Forty-three articles for summary and critical analysis were included in this study. The majority of them described the presence of symptoms or mental disorders during the COVID-19 pandemic, especially in the most vulnerable population groups. These findings suggest that the advance of the pandemic may increase the likelihood of illness and psychiatric morbidities in different population groups, such as among the elderly and health professionals, and that it may be related to various aspects of the pandemic, such as social distancing measures, negative news and the growing number of confirmed and suspected cases.54
There is a growing number of scientific publications showing the possible relationship between the COVID-19 pandemic, and the presence or worsening of mental disorders, or symptoms of anxiety and depression. However, no controlled or longitudinal studies were found that could more robustly explore the relationships between the COVID- 19 pandemic and mental health outcomes (MH). Despite the noted effort to describe the problem (the effect of COVID19 on MH) while it is still occurring, there are problems in generalizing these findings, since most studies are cross-sectional, with no previous measurement of the outcomes studied for comparison. Also, some studies used samples based on voluntary selections, using online questionnaires. Therefore, selection bias is likely, due to samples concentrated in specific populations, often included according to availability criteria, in addition to many possible participants not being included because they do not have access to online tools, or have greater difficulty of using them.
Another limitation present in the studies was the collection of information in a single period and during different periods of the pandemic. While some studies measured outcomes at the beginning of the pandemic, others evaluated them at more advanced stages, therefore hindering comparisons.2 Long-term exposure was also not measured, which would be important since an increase in mortality and confinement time can influence the way people evaluate their own MH.3
Mental disorders and symptoms associated with COVID-19
Anxiety
Of the 43 articles selected, 77% (n = 33)10,11,14–44 indicated a relationship between anxiety symptoms and the COVID-19 pandemic. High anxiety scores were found associated with the diagnosis of coronavirus, coping with alcohol/drugs, extreme hopelessness and suicidal ideation.35 A study found high levels of anxiety among the population studied, 80% of which reported being concerned with COVID-19.31 Issues associated with the risk of anxiety and depression were related to the fear of the COVID-19 pandemic, and the fragility related to patients' clinical issues, the fear of being infected and becoming ill,40 and that family members would contract COVID-19 (75.2%).38 Anxiety generated by the fear of running out of medication was also one of the issues cited as sources of concern.40 Negative emotions (anxiety, depression and indignation) increased, while positive emotions (measured by the Oxford happiness scores) and satisfaction with life decreased with the pandemic.11
A study carried out with 7,236 Chinese individuals showed a general prevalence of symptoms of anxiety, depressive symptoms and poor sleep quality in 35.1%, 20.1% and 18.2% of those investigated, respectively.29 The prevalence of symptoms of anxiety and depressive symptoms was significantly higher in younger participants (<35 years) (p<0.001).29 Another study conducted in China on 5,851 individuals found a prevalence of depression, anxiety and a combination of depression and anxiety during the Covid-19 period among 48, 3% (95% CI 46.9% -49.7%), 22.6%
(95% CI 21.4%-23.8%) and 19.4% (95% CI 18.3%-20.6% ) of participants, respectively.48 Lei et al. (2020)27 found the prevalence of anxiety and depression to be approximately 8.3% among the 1,593 survey participants. Moghanibashi- Mansourieh (2020),10 in applying an online questionnaire to 10,754 participants, found that the level of severe anxiety was serious for 9.3% of the participants and very serious for 9.8%. Chew et al. (2020),28 conducting research among health professionals (n = 906), found that 8.7% (n = 79) of participants suffered from moderate to extremely severe anxiety, while Ahmed et al. (2020)30 found a higher anxiety rate (29%), dangerous, harmful alcohol consumption or alcohol dependence (30%), and lower than usual mental well-being (32.1%) among the 1,074 individuals in the Chinese province of Hubei who answered the online questionnaire.
