Mental Health Consequences from COVID-19 Pandemic and Strategies for Community Level Recovery

Background: The COVID-19 pandemic has spread across the globe from 2019 affecting millions of people physically, mentally, and socio-economically. The purpose of the study was to map out the mental health consequences of the COVID-19 Pandemic and suggest recovery strategies. Methods: A qualitative inquiry into the mental health aspects of the COVID-19 pandemic using observations from working in busy health clinics, general practices, primary and community care setting, and dedicated COVID acute care wards during the pandemic in Australia, United Kingdom and Sri Lanka; discussions with colleagues worldwide; analyzing social and news media comments; literature survey and experience of dealing with past disasters were used to map out mental health consequences and put forward recovery strategies. Results: In covid sufferers, neuropsychiatric symptoms lasting months, unrelated to respiratory insuciency suggested brain damage due to vascular endothelial injury and/or cerebral venous thrombosis (CVT). A third went onto develop or have a relapse of a psychological or neurological conditions. In the general population, common consequences included common mental health disorders; changing patterns of substance abuse including alcohol; increased domestic violence and child abuse. Family relationships, interactions and understanding improved in many but minority had strained dynamics. Vulnerable groups included the elderly, women, youth; children; disabled; frontline and health workers; minorities and severely mentally ill. At the community level, there were signs of collective (mass) hysteria from panic buying to conspiracy theories, public shaming, fake news and disinformation spreading on social media and mass protests. There were also positive effects such as better understanding of bio-knowledge; interventions (rapid vaccine production, contact tracing methods) and discoveries (mRNA Vaccines), health systems improvements (tele-health), online learning, gratitude toward heath care workers, increased social/community/family cohesion, closer international networking, reduction in suicide rates and drop in interstate and civil conicts, road accidents, crime and communicable diseases with their resultant morbidity, mortality and mental health consequences. Conclusions: In view of the widespread mental health and psychosocial consequences from the COVID19 pandemic, a community-based approach is suggested while treating more severe mental disorders at the primary care or specialist level.

comments and articles that appeared in social media or news media related to covid pandemic. A systematic search of medical and reputed journals was done for relevant reports and articles on the current covid pandemic and comments from social or news media related to themes from participant observation. Relevant reports and articles that participants had read while working during the pandemic were also included. Participant observation data from actively working during the pandemic in various clinical settings including dedicated COVID-19 acute care wards from different parts of the globe were collected. Thematic analysis was carried to understand the collected data. We looked speci cally into the direct mental health effects related to catching the infection, and indirect psychosocial effects on the general population including consequences from multiple public health measures adopted to curtail the infection such as lockdowns, border closure and quarantine, isolation of contacts, COVID -19 testing and vaccination roll out.
This study was aimed to address the following objectives (O s): The study period: Since the start of pandemic December 2019-30 th November 2021.The search was performed until 30th of November 2021. Data extraction, collection and categorizing the key phrases were carried out from published reports and articles, comments from social media, news media, discussions and personal observations and crossed checked by all the investigators. Analysis of the collected data was carried out to uncover negative and positive themes, identify relevant study ndings and those representing signi cant public perceptions and responses toward the COVID-19 pandemic was done.
The data (comments from news media and social media and participant observations) were grouped together to identify emerging themes. This thematic analysis frame work [11,12] (Figure 1) grouped the data under the same themes summarized in Tables. All authors agreed on the grouping through discussion.
Participant observations and experience of working in busy mental health clinics, primary care setting, emergency departments and dedicated COVID-19 wards during the pandemic in major cities in Australia, UK and Sri Lanka; discussions with colleagues worldwide and experience of dealing with past disasters were used to map out mental health consequences and put forward management strategies. This paper is in a way a record of the extraordinary journey of clinicians originally from the Faculty of Medicine, University of Jaffna but now dispersed globally struggling to understand the unfolding pandemic so as to offer the best treatment to patients, their families and communities caught up in the COVID-19 crisis.

Results
In this study we analysed news and social media comments and participants observations to uncover people opinions or perceptions regarding COVID-19 pandemic mental health and psychosocial issues.
