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 difficulties 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 conflict.
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 influence 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, inflammatory 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 influential 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 fifty 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 difficulties 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 traffic 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 compared to pre-pandemic levels [58]. Similarly, data from the Australian Bureau of Statistics (ABS) show that the rate of suicide in 2020 dropped when compared with previous years [59]. Further reports from several countries mostly from high and middle income countries confirmed that suicide rates have not risen including England [60, 61]. Similarly in Sri Lanka, where some of the authors are practicing, noticed a marginal reduction even though it was not statistically significant (P>0.05) [62] (Table 3).
Table 3: Impact of pandemic on suicides in author’s practicing area
|
|
2019(Pre pandemic year)
|
2020(Immediate Post pandemic year
|
|
Place
|
Number of Suicides
|
Suicide rate
(per 100000)
|
Number of Suicides
|
Suicide rate
(per 100000)
|
|
Australia
|
3318
|
12.9
|
3139
|
12.1
|
|
England
|
5316
|
10.8
|
4912
|
10.0
|
|
Sri Lanka
|
3135
|
14.4
|
3074
|
14.1
|
Source: ABS [59], Samaritans [61], Sri Lanka Police [62]
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 [63].
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 [7-9]. 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 first 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 reflective 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 beneficial.
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 fitness 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 pre-pandemic 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 conflicts, 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 South Korea [75] , India [76], US [77] and Sri Lanka where unrestricted new year celebrations set of the second wave of infections [78]. In South African countries where some pastors preach against vaccination and promote conspiracy theories, leading to vaccine hesitancy and poor testing, can possibly result in spread of infection and emergence of deadlier mutations [79]. Similarly in Melbourne, Australia, the second wave of infection spread among culturally and linguistically diverse people' (CALD) led many states and organizations in Australia to adopt culturally adopted translation of key messages disseminated through their own community leaders [80, 81] . Royal Australian College of General Practitioner’s (RACGP) highlighted the need for “Different communication styles and approaches for culturally and linguistically diverse people (CALD)” [82].
Encouraging and promoting family and social activities within appropriate precautions of social distancing, masks and social vaccine measures; particularly for ethnic minority groups, economically disadvantaged, disabled, children and young people and/or older people, in the gradual community recovery process can reduce social isolation and loneliness, enhance psychosocial health and re-establish positive community relationships, trust, structures, functioning institutions, real-life networks, dynamics and processes. Improving access to nature through “green social prescribing”[18]; cultural practices, rituals, ceremonies, celebrations; individual, family, group, community stress reduction/ relaxation programs such as mindfulness, yoga, Tai Chi, meditation [83-85]; sports; artistic expressions, festivals; exhibitions; competitions; discussions, seminars, conferences, debates, drama, performances, and musical programs are examples that serve multiple healthy purposes of cathartic release of pent up emotions, exercise creative impulses and socialization in COVID safe community re-activation strategies. Fractures created on community organizational level can be rebuilt through positive community engagement. Empowering organizations and communities may be more successful when experts’ advice is combined with local community knowledge [86].
Royal Australian College of General Practitioner (RACGP) have highlighted the importance of critical role of GPs to address disparities caused by pandemic such as low vaccine uptake among Aboriginal and Torres Strait Islander people [82]. They also stressed the need to support GPs through adequate funding and more integration with referring facilities to strengthen Australian Health Care System [82, 87].
COVID-19 pandemic decreased inter/intrastate/civil conflicts and political violence in 2020, approximately 22% or 24,539 events decrease compared to 2019 reported by ACLED (Armed Conflict Location and Event Data Project) [88] with drops in resultant deaths, injuries and mental health consequences from such disasters [88].
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].