In another study, where 124 questionnaires were distributed, with a response rate of 84.7% (105/124),26 it was found that the prevalence of total, mild, moderate and severe anxiety were 18.1%, 10.5%, 5, 7% and 1.9%, respectively. Respondents who had experience of exposure to COVID-19 reported higher rates of anxiety, accompanied by depression, than those who had no experience of exposure (incidence rates of 31.6% and 12.6%, respectively).26
In addition to these studies, Lei et al. (2020),27 in a study conducted on 1,593 participants in southeastern China, found a prevalence of 8.3% of anxiety, and 14.6% of depression. The prevalence in the affected group (12.9%, 22.4%) was significantly higher than in the unaffected group (6.7%, 11.9%). Subjects were considered affected if they or their families/colleagues/classmates/neighbours had been quarantined. Lower average family income, lower education levels, greater concern about being infected by COVID-19, not having psychological support, higher economic losses and poorer self-reported health conditions were statistically significant, associated with higher scores on the self-rating anxiety scale (SAS) and self-rating depression scale (SDS).27
Depression
Of the selected articles, 56% (n = 26)11,15,18–20,22,23,25–30,32,33,36,37,39–41,43,45–48 investigated the relationship between COVID-19 and depression or depressive symptoms. Among these, a study with 1,593 participants in China found a prevalence of depression of approximately 15%.27 Another study carried out in the most affected areas of China found that 634 [50.4%] of participants reported symptoms of depression.38 Multivariate Logistic Regression analysis showed that participants from outside Hubei province were less likely to experience symptoms of distress, compared to those in Wuhan (OR: 0.62; 95% CI: 0.43-0.88).38
A study found a prevalence of depression, and a combination of depression and anxiety, during the Covid-19 period of 48.3% (95% CI 46.9% -49.7%) and 19.4% (95% CI 18.3% - 20.6%), respectively.48 Furthermore, a study in Vietnam found an increased prevalence of depression (29.2%) in patients who had COVID-19 infection (p 0.016).46 There was an increase in the prevalence of comorbid depression with anxiety (p 0.086), both in patients with COVID- 19 infection (21.1%) and in the general public (22.4%). Patients who had COVID-19 infection (19.3%) and the general public (14.3%) also had a higher proportion of severe depressive symptoms (p 0.002). In addition, patients who experienced COVID-19 infection, and the general public, were more likely to display a depressed mood (p 0.038) and somatic symptoms (all p <0.01), compared to quarantined individuals. Survey participants (3,947 people recruited from the outpatient departments of nine hospitals and health centres in Vietnam) who were diagnosed with COVID-19 had a higher probability of depression (OR 2.88; p <0.001), and a lower score on the scale that measures health-related quality of life (HRQoL) (B -7.92; p <0.001). Health literacy was a protective factor for depression and HRQoL during the COVID-19 epidemic, especially among people not diagnosed with the disease.46
In a study of 500 individuals, 62% reported no likelihood of psychological distress, while 19.4% and 18.6% had a mild and moderate to severe likelihood.45 Cyclothymic (OR 1.24; p <0.001), depressive (OR 1.52; p <0.001) and anxious temperaments (OR 1.58; p 0.002) and the ASQ "Need for approval" (OR 1.08; p 0.01) were risk factors for moderate- to-severe psychological distress, compared to no distress. On the other hand, the ASQ "Confidence" (OR 0.89; p 0.002) and "Discomfort with closeness" were protective (OR 0.92; p 0.001). The cyclothymic (OR 1.17; p 0.008) and depressive (OR 1.32; p 0.003) temperaments resulted in being risk factors in individuals with moderate to severe psychological distress, compared to mild distress, while the ASQ "Confidence" (OR 0.92; p 0.039) and “Discomfort with closeness” (OR 0.94; p 0.023) were protective.45
In another study in which 124 questionnaires were distributed with a response rate of 84.7% (105/124), the results showed mild (SAS score 53 to 62), moderate (SAS score 63 to 72) and severe depression (SAS score ≥ 73) in 22, 5 and 4 cases, respectively.26 The incidences of cases of total, mild, moderate and severe depression were 29.5%, 21.0%, 4.8% and 3.8 %, respectively. Respondents who had the experience of exposure reported higher rates of anxiety, accompanied by depression, than those who had no experience of exposure (incidence rates of 31.6% and 12.6%, respectively).26