Even though some of the participant observations were more relevant to health care workers, they indirectly applied to the general community as well. Our ndings revealed negative and positive themes in PSMH consequences due to COVID-19 pandemic as summarised in Table 1 and Table 2. Further we searched the medical literatures for studies and reports related to mental health sequelae due to direct pathological changes caused by COVID-19 infection on brain, indirect PSMH consequences and to identify strategies to overcome them. "Yesterday the 26-year-old man was ned almost $10,000 for allegedly eeing Sydney's lockdown to meet the 36-year-old Qantas ight attendant in northern NSW" C2 "A search for villains': As Australia's outbreak grows, so does covid shaming"-C3

2.Conspiracy theories
Blaming certain countries, religious society, religion, industries (Big Pharma) or certain technologies (G5) as cause/ origin/ spread of COVID -19 "We are not the virus': Two-tier Delta lockdowns divide Sydney"-C4 "It's like a shock for them as they believed they arrived in a free country and they say, 'we face same what we face in our (home) country"-C5 "It's your own democratic right to choose [but] I just say that life and death is in the hands of God,"-C6 "Omicron variant hits South Africa, as country encounters vaccine hesitancy, conspiracy theories"C7 "GOP Medical Witnesses: Covid19 'Exactly what you'd expect if you'd Gone through Gain-of -Function'-C8 "Defence is aware of social media posts claiming the Australian Defence Force is forcibly vaccinating or detaining members of the Australian community,"C10

3.Panic Buying or Hoarding
Fear and panic through social media could fuel psychological reactions in midst of crises.
"People in NSW are panic-buying toilet paper again after Greater Sydney, the Blue Mountains, the Central Coast and Wollongong were placed into a two-week lockdown on Saturday"-C11 "Once Again Australians Need Reminding That COVID-19 Does Not Give You Diarrhoea"-C12 "Sri Lanka said-it would bring in new laws to deter hoarding and increase penalties on traders to tackle food shortages caused largely by the country's deteriorating forex reserves. Shortages of essential foods including rice, sugar and milk powder in recent months pushed the government to declare a food emergency, empowering authorities to seize stocks of staples and sell them at guaranteed prices"-C13

Protests, violent outbreaks (Mass Hysteria)
Certain group come together over COVID, and capitalised on the unemployment, restrictions, frustrations, anger and uncertainty in sections of the community 'It's almost like grooming': how antivexers, conspiracy theorists, and the far-right came together over COVID-19"-C14 "Public opinion about coronavirus is more politically divided in U.S. than in other advanced economies"C-15 "They're motivated by a fear of societal collapse or a speci c social or economic grievance or conspiracy, the ASIO boss prophetically explained in March 2021" -C16 5.Concern of parents of children with special needs Imposed a greater challenge to the families with special needs e.g.: Autism children. Assessing their routine services and recreational places were limited posing effect on family dynamics "Pandemic Lockdown; Autism: A Parent's Concern from Sri Lanka -Colombo Telegraph"-C17 6.Health System Strain/Health Staff Burn out a. Hospital settings (Emergency/ICU) " I have witnessed doctors and Nurses( mainly working in ITU and Respiratory wards) struggled to cope with sheer volume of deaths within a short period of time"-PO1 "As Respiratory Physicians we have been inundated with acute COVID management , post COVID follow ups , rising number of new lung cancer /pleural /TB cases ( delay in diagnosis due to COVID ) and of course long COVID" PO2 "One of my colleagues is currently off sick due to PTSD and getting treatment. Junior doctors needed support from Psychologists"-PO3 "One of my Patient was very ill and needed elective intubation. But he refused to consent for intubation and mechanical ventilation. During that time ITU beds were like gold dust. When I asked him the reason he told me that he was very anxious thinking about being in a coma stage with huge uncertainty about the recovery. We persuaded him to accept the treatment eventually. He survived at the end"-PO4 "I had a GP and his patient were in the same day opposite to each other. Sadly GP died within few days and patient witnessed the death. That gave him huge anxiety. But he later survived"-PO5 "Surge in doctors seeking help for own mental and physical health concerns-What we see on the doctors' helpline is only the tip of the iceberg, there are many more doctors who are impacted by burnout who don't call us,"-C18 "I currently have another patient who got admitted to our hospital in late December. I inserted his rst chest drain for pneumothorax secondary to Pneumomediastinum. He spent 4 months in ITU. Currently on Respiratory ward getting rehabilitation. He went through a lot. He had 16 chest drains in total during this admission. He is one of the longest surviving in patients in England" PO6 "Sydney hospitals erect emergency tents as COVID-19 cases hit record -The Australian Paramedic Association said paramedics were given a choice to wait in their vehicles with infected people or "wait outside in the freezing rain" due to the rise in patient"-C19 'We did a bit of informal research a few years ago and it was really disheartening; the vast majority of people who've been burnt out have not told anybody -C20 b. Primary Care setting 1.COVID -19 posed several situations where primary care physicians has to refuse several request from patient which are against the public health advice" 2.New system related issues after COVID-19 pandemic causes signi cant stress on GPs

COVID -Vaccine rollout
