in Korean society.56 Khan and Huremovic7 have explained the psychology of the pandemic as follows: “Not only can contagion not be controlled or mastered, but the search for causality creates the unconscious narrative of the pandemic being a result of the community's own badness.” It is likely that the secrecy and collectivism of the Shincheonji religious group has contributed to the rapid spread of COVID-19 and also to non-cooperation with the epidemiological survey for COVID-19 in Korea. Therefore, apart from facing discrimination because of their religious activities, Shincheonji congregants who are infected with COVID-19 are likely to face anger and be blamed for the COVID-19 outbreak in Korea. Moreover, they may develop serious emotional problems after they leave the cohesive large group. Therefore, based on the previous psychosocial support for the Unification church (Moonie) dropouts, Shincheonji congregants with COVID-19 must be supported by “establishing social networks with a clear-cut cognitive framework at the level of individual mental health” and also with specific treatment for the psychological trauma of COVID-19.568

Approximately 25% of workers in Korea are self-employed, which is much higher than the average figure of 15% in the Organization for Economic Cooperation and Development countries.9 Because social distancing in response to the COVID-19 outbreak is persistent and may be prolonged, most self-employed workers in Korea are experiencing severe economic difficulties. In addition, the difficulties of the economically weak population in Korea have worsened during the COVID-19 outbreak. Based on previous findings, Korea has shown a tendency to experience an increase in suicide rates during crises, such as during the 1997 financial crisis. The psychological autopsy reports have shown that economic problem is the main cause of stress for more than 60% of suicide completers.10 In addition, the unemployment rate and income inequality have been proportional to suicide rates.11 According to a report by the Korean Suicide Prevention Center, over 60% of suicides were associated with economic problems that were a key source of stress at the time of suicide. Economic problems had the largest effect on suicide among elderly adults.1213 Thus, even after the end of the COVID-19 outbreak in Korea, it will be necessary to strengthen the social welfare support system and suicide prevention programs for the economically weak people. In terms of the medical policy for suicide prevention, strengthening early and effective intervention programs in the psychiatric area has been proposed as the effective reduction method for suicide rates.14

Mental health care related to the COVID-19 outbreak in Korea should cover not only primary emotional reactions, but also secondary emotional reactions. Also, pro-active care for secondary emotional reactions in Shincheonji congregants and the economically weak is of key importance. Special care is required to treat followers of pseudo-religions and the groups at high-risk of suicide experiencing the COVID-19 outbreak in Korea.