Analyzing the overall prevalence of generalized anxiety disorder (GAD), the public's depressive symptoms and sleep quality were 35.1%, 20.1% and 18.2%, respectively.29 Young people, however, reported a significantly higher prevalence of GAD and depressive symptoms than the elderly. Compared to another occupational group, health workers were more likely to have poor sleep quality. Age (<35 years) (OR 1.77; 95% CI 1.38-1.95) and time spent focusing on COVID-19 (≥3 hours per day) (OR 1.91; 95% CI 1, 77-2.15) were associated with GAD. Young age was also associated with depressive symptoms (OR 1.80; 95% CI 1.35-2.01), and health professionals were at high risk of having poor sleep quality (OR 1.48; 95% CI 1.15-1.95).29
Changes in sleep pattern
Another symptom frequently reported in the articles was changes in sleep pattern.22,29,31,32,36,49,50 Huang & Zhao (2020)29 found a general prevalence of anxiety symptoms, depressive symptoms and poor sleep quality of 35.1 %, 20.1% and 18.2%, respectively. The prevalence of symptoms of anxiety, depressive symptoms and poor sleep quality was significantly higher in health professionals who spent a great amount of time (≥3 hours / day) dealing with COVID-19 patients, as compared to those investing less time (<1 hour / day and 1-2 hours / day).29
Roy et al. (2020)31 reported negative sleep changes in 12.5% of the survey participants, Huang & Zhao (2020)29 in 18.2 of the 7,236 participants, and Liu et al. (2020)49 demonstrated that participants with better sleep quality or lower frequency of nighttime waking reported lower PTSD. While anxiety was associated with greater stress and reduced sleep quality, higher levels of social capital were positively associated with increased sleep quality.50 Compared to another occupational group, health professionals were more likely to have poor sleep quality (OR 1.48; 95% CI 1.15- 1.95).29
Another study carried out in China, including a total of 1,563 participants, showed that 36.1% of participants (n = 564) had symptoms of insomnia, according to the Insomnia Severity Index (ISI) (total score ≥ 8).22 Insomnia symptoms were associated with education levels (high school or lower) (OR 2.69; p 0.042; 95% CI 1.0–7.0), type of team (physician) (OR 0.44; p 0.007 ; 95% CI 0.2–0.8), current work department (isolation unit) (OR 1.71; p 0.038; 95% CI 1.0–2.8), concern about being infected (OR 2.30 ; p <0.001; 95% CI 1.6–3.4), perceived lack of utility of news or social media in relation to COVID-19, in terms of psychological support (OR 2.10; p 0.001; 95% CI 1,3–3,3) and strong uncertainty regarding effective disease control (OR 3.30; p 0.013; 95% CI 1.3–8.5).22
Obsessive behaviors
Four of the studies included in the current review addressed factors related to obsessive behaviours.13,15,31,44 Among these, a study carried out in China, including 1,060 respondents who accessed the online platform Wenjuanxing, showed a 70% prevalence of symptoms of moderate and higher psychological changes, with specifically high scores for obsessive-compulsive disorder, interpersonal sensitivity, phobic anxiety and psychoticism.44 People aged over 50, who were better educated, divorced or widowed, and who performed agricultural work, had a higher number of symptoms. People who were younger, and those on a medical team, were in the highest risk group, in terms of the severity of psychological symptoms.44 Another study also conducted in China found that living in rural areas, being a woman, and being at risk of contact with patients diagnosed with COVID-19, were the most common risk factors for being obsessive-compulsive.15
Comparing doctors to other health professionals, the study found that doctors had a higher prevalence of obsessive- compulsive symptoms (5.3 vs. 2.2%; p <0.01).22 They also had higher total scores for obsessive-compulsive symptoms in the Generalized Anxiety Disorder 2-item (GAD-2) psychological test and Revised Symptom Checklist- 90- (SCL-90-R)(p ≤0.01).15 Research on 3,947 participants in Vietnam showed that the COVID-19 epidemic led to panic and hypochondria, resulting in the unnecessary seeking-out of health care, and increased demand for health care services among people consulted online in the general population.13
Among the concerns that could increase obsessive symptoms, 72% (n = 662) of participants in a survey conducted in India cited excessive concern about the use of gloves and disinfectants.31 Participants reported symptoms such as negative sleep changes (12, 5%), paranoia about the use of social media related to COVID-19 infection (37.8%), and anguish (36.4%).