Tier systems for covid vaccination led to mass panic in lower end of priority risk groups as they wanted to have it quickly "Are there still a lot of COVID exemptions Handed over? Faced abuse and anger from a mother whom I refused to give COVID-19 Vaccine exemptions for herself and her 16 year old kid (they are healthy individuals),now I am the one responsible for them losing their jobs . and apparently their friends' doctor does exemption(did not believe this bit).This is draining, they are not willing to listen" -C21 'The pandemic has tipped us over ' -C22 "Adjusting to new numbers, adjusting to new ways of practising, adjusting to everybody's distress, spending hours and hours reading the new COVID-19 rules and having them change again and again to get to the stage where we are now, where we feel like we're ghting people to get vaccinated. 'It's affecting us at a very personal level"-C23 "We work too much, we work too hard, we see too many people, we see too many people too quicklyand why do we do that? The way the Medicare system is structured with fee for service and with predominance of bulk billing" -C24 "NSW is struggling to keep up with vaccination demand in the hotspot areas of south-west Sydney due to insu cient P zer doses and a reluctance of older residents to take AstraZeneca" -C25 "The great concern about having a blood clot after the AstraZeneca vaccine is not logical because there is a much greater chance of being severely affected, and possibly dying, by being infected but people worries around this causing signi cant mental health issues among patients and treating physicians"-C26 "Depleted and exhausted': British GPs demand fee-for-service payments" C27 c. Mental Health Facilities Disruptions to mental health services for vulnerable people, to counselling and psychotherapy; critical harm reduction services; to emergency interventions, including those for people experiencing prolonged seizures; severe substance use withdrawal syndromes; and delirium to access for medications for mental, neurological and substance use disorders and disruptions to school and workplace mental health services "Mental health services struggle under surge of demand" C28 "Mental health specialists closing books as demand peaks during COVID-19 pandemic-The ABC has spoken to several GPs who are frustrated and concerned they can no longer refer people to psychologists or psychiatrists" C29 "There has been a shortage of psychiatrists in Australia for many years, but increased demand due to the pandemic has exacerbated the issue"-C30 Lots of high street starter business were ruined as online platforms took over everything. This caused uncertainty and anger/anxiety for those people working in those sectors. Also uncertainty of future job losses exacerbated mental health issues.
"Bills keep coming in, real estate agent asks for deferred rent to be repaid in full… daughter needs glasses, other daughter has anxiety and becomes depressed."-C41 "The government does not see that mental impact of being unemployed and getting the distinct feeling you are seen as scum."-C42 "There were periods of restriction to open to alcohol outlets even after listing lockdown and travel restrictions in Sri Lanka" PO10 11. Concerns Children / They lost the social interaction with their peers and teachers in general.
'It breaks my heart': Australian parents say mental health strain on their children is worsening" C43 Adolescent mental health They are affected by "zoom fatigue" due to prolong online education.
Many children spent long hours in computers and gaming gadgets which led to not only issues with eye sights but also wide mental health issues such as anxiety, dgetiness, hyper arousal, poor sleep and bad dreams as sometimes they played non-age-appropriate computer games "Her world contracted. She began living on social media, seeing her peers' interstate and overseas living their best lives." C44 "There are many other families doing it much worse with their kids who already had di cult circumstances to deal with before the pandemic," -C45

12.Fitness issues
The perceptions and social media messages; those doing regular activities, sports and using gyms for a regular workout before the lockdown, were greatly impacted by the COVID-19 pandemic.
"I used to run. After the last lockdown 18 months ago, I found it really hard to get back into running, but I had just started to, and this lockdown just killed that."-C46 The coronavirus pandemic has forced millions to work from home -and the o ce will never be the same" C-53 "Initially it was quite a challenge to ask that small question. It would usually take a couple of minutes by just walking over to someone face to face in the o ce," C-54 "Even though many people found it blessing at working from home, but many also struggled particularly when children also at home as having to look after and work at the same time" C-55 16. Anxiety about life after lockdown.
Mental health issues (fear, anxiety) of going back to work; socializing after long lockdowns "After you've been inside for a long time, it can feel very strange to go outside" C-56 "People are trying to cope by loving being in lockdown, by creating a cocoon of safety, a haven, to make the whole experience more tolerable. C-57 "Ironically that can create problems later on because people can love their lockdown too much and become anxious about going outside."-C-58 "Furlough from work has been a problem for some as they found it di cult to go back to work, workplace anxiety increased and led to many frictions within work teams" -C59 * C-Comments from social media or news media, PO-Participant observation Mental Health consequences of COVID-19 can be usefully seen within a framework of bio psychosocial dimensions. COVID-19 infection can cause pathological changes in the brain through direct vascular injury, neurotransmitter system dysfunction and/or thrombosis; leading to neuronal damage believed to be mediated mainly via micro thrombosis formation and cytokine storm resulting in neuropsychiatric symptoms ( Figure 2) [13,14]. Common symptoms reported were "anosmia, cognitive and attention de cits (i.e. brain fog), new-onset anxiety, depression, psychosis, seizures, and even suicidal behaviour" [13,14].

