We reviewed fifty-five studies that focused on mental health deterioration and were considered part of LAU’s contribution to research in the era of COVID-19. It was clearly shown that mental health was largely studied in the early stages of the pandemic then the approach decreased later, despite the continuation of the severe socioeconomic crisis in Lebanon. This finding is of importance since it was essential to study the psychological burden imposed by COVID-19 in order to seek clinical updates and find solutions for this fast-growing pandemic. This pattern of results may represent an acute and normal response to an unforeseen and distressing traumatic event which was then followed by a period of psychological adaptation and resilience [90]. Similar to concerns raised early in previous publications [8], changes in existing mental health may be in part explained by imposed restrictions that provided a more structured daily routine and increased exposure to external stressors [91]. However, there was some heterogeneity observed for the change in mental health during the pandemic. Our review showed that worsening of mental health symptoms was most common in studies examining depression and mood disorders symptoms whereas the number of studies that assessed the change in anxiety symptoms was smaller. Again, the more pronounced change in depressive symptoms may be reflective of the effects of isolation and social restrictions and loss of social life during the pandemic [92].
Increases in mental health problems were observed across most population sub-groups (e.g. general population, university students, healthcare workers, etc.) even in vulnerable population such as prisoners and patients with pre-existing disease condition. Moreover, many studies have shown that mental health and wellbeing levels seemed to deteriorate in younger age groups – while adolescents and young adults are at greater risk of poorer mental health regardless of pandemic conditions [93]. Another important subgroup that was affected by the pandemic was the patients with pre-existing mental health problems. The same finding was highlighted by a previous study conducted earlier in 2020, where Galletly C. stated that the pandemic would be a difficult time for people with chronic mental illness [94]. However, the lack of studies reporting pre-COVID comparative data makes it difficult to determine the extent to which mental health declined for this type of patients when compared to those with no pre-existing mental health problems.
From the research productivity point of view, our results showed that researchers who addressed mental health deterioration in the era of COVID-19 research were mainly associate professors regardless of their affiliation or specialty. This is in line with the findings of Aksnes DW. et al. suggesting that faculty with a higher academic position tend to be more interested in publishing, especially in emergency situations where the chance of having more publications/citations increases even more [95]. More broadly, the emphasis on peer reviewed publication as a key criterion of academic success encourages academics to prioritize research. Moreover, it was noted that most of the work related to mental health research during COVID-19 pandemic have been published in Q1 and Q2 journals. In addition, there was a statistically significant correlation between the journal SJR Q and the publication citation rate. This is important in an academic environment because of the impact these journals have on one’s academic career such as on contract renewal, promotion and tenure. Having said that, most of researchers are usually eager to publish in highly reputable journals to promote their social and professional desirability [96].
Moreover, a positive association was shown between citation count and international authors’ collaboration. This is consistent with other prior publications, confirming that research collaboration adds benefits for both the researchers and the organizations and enhances the quality of research resulting in higher numbers of scholarly output [97]. To add, a significant positive association was demonstrated between LAU publications’ citation count and their relation to COVID-19. In fact, many international studies described the association between COVID-19 and worsening psychological symptoms, which may have played a major role in increasing the citation count of studies related specifically to COVID-19 [98, 99]. Unsurprisingly, several seminal Covid-19 publications have been cited at incredibly high rates as researchers have turned to these papers to help guide their next steps[100, 101]. For example, the results of the study conducted by Brandt MD. et al. concluded that COVID-19 articles published between January 1, 2020 and December 31, 2021 are being cited at considerably higher rates than the non-COVID-19 papers [102]. Reasons behind the major increase in citations for COVID-19 articles are clear. In fact, this outbreak has dominated global focus since its onset in 2020, affecting over 200 countries across the world [103]. As such, researchers are eager to add their contributions to what can be done to combat this disease and, to do this, are citing earlier works to support their approaches.
The impact of COVID-19 on mental health was mainly assessed in observational and qualitative studies with a moderate to low GRADE quality of evidence. This was consistent with our expectations since this type of studies is usually more convenient despite having a lower level of evidence when compared to interventional studies [104]. However, a conclusion about the exact association between COVID-19 and worsening psychological symptoms seems to be difficult because of the scarcity of robust longitudinal cohort studies. To add, the number of LAU publications relating the deterioration of mental health due to COVID-19 were not abundant, which could be due to the lack of funding for such types of research in low-income countries such as Lebanon where the health system suffers severely [105]. For these reasons, there would a necessity to think of more experimental human studies since these are known to be more relevant with more generalizable results.
4.1. Future recommendations
4.1.1. Recommendations regarding education
The characteristics of a successful professional institution should be adequate to the requirements of the social situation. In this regard, university education should attain a crucial role in developing research-centered training, especially in the era of pandemics. Several initiatives were launched to communicate accurate scientific information to the public. For instance, medical and nursing students focused on mental health provision, such as online cognitive behavioral therapy for monitoring of deterioration of psychological symptoms and several blogs and podcasts were launched to explain different aspects of the pandemic. More specifically, schools of public health need to embrace more flexible modes of program delivery, e-learning, distance learning and life-long learning. Such developments are crucial to train the public health workforce that is needed in both the developed and the developing world.
4.1.2. Recommendations regarding research
Besides education, other challenges need to be addressed. These include the safety of the community, the financial sustainability, and the internationalization strategy with the government. Perhaps most importantly, universities must provide basic and applied research as well as direct medical assistance. They must also disseminate scientifically correct content and participate in campaigns to ensure that the population obtains timely and accurate information. Higher education institutions have a duty to pursue their research activities, despite the restrictions that the current situation imposes.
4.1.3. Public health recommendations
In addition to the previously mentioned recommendations, a national action plan is required to manage poor mental health. Given the pervasiveness of economic impacts due to the pandemic, a focus on national prevention interventions that targets social determinants of health such as food security, safe housing and access to education is also warranted. Moreover, research studies with longitudinal designs and with defined comparison groups are needed to investigate possible risk factors and other long-term mental health impacts on people’s mental health.
4.2. Strengths and Limitations
To our knowledge, our review is among very few studies that have addressed the different mental health research fields that continued in the era of COVID-19. One of the strengths of this review is that we aimed at selecting studies that were conducted not only during the early stages of the pandemic but one year later. Given that there have been second waves of the pandemic in many countries, it was important to continue to monitor the impact of COVID-19 on mental health over the following years. However, few limitations are to be acknowledged. First, this review only provides a snapshot of the research available during the period when the existing literature was searched and it is possible that some published information has been missed. Although they are quite representative to date, it should be noted that other mental health-related studies might have been published during the time of the redaction of this review but were not included. Second, given the heterogeneity of studies included, it was difficult to conduct a meta-analysis that summarizes the overall findings in a quantitative manner. One key gap is the lack of longitudinal studies with comparative pre-COVID data. Consequently, conclusions about how mental health changed over the course of the pandemic and how people adapted during COVID, are currently limited. Third, the review does not provide detailed data on prevalence rates and statistical associations for each study as many of them did not provide this information. Therefore, it would be helpful to conduct future systematic reviews to make it challenging to combine the data to obtain comparative estimates in order to reflect a better impact of COVID-19 on psychological health and improve the country’s responsiveness to comprehensively study future challenges.