Post-Traumatic Stress Disorder (PTSD)
In addition to symptoms of anxiety, depression and sleep disorders, Post-Traumatic Stress Disorder (PTSD) has been linked to COVID-19. Liu et al. (2020)49 found a 7% prevalence of PTSD symptoms in the areas most affected by the COVID-19 outbreak in China. Hierarchical regression analysis, and a nonparametric test, suggested that women had higher PTSD, with negative changes in cognition, mood or hyperexcitation. Participants with better sleep quality, or less frequency of nighttime waking, reported lower PTSD.49
Tan et al. (2020),32 found that a prevalence of 10.8% of the 673 respondents to the questionnaire fit the diagnosis of PTSD after returning to work, and Chew et al. (2020)28 found a high risk of PTSD (OR 2.20; 95% CI 1.12–4.35, p 0.023) associated with the presence of physical symptoms experienced in the previous month among 906 health professionals who participated in the research. The most common reported symptom was headaches (32.3%), with a large number of participants (33.4%) reporting more than four symptoms.28
Specific populations
In addition to specific symptoms and disorders, the crisis caused by COVID-19 seems to be characterized by having a distinct influence on specific population groups. Two of the selected studies44,53 investigated the influence of the COVID-19 pandemic on the elderly, and five others17,22,25,29,39 its influence on children, schoolchildren or young people. In addition, seven studies addressed the relationship between COVID-19 and MH among women.10,12,18,20,33,38,49
The elderly
Elderly subjects are more susceptible to depressive symptoms, due to losses they experience during their lives and cerebral vascular changes.55 Depression and anxiety in the elderly appear among the most frequent reasons for requesting a psychiatric consultation.56 The elderly population are among the most affected by the COVID-19 pandemic, both in terms of severity and mortality, and are also more likely to suffer psychological impacts during this period.4,57
Tian et al. (2020),44 observed a 70% prevalence of symptoms of moderate and greater psychological changes, with specifically high scores for obsessive-compulsive disorder, interpersonal sensitivity, phobic anxiety, and psychoticism. People aged over 50, who were better educated, divorced or widowed, and who performed agricultural work, had more symptoms. However, younger people and those in a medical team, were in the highest risk group, in terms of the severity of psychological symptoms.44 Another study indicated that individuals over the age of 60 had higher anxiety scores than the general population.12 Losada-Baltar et al. (2020),53 however, suggested that it is not chronological age itself, but the negative self-perception of ageing that is related to loneliness and psychological suffering in people during a forced stay at home during the COVID-19 crisis. Elderly people with a positive self- perception of ageing seem to be more resistant to loneliness and distress during the COVID-19 outbreak.