Emerging negative themes
We observed most of the news media and social media comments and participant observations indicated negative impact caused by the COVID-19. Hospital admission due to infection signi cantly caused stress on patients which led to mental health consequences. One of the participant observation comments regarding the enormous stress on COVID-19 patients in hospitals is as follows: "I had a GP (General Practitioner) and his patient were in the same ward opposite to each other. Sadly GP died within few days and patient witnessed the death. That gave him huge anxiety. But he later survived"-C13 In addition surging admissions caused signi cant stress on heath staffs and we observed several examples: "I have witnessed doctors and Nurses (mainly working in (Intensive Therapy Unit (ITU) and Respiratory wards) struggled to cope with sheer volume of deaths within a short period of time"-PO1 "One of my colleagues is currently off sick due to PTSD and getting treatment. Junior doctors needed support from Psychologists"PO3 Many worried about children/adolescent mental health due to the lockdown and closure of schools, sports activities and reduced social connections. Some example comments are as follows: "Her world contracted. She began living on social media, seeing her peers' interstate and overseas living their best lives" C43 "There are many other families doing it much worse with their kids who already had di cult circumstances to deal with before the pandemic" -C45 "It breaks my heart': Australian parents say mental health strain on their children is worsening" C42 "Healthcare workers have taken their already high resilience to the next level, they have also shown the lengths to which they will go to protect the community and in doing so a deeply human side that won't be forgotten, earning them even more respect than previously" C -60 "Doctors lead international 'most trusted' profession poll-Faith in doctors has risen even higher since the pandemic began, seeing the profession overtake scientists for the rst time" C-61 "I've seen people begin to re-establish lost connections, not only with other people, but also with themselves," C-74 "The pandemic has allowed my husband, daughter and I to spend much more time together," adds G. "As a couple, we've been able to communicate frequently and as parents, we've been able to play with our daughter a lot more. So, I think we've emerged out of this crisis as a closer and more tight-knit family."C-75 "In Sri Lanka at quarantine centres children were not allowed and they were left alone at home with grandparents while parents are kept alone for 10 days. That has created lot of psychological issues"PO7 Substance use, particularly use of alcohol increased during lock down imposed to curtail the virus spread. One of our observation as below may explain a contribution to increase alcohol use in Sri Lanka.
"Alcohol outlets were opened for business even after listing lockdown of cities and travel restrictions for people movements in Sri Lanka during initial months of outbreak" PO10 Consequences at the community or collective level Mental health issues among the health care workers due to overstretched health system noted was one of the common collective negative themes in our qualitative exploration. The following are sample comments: "Mental health specialists closing books as demand peaks during COVID-19 pandemic-The ABC has spoken to several GPs who are frustrated and concerned they can no longer refer people to psychologists or psychiatrists" C29 "Sydney hospitals erect emergency tents as COVID-19 cases hit record -'paramedics were given a choice to wait in their vehicles with infected people or "wait outside in the freezing rain" due to the rise in patients"-C19 During initial stage of the pandemic many countries adopted travel restrictions and border control as a public health response and many blamed this for mental health consequences as mentioned in following comment.
"From March [2020] onward it was total lockdown," she says. Because of continuing travel restrictions, she fears it might be another year before they can reunite. "It's going to be really heartbreaking" C-39 Many comments in our analysis indicated the common negative theme as "Economical strain" especially in developing countries such as Sri Lanka which was a main reason for poor mental health during pandemic. Following are sample comments: "Bills keep coming in, real estate agent asks for deferred rent to be repaid in full… daughter needs glasses, other daughter has anxiety and becomes depressed"-C40 "The government does not see that mental impact of being unemployed and getting the distinct feeling you are seen as scum."-C42 Participant observations attributed economic hardships and poverty to increasing suicide rates in Jaffna.
Comparatively, it was observed that in Australia and UK, there were generous economic support and packages that could have been one factor for the lower suicide rates there.
At the community level, stigma of being identi ed as an individual with COVID-19 caused signi cant stress especially in developing countries but also observed in developed countries as mentioned in the following comment.
"It's like a shock for them as they believed they arrived in a free country and they say, 'we face same what we face in our (home) country"-C5 "Shame, stigma barriers to COVID-19 testing for young and culturally diverse"-C33 Main nding out of our analysis were of collective level, community reactions in several countries that appeared in the media during this COVID -19 pandemic, for example resulting in mass panic reactions.
Further politically motivated division was observed in some developed nations such as US during 2020 election. Following are sample comments: "People in NSW are panic-buying toilet paper again after larger area were placed into a two-week lockdown on Saturday"C11 "It's almost like grooming': how anti-vexers, conspiracy theorists, and the far-right came together over COVID-19"C14 "Public opinion about coronavirus is more politically divided in U.S. than in other advanced economies"C-15 Further we also found media reports that related religious preaching of beliefs and conspiracy theories to vaccine hesitancy leading to emergence of new variants such as "Omicron".
"It's your own democratic right to choose [but] I just say that life and death is in the hands of God" C6 "Omicron variant hits South Africa, as country encounters vaccine hesitancy, conspiracy theories"C7 Emerging Positive themes Even though many media comments highlighted negative themes, our analysis showed positive themes which can be used as interventions summarized in Table 2. Some comments indicated they had more time to do exercise during lockdown than usual working period. Following comment is an example that some get more opportunity to do tness activities during the pandemic: "It's given me an opportunity to get out and about and do a lot more physical exercise than I normally would, And so now, a normal day might begin with a 14-kilometre run"C92 Further we noted reports regarding increased gratitude towards health care workers. Following comments were some examples observed in our study regarding positive gratitude towards health care workers: "Doctors lead international 'most trusted' profession poll-Faith in doctors has risen even higher since the pandemic began, seeing the profession overtake scientists for the rst time"C60 "India's COVID-19 health workers showered in ower petals as military thanks 'warriors'"C61 Online learning was introduced in schools during out breaks COVID-19 for the rst time in some developing countries such as Sri Lanka.
"Online learning and distant learning were at primitive level in Sri Lanka in the pre covid era however that pandemic had a great impact on that. Almost all the school and private tuition centres now highly depend on that. Students too feel it is more effective in terms of time and cost. It has provided ample opportunity to learn from remote areas Northern Sri Lanka" PO12 Further in health sector Tele health introduced during this pandemic to mitigate the risk of face to face contact was one of the useful interventions which may continue beyond the pandemic as mentioned in the comment.
"Tele health should become another plank of the healthcare system"C80 In spite of concerns raised by many that the pandemic caused family relationship strain and increased domestic violence, our analysis indicates that overall, family relationships improved during the pandemic as mentioned in the following comments: "The pandemic has allowed my husband, daughter and I to spend much more time together-As a couple, we've been able to communicate frequently and as parents, we've been able to play with our daughter a lot more. So, I think we've emerged out of this crisis as a closer and more tight-knit family"C74 "It Has Stopped Our Lives to Spending More Time Together Has Strengthened Bonds"C77 We observed reduction in morbidity and mortality due to other respiratory infections, deaths due to road tra c accidents (RTA) and even reduced suicide rates following the pandemic as indicated in the following reports.
"COVID-19 pandemic drove u to historic lows, and may have eliminated one virus type completely"C-65 "UK road deaths drop 16% during pandemic year"C-67 "Australian suicide rates down during COVID-19-The Australian Government welcomes the release of the Australian Bureau of Statistics (ABS) Causes of Death, Australia, 2020 report today, with Australia recording the greatest drop of deaths in the last decade"C-66 We also noted various community and religious organisations that offered various health promotion activities during the pandemic.
"BBC 3CR Sunday 19SEP21 Dr S talks about "Chatterbox a recent initiative at Cross and Stable Church in Downs Barn Milton Keynes which enables people who are isolated or alone to come together and enjoy coffee and cake and a chat. Broadcast on BBC Three Counties Radio Sunday Breakfast 19th September 2021" C85 Our analysis found common calls for improved public health campaign and international collaboration as mentioned in the following comments: "It's vital that we learn from COVID -19 so that next time a public health crisis emerges we are ready with a comprehensive, well-targeted, nationwide campaign" C95 'Expanding global vaccine coverage with ensuring equitable distribution, and combating hesitancy and misinformation remains critical to limit overall viral evolution, protect vulnerable people and l to prevent mutation of viruses all of which can directly or indirectly lower the risks of new variants emerging" C89

Discussion
Increased risk of mental health disorders including anxiety disorders (adjustment disorder, generalized anxiety disorder, and panic disorder), depression, post-traumatic stress disorder, substance abuse, and sleep disorders were observed among the COVID-19 survivors [13,15,16]. Depression, dementia, psychosis and stroke were commonly observed among patients who had COVID-19 infection [15]. One third of patients develop a psychiatric or neurologic condition within six months of COVID-19 infection [15]. Hospital or in intensive care admission increased the risk for mental illness due to the stress in hospital and effect of virus on the brain [17]; in particular, Post-traumatic stress disorder (PTSD) after ICU admission and severe COVID-19, dementia; myalgia encephalomyelitis/chronic fatigue syndrome (ME/CFS) or 'Long COVID', [18]. Patients with pre-existing psychiatric disorders have worsening of psychiatric symptoms [17,19].