Bacon & Corr (2020),21 found that interviewees who were more concerned were older, had negative attitudes towards illness, and scored higher in reactivity of the reward (RR), indicating motivation to adopt a positive attitude, despite prevailing concern/anxiety. Concerns about personal safety were greater in those with negative attitudes towards illness, and with higher scores in the fight-flight-freeze system (FFFS, reflecting fear/prevention). The results suggest that people are experiencing psychological conflicts between the desire to remain safe (related to FFFS), and the desire to maintain a normal and pleasant life (related to RR). Ways to reduce the conflict may include maladaptive behaviours (panic buying) reflecting reward-related displacement activity. Self-isolation is intended to be related to FFFS, but is also related to low scores in the behavioural inhibition system (related to anxiety). The elderly reported being less likely to isolate themselves.21
Children, schoolchildren and parents
The COVID-19 pandemic can also affect children's thoughts, behaviours and emotional responses, the most affected being those who are separated from their caregivers during this process.58 Yuan et al. (2020),39 found that the anxiety scores of parents of children undergoing epidemic hospitalization can also be altered, and were significantly higher (EH) (7.02 ± 3.01) when compared to the anxiety score of parents undergoing non-epidemic hospitalization (NEH) (3.62 ± 2.10) (p <0.001). Likewise, the depression score of parents of children with EH (7.72 ± 2.81) was higher than the depression score of parents of children with NEH (4.54 ± 2.56) (p <0.001). There was a positive correlation between the anxiety, depression and drowsiness scores among parents of children with EH. Parents of children hospitalized during the COVID-19 epidemic face enormous pressure and anxiety. Post-traumatic stress disorder and MH problems can occur in parents, which can affect the child's recovery.39
Zhang & Ma (2020),22 demonstrated that the average behaviour of children with ADHD (M 2.25; SD 0.54) worsened significantly, compared to their normal state (95% CI 2.18-2.32); 53.94% of parents reported that their children's ability to stay focused worsened, 67.22% that the frequency of anger increased, and 56.02% that the daily routine worsened. More than half the parents reported that their children's behaviour in other domains had improved, or stayed at the same level. Children's ADHD behaviors were positively linked to acute stress in response to the COVID-19 outbreak (r 0.21; p 0.001), parental attention to the media coverage of COVID-19 news (r 0.13; p 0.048), general mood (negative) of children and parents ((r 0.48; p <0.001) and (r 0.41; p <0.001) respectively) and negatively correlated with the children's study time (r -0.19; p 0.004) and children's interaction with parents' time (r - 0.17; p 0.008). In the regression analysis, children's general mood (β 0.17; 95% CI 0.11-0.23; p <0.001), parents'
general mood (β 0.13; 95% CI 0.06 -0.20; p <0.001) and children's study time (β -0.09; 95% CI -0.15, -0.02; p 0.010) significantly predicted children's ADHD behaviors.22
Young people can also be impacted by COVID-19 contingency measures, especially the most vulnerable population groups, such as informal and unemployed workers, in the face of scenarios in which the possibilities of work become scarcer. Research conducted in China, based on interviews with 7,143 university students, showed that 25% of participants suffered from anxiety. Of these, 0.9% experienced severe anxiety, and 21.3% experienced mild anxiety.17 Protective factors against anxiety were seen to be: living in urban areas, having family income stability, and living with parents.17 On the other hand, having relatives or acquaintances infected with COVID-19 was a risk factor for anxiety among these university students.17 The results reinforce the importance of implementing social protection measures during social distancing, in order to mitigate possible MH impacts on the most vulnerable people in the population.