Fear of getting infection was common among many individuals and generally in the community which caused acute and prolonged stress. With di culties in availability, changing patterns of substance abuse was reported [20]. There was increased alcohol use as a way of coping, and with lockdowns and transport restrictions leading to unavailability, a tendency for home or illicit brewing [21]. In a survey in China authors found out so called coping behaviours (online use, smoking and alcohol) related risks such as substance use and internet addiction was increased during COVID -19 pandemic. For example among 6416 respondents on this survey 46.8% reported internet use increased (dependence), and 16.6% said using it for longer hours [22]. The negative effect of COVID-19 pandemic (with physical distancing, lockdowns and other travel barriers and consequent socio-economic hardships) on relationships, especially in family relationships which in turn increased domestic violence, child abuse and alcoholism; caused strains at the family level [17,23]. This may be one of the reason the British roadmap to covid recovery identify women, youth and children as a vulnerable group in addition to several other vulnerable groups such as the elderly (increased risk of morbidity and mortality, isolation, loneliness, dementia); disabled; frontline and health workers; ethnic groups and severely mentally ill [16,17].
Recent systemic reviews of studies among health care workers (HCW's) found that depression, anxiety, psychological distress, burnout and poor sleep quality were prevalent after the pandemic [24]. Further a study based on self-reports of "stress, resilience and coping" among HCW's during the COVID-19 pandemic, showed "moderate-high stress scores" with normal levels of "resilience and coping"; but showed inter-professional differences where the MD/NP/PA (medical doctor/nurse practitioners /Physician assistant) group having the highest resilience, compared to nurses [25].
During initial stage of the pandemic many countries adopted strict public health measures such as lockdown of local government area /cities or entire countries to curtail the spread which were blamed to be the cause of high mental health fall out. For example, in Assam province of India a survey revealed prevalence of "depression, anxiety and stress" among the population was quite high compared to national survey conducted in 2016 [26]. Further pandemic security measures and social distancing affected how people handled interpersonal relationships and empathy to others which were perceived as breaking relationships [27]. A recent study among 1005 participants found that the prevalence of symptoms of depression increased according to "relationship quality" from 13% up to 35% during COVID-19 [28]. A study conducted among Australian adults during the pandemic reported impairments in work and social functioning with elevations in depression and anxiety symptoms and decreased psychological wellbeing [29].
Economical strain due to the pandemic was a key correlate of poorer mental health [30], especially in Sri Lanka due to the impact on small and medium scale enterprises where employees not only lost their income, they found it hard to repay loans resulting in severe mental health consequences [31,32]. A recent study in US (United States) investigating school closure and children's mental health wellbeing pointed out that older children with "Black and Hispanic" background and from lower income families showed more impact on mental health than "white", younger and higher-income counterparts [33].
Community Level stigma related to catching infection was an issue during this pandemic; however, this is not only common to COVID-19 but was also observed in several pandemics or outbreaks in the past such as leprosy, cholera, TB and more recently HIV-AIDS which cause stigmatisation among patients and marginalized populations [34,35]. Misconceptions and rumours that COVID-19 infections are more prevalent among certain marginalized socio-economic groups and religious minorities such as Muslims, lower-caste groups, rural-poor population and frontline workers (healthcare, police) [36] lead to community stereotyping, discrimination, unrest, and con ict.