Research carried out with schoolchildren in home confinement in Wuhan & Huangshi, a province in Hubei, China, showed that of the 1,784 survey participants, 22.6% reported depressive symptoms, and 18.9% anxiety symptoms.25 Wuhan students had significantly higher CDI-S scores than those from Huangshi (β 0.092; 95% CI, 0.014-0.170), with a higher risk of depressive symptoms (OR 1.426; 95% CI 1.138-1.786). Students who were not concerned about being affected by COVID-19, or only slightly, had significantly lower CDI-S scores than those who were very concerned (β -0.184; 95% CI -0.273 to -0.095), with a reduced risk of depressive symptoms (OR 0.521; 95% CI 0.400-0.679). Those who were not optimistic about the epidemic, compared to those who were quite optimistic, had significantly higher scores on the Children's Depression Inventory–ShortForm (CDI-S) (β 0.367; 95% CI 0.250-0. 485), with an increased risk of depressive symptoms (OR 2.262; 95% CI 1.642-3.117). There was no significant association between demographic characteristics and symptoms of anxiety.25
Huang & Zhao (2020),29 on the other hand, found a general prevalence of generalized anxiety disorder (GAD), depressive symptoms and sleep quality disturbances in the public in 35.1%, 20.1% and 18.2% of young people, respectively. Young people reported a significantly higher prevalence of GAD, and depressive symptoms than the elderly. Age (<35 years) (OR 1.77; 95% CI 1.38-1.95) and the time spent focusing on COVID-19 (≥3 hours per day) (OR 1.91; 95% CI 1.77-2.15) were associated with TAG. A young age was also associated with depressive symptoms (OR 1.80; 95% CI 1.35-2.01), and health professionals were at high risk of having poor sleep quality (OR 1.48; 95% CI 1.15-1.95). Young people who spent more than 3 hours a day thinking about the outbreak had a significantly higher prevalence of symptoms of anxiety (p <0.001).29 A previous study found that isolated or quarantined children during epidemics, or in disaster situations were more likely to develop acute stress and adjustment disorders, and suffering.59
Women
A study using hierarchical regression analysis and a nonparametric test, in research conducted in the areas most affected by the COVID-19 outbreak in China, suggested that women had higher levels of PTSD.49 Another study in China, carried out among health professionals, found that young women were the most affected psychologically.33 The chance of experiencing anxiety during the pandemic period seems to be greater among women (OR 3.01; 95% CI 1.39-6.52) and among people aged over 40 (OR 0.40; 95% CI 0.16-0.99).18 Almost 35% of respondents experienced psychological distress.12 Multinomial logistic regression analyses showed that women showed significantly higher psychological levels of distress than men.12 Female nurses, women, first-line health professionals, and those working in Wuhan, China reported more severe degrees of all MH measurements than other health professionals.20 Female gender, the presence of Covid-19 symptoms, and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety and depression (p <0.05).38
Another study, of more than 12,000 people, of which approximately 90% (10,754) completed the questionnaire, showed that the total anxiety level was 8.61 ± 6.95, and the severity of anxiety symptoms in 49.1% of the cases was normal, in 9.3% it was severe, and in 9.8% it was very severe, with the highest level of anxiety being among women (p <0.001).10
Health professionals
Doctors, nurses, and other healthcare professionals may experience trauma while treating patients, especially when they are dealing with a new disease that they are unsure how to treat effectively. According to Bao et al. (2020),60 the stress they experience can trigger common mental disorders, including post-traumatic stress disorder, anxiety and depressive disorders which, in turn, can result in threats exceeding the consequences of the COVID-19 epidemic itself.
A study conducted in China showed that of the 994 medical and nursing staff surveyed in Wuhan, 36.9% had MH disorders below the threshold (PHQ-9: 2.4 average), 34.4% had mild (PHQ-9: 5.4), 22.4% had moderate (PHQ-9: 9.0) and 6.2% had severe disorders (mean PHQ-9: 15.1), shortly after the COVID-19 epidemic.33 With regards to these professionals' Mental Health in this period, 36.3% reported having accessed psychoeducational materials (such as books on MH), and 50.4% psychological resources available in the media (such as online messages about MH self-help methods). Meanwhile, 17.5% of professionals participated in counselling or psychotherapy.33 A similar result was also found by Zhang Y. and Ma Z.F. (2020),22 in China, with the prevalence of depressive, anxiety and stress-related symptoms being 50.7% (PHQ-9 ≥5), 44.7% (GAD-7≥5) and 73.4% (HEI-R ≥9), respectively, among the medical team. Xu et al. (2020)41 compared MH measurements during and prior to the outbreak among the medical team, and found that the surgical team's anxiety, depression, dream anxiety, and SF-36 scores during the outbreak period were significantly higher than in the non-outbreak period (p <0.001).