Pandemic showed collective phenomena with fake news, misinformation, disinformation and exaggerations that spread through social media and online platforms manifesting as unfound rumours [37,38] , panic buying (for example in Australia of toilet paper and other 'essentials' [39], hoarding (including ventilators and oxygen cylinders in India), naming and shaming [40], conspiracy (virus is a hoax, that it is caused by 5G, that tracking microchips are being implanted with the vaccine, that the virus is a scam for big pharma to make money, that big media is in cahoots with big pharma) and QAnon theories (world is run by a global cabal of Satan-worshipping paedophiles who control American politics and the media) [41] , doomsday predictions, and mass protests (anti-vaxers , far right against mask wearing, COVID -19 vaccination and lockdowns). These phenomena of group or herd behaviours could be termed 'mass hysteria' in times of heightened fear, mass anxiety, heightened emotions, uncertainty and frustrations with increased vulnerability and extreme suggestibility to misinformation [42]. Groups become easy prey to in uence where pent up emotions and anger are channelled or directed in pathological ways. A study in Germany revealed an association between "High level perceived threat of COVID-19" and less frequency of purchasing (P < 0.001) but increase of amount in one purchase (p < 0 .001) which was associated with perception of high level uncertainty through media exposure (P< 0.001) [43]. It was compared to foraging behaviour in rodents under threat conditions. Toilet paper became a target of panic buying for people frightened of contracting COVID-19 [44]. The need for further research on impact of COVID-19 on diagnosis and management of panic disorders was highlighted by a recent review [45]. Many complained that their freedom was compromised but researchers pointed out elimination strategies such as lock down has been viewed as a civic solidarity approach to restore perceived civil liberties the soonest compared to catching infection and living with long term effects such as "Long COVID" [46]. However, in ammatory speeches like that from an Australian parliamentarian that likened "state and territory COVID-19 restrictions to the despotic regimes of Nazi Germany and Cambodia, calling for civil disobedience as a response" are a call to arms that can whip up mass protests, frenzy and hysteria. Some of his latest comments were featured on the Infowars web series hosted by far-right American conspiracy theorist, who has been largely banned from social media sites such as Facebook, Instagram and YouTube for violating hate speech policies [47]. Even doctor groups [48] and other reputable professionals [49] including powerful and in uential world leaders [50] have been propagating conspiracy theories that have gone viral through social media during the pandemic.
In US around 142 637 youths lost a parent or grandparent or care giver to COVID-19 from April 1, 2020, to June 30, 2021 [51]. Seeing a parent grasping for breathe and continue to suffer for a month before death is very traumatic experience for a child. In US around one hundred and fty thousand youths lost their caregiver (parent or grandparent) to COVID-19 since early 2020 to mid-2021 [51]. This leads to "depression, PTSD suicidal ideation and attempts, and an increased risk of substance abuse, violence, risky sexual behaviours and sexual abuse, and shorter schooling" [51]. Further due to school closures and lack of community sports activities many worried about children and adolescent's mental health [52]. It's appeared as a common theme in our analysis: "Concerns about Children / Adolescent mental health".
A national survey found out that approximately 20% Australian children showed "disruptive behaviours, disturbed sleep or symptoms of anxiety or depression" during public health restriction period and "Children's Health Queensland's COVID-19 Unmasked (Young Children)" study found that to recover from this impact up to 10% of children may need specialised mental health support [53]. In a qualitative research among parents regarding parent -child relationships, participants reported increased fear, anxiety, uncertainty, and stress due to pandemic generated threats that had to be navigated with restrictions from public health orders within the context of parent child relationships [54].
In spite of the negative impact on mental health we noticed some positive themes during analysis which can be considered when planning to counteract the negative PSMH consequences from COVID-19 pandemic. Positive proactive, prosocial behaviours were also in evidence; such as encouragement, help and support for others; gratitude towards heath care workers; increased concern for cleaner environment and ecological causes; awareness of bio-knowledge (vectors, viruses, vaccines, immunity); charity and spiritual support, and innovative research observed during pandemic which can be used as social intervention tools in recovery strategies [55].
At the family level, improved understanding, support, family activities and cohesion during lockdowns were observed. Strategies to heal relationship di culties and ways of coming out of social isolation (managing social phobia/anxiety) can be the basis for post covid recovery. Compared to no relationship, a good relationship quality was a protective factor for mental health and wellbeing [27] . Further the closure of licensed pubs and social distancing measures in Australia in response to the COVID-19 appeared to have reduced harmful alcohol consumption in younger drinkers, particularly young women [56]. The COVID-19 pandemic has generally reduced the numbers of road tra c accidents (RTA's), and their deaths and injuries despite the relative increase of severity of injury and death [57]. Drops in suicide rate were reported during the COVID-19 pandemic, for example, 7% decreased in suicide rates observed in Taiwan  ( Table 3). Further a recent systematic review that investigated suicidal rate in middle-and low-income countries also concluded that suicide rates were not changed from 2019 to 2020 with the limited studies available Non-covid respiratory infections in Sri Lanka decreased during pandemic [64]. Flu incidences were historically low in Australia during the pandemic years due to preventive measures adopted to combat the COVID -19 and the community's adherence to public health messages [65]. The ABS also reported a decrease in overall death rates in 2020 [59]. These facts would be an argument for supporting the social distancing and public health measures as "social vaccine" in the political process of reopening the pubs and borders for economic reasons. It was argued that the "social vaccine": social distancing, travel restrictions and border closures, was the most powerful and effective measures to control spread of COVID-19 before the biological vaccines became available [7][8][9]. It could well continue to be useful as an additional measure, particularly in the context of possible evolution of newer, more infectious, deadlier and/or vaccine resistant variants.