In India and Singapore, a study showed that of the 906 health professionals who participated in the survey, 5.3% (n =48 had positive results for moderate to very severe depression, 8.7% (n = 79) for moderate to extremely severe depression, 2.2% (n = 20) for moderate to extremely severe stress and 3.8% (n = 34) for moderate to severe levels of psychological distress.28 Depression (OR 2.79; 95% CI 1.54 -5.07; p 0.001), anxiety (OR 2.18; 95% CI 1.36-3.48; p 0.001), stress (OR 3.06; 95% CI 1.27-7.41; p 0, 13), and post-traumatic stress disorder (PTSD) (OR 2.20; 95% CI 1.12-4.35; p 0.023) were significantly associated with the presence of physical symptoms experienced in the previous month.28
Studies have also shown that professionals who are on the front line for the treatment of Covid-19 may be more impacted by the consequences of the pandemic.14,20,29,41,51 For example, a study conducted in China showed that health professionals involved in the diagnosis, treatment and care of patients with COVID-19 were more likely to have symptoms of depression (OR 1.52; 95% CI 1.11-2.09), anxiety (OR 1.57; 95% CI 1.22-2.02), insomnia (OR 2.97; 95% CI 1.92-4.60) and anguish (OR 1.60; 95% CI 1.25-2.04) than those working in other areas.20 Also in China, trauma scores of frontline nurses, including those for psychological and physiological clinical responses, were significantly higher than staff who were not on the front line (p <0.001).51
Huang & Zhao (2020),29 also found a higher prevalence of symptoms of anxiety, depressive symptoms and poor sleep quality in health professionals who spent more time caring for COVID-19 patients.29 Sun et al. (2020),14 explained that nurses who care for patients with COVID-19 may have negative emotions, such as fatigue, discomfort and helplessness, caused by high-intensity work, fear, anxiety, and concern for patients and family members. A study carried out in China compared fear, anxiety and depression between two groups of hospital employees,43 with the medical team showing greater symptoms of fear, anxiety and depression than the administrative team. In addition, the analysis also showed that medical staff working in departments that maintain direct contact with patients with pneumonia resulting from coronavirus infection had more psychological disorders and almost twice the risk of experiencing anxiety and depression.43
Other factors can also influence the mental health of health professionals, such as living in rural areas, being a woman, and being at risk of contact with patients diagnosed with COVID-19.15 Mo Y. et al. (2020),16 investigated work-related stress among female nurses who supported the fight against the COVID-19 infection in Wuhan, and found that being an only child, having a greater weekly workload, and anxiety, were the main factors that affected the nurses' stress levels.
Summary of recommendations and strategies listed by the studies
Although controlled or longitudinal studies related to MH at the time of COVID-19 were not found in this review, research indicates that there may be expected MH consequences for populations. The studies published so far point to the need of emphasising on MH care while the pandemic is still ongoing, in order to avoid extensive future problems, and possibly reduce the duration and cost of treating subsequent psychological effects. Psychotherapy and counselling are fundamental to this aim. They also listed specific measures for the most vulnerable population groups or those that may be most affected by COVID-19, such as the elderly and health professionals. Cognitive Insomnia Behavior Therapy (CIBT) is a promising intervention for acute sleep pattern alterations, it also can improve patients' self-efficacy and confidence in controlling their sleep problems.22
Mental Health (MH) Professionals
It is recommended that mental health professionals be attentive to individuals' emotional responses during the current pandemic, as well as to pre-existing risk factors, and people with a history of mental illness presenting pathological levels of negative emotions and related behaviours.23 They should suggest limiting the time for taking in information related to COVID-19 to a maximum of two hours a day; maintaining a normal work rhythm, and resting as much as possible; exercising regularly in order to promote sleep quality; and not accessing information about outbreaks before bed.29 They should educate the public about common adverse psychological consequences and promote healthy behaviour, for example using alternative forms of communication, such as virtual networks.10
MH professionals currently have an important role to play in supporting the public's well-being. Continuous surveillance and monitoring of the psychological consequences of outbreaks of potentially epidemic and life- threatening diseases, and establishing early mental health interventions should become routine, as part of efforts to prepare for outbreaks worldwide.29
Health professionals on the front line