In times of distress, the rst point of contact for many patients are family physician/GPs and primary health care workers. So they can be encouraged to manage mental health issues with additional support from government. They can prevent their own burnout by being re ective on their own vulnerabilities and seeking help when needed. There were calls for strengthening primary care system to navigate the mental health consequences during and after the pandemic [66]. Spirituality, considered as one dimension of health by WHO since 1995 [67], might be considered as a valuable coping mechanism for health care workers and the general public exposed to extreme stressful conditions during COVID -19 pandemic [68] .
As COVID-19 pandemic and public health responses affected social domains such as networks, relationships, interaction and intimacy; for long term social recovery, rebuilding locally sustainable stronger communities should be one of the key aspects of public health policy [69]. As shown in Figure 3, policy-level agenda addressing the wider social determinants of health highlighting the importance of mental health promotion as central to successfully counteract the effects of COVID-19 and as a means to addressing health inequality created by COVID -19 pandemic [70] would be bene cial.
There were many positive aspects noted during the pandemic that can be used to promote mental health.
For example, even though concerns regarding overdependence on social media and psychological effects raised by many when their free time increased, it was used for positive self-motivation to do more gym and tness exercises at home. Participants indicated playing music as a tool while working out and greatly helped them to overcome psychological issues [71].
During the COVID-19 lockdowns there were different ways of showing appreciation: a banging of pans as appreciation for health workers, a shout out at a zoom meeting, a thumbs up emoji, a retweet, regular email to team highlighting achievements, awards for colleague who showed great passion to ward patient care were mentioned by some authors. Many consider selecting one of these gratitude mindfulness exercises to enhance well-being is one of the intervention tool that can be used beyond the pandemic as well [72].
In spite of concern of overuse of social media during the pandemic, evidence showed online learning during COVID-19 produced equivalent or better student course performance as compared with prepandemic performances [73]. Further telehealth services enormously helped to continue health provision with minimal interruptions. Enhanced telehealth services will probably continue well beyond the pandemic to become routine practice.
Despite domestic violence and strained relationships due to covid restrictions, many families reported positive aspects, better understanding, such as opportunities for improving relationships, interactions, clearing unresolved con icts, adapting new hobbies, and developing appreciation, gratitude, and tolerance [74]. In another study many parents indicated that their relationships had improved and had utilized strengths during the pandemic [52]. So future research is needed regarding utilizing family strengths to identify what is working in parent-child relationships.
We also observed various community and religious organisations that offered various health promotion activities during the pandemic. However, religious or traditional festivals and mass gatherings such as for political rallies or protests, can become the source of super spreader events such as in some churches in As community across the world are now highly interconnected, greater international support and coordination are needed to strengthen further not only to curtail the spread of COVID-19 but also to overcome the effect of COVID -19 pandemic on mental health. This collaboration can be further strengthened if countries politically join in common agenda to combat the pandemic impact. Expanding global vaccine coverage and addressing inequitable distribution and handling the misinformation are essential to prevent emergence of new variant. So international collaboration such as the WHO Covax initiative should continue beyond the pandemic to address disparities caused by covid-19 pandemic and peace which are essential to create an environment conducive for mental well-being. 'With the global community now highly interconnected, countries will struggle to keep their citizens safe in the face of pandemic threats without embracing a framework for greater international cooperation and coordination' [89].

Conclusion
Mental health consequences due to COVID -19 pandemic and it affects are enormous at individual level, family level and community levels. We have witnessed several community level (mass hysteria) reactions during pandemic such as panic buying, hoarding, spreading conspiracy theories and protests such as anti-vaccination and anti-mask movements. Further, several myths, rumours and misinformation spread through the social media signi cantly contributed to community level psychosocial consequences.
Community level PSMH promotions through community organizations and/or religious/social organizations with the support of experts in relevant elds, strengthening primary health care to support individual and family level coping and appropriate use of social media by primary care physicians to counteract the misuse of social media by others are some of the way forward to build community resilience during and after the pandemic. In addition, international collaborations are essential to support struggling nations in order to overcome the impact posed by COVID-19 in many aspects.  Tables 1 &2, BK prepared Table 3. All authors read and approved the manuscript. Pathological changes in brain due to COVID-19 infection, adapted from [13,14] Figure 3 Socio ecological model of mental health promotion intervention