The study results pointed to the importance of being prepared to support frontline workers fighting the pandemic through mental health interventions in times of crisis,33 especially those allocated to the respiratory, emergency, ICU, and infectious disease departments.43,51 The main measures cited by the articles were: to increase the availability of specialized treatment with psychologists and psychiatrists;33,44 to enable multidisciplinary interventions, addressing both psychological manifestations and physical symptoms; to provide counselling dedicated to relieving the fear of transmitting the infection to family members, and increase confidence and self-esteem;28 and to develop the strengthening of support from colleagues in the workplace, online forums for teams or advice hotlines, and early identification of risk factors by employers,32 through stress management and professional health services in psychological consultancy, and early intervention.32,61
Health professionals also require adequate working conditions, with the provision of sufficient protective medical equipment, and adequate rest time, as well as access to programs designed to increase the capacity for resilience and psychological well-being.15 They must be mobilized so that they actively seek out their social support systems. Leisure activities and training on how to relax should be organized, to help staff reduce stress.16
The post-pandemic period is also a concern, it will also involve MH impacts seen during the pandemic. It is highly recommended that health professionals include the promotion of mental health as part of their follow-up after the pandemic, and that they observe symptoms of traumatic stress, which can lead to the development of avoidance behaviours, or passive lifestyles after the pandemic.22 Finally, in order to better prepare for future outbreaks of infectious diseases, greater investment in MH tools is needed, in order to assist and protect the medical and nursing teams working on the front line.33
Meanwhile, as far as patients are concerned, the importance of performing a periodic assessment of patients' health- related quality of life under clinical-home care should be emphasized. At-risk patients require adequate care, planning individualized medical and psychological support throughout life, especially in exceptional cases, as in the COVID-19 pandemic.40
Children and young individuals
For children and parents, early detection of parental MH problems, and the timely provision of certain psychological interventions will help parents to take better care of their children in hospital, and help children to recover and be discharged as quickly as possible.39 Attention is also needed to identify an appropriate approach for children with Attention Deficit Hyperactivity Disorder (ADHD), in terms of disaster risk reduction activities.22
Special attention must also be paid to the psychological health of individuals under the age of 18, and from middle age to the elderly (aged over 50), providing psychological interventions through television, internet and the telephone. For young people, guidance should be given, in order to understand the epidemic, and to alleviate panic and fear.4
Public policies
Governments must first recognize COVID-19 as an emergency public health concern, in order to improve health literacy and control the disease and its consequences during the outbreak.46 It is necessary to provide the public with transparent, up-to-date, accurate, brief and simple information, and knowledge about the epidemic, pathogenicity and transmissibility, in order to better control the disease.29,46 It could also establish an official, integrated and uniform platform for MH counselling, to provide psychological counselling to people in need.29
Identifying those who may be most affected by COVID-19, not exclusively epidemiologically, but also through working and living in the most affected regions, has important implications. This identification helps direct resources to those who need most.52 The timely identification of psychological distress, and accurate classification of MH needs among populations, will facilitate the development of targeted psychological interventions.47 Similarly, it is necessary to adopt preventive measures for PTSD, and other mental problems.49 Professional psychological assistance and counselling should focus on the psychological health of vulnerable populations, those with lower levels of education, women and susceptible groups, such as the divorced or widowed,44 suspected and diagnosed patients, young people and health professionals, especially doctors and nurses who work directly with patients or quarantined people.29
In summary, it is necessary to formulate psychological interventions to improve MH and psychological resilience during the COVID-19 epidemic.38 The government should aim to adopt appropriate subsidy policies to alleviate the economic pressure on the general population caused by the epidemic,44 and increase medical support,27 in addition to implementing public policies that stimulate social capital during isolation.50 Social support not only reduces psychological pressure during epidemics, but also changes attitudes towards methods for seeking help.17
The Media
The use of social media data can provide a timely understanding of the impact of public health emergencies on the public's MH during the epidemic period.11 However, the media can also have negative consequences on people's MH. Research has found that more than 80% (95% CI 80.9%-83.1%) of participants reported being frequently exposed to social media,48 and high chances of anxiety (OR 1.72; 95% CI 1.31-2.26) and a combination of depression and anxiety (CDA) (OR 1.91; 95% CI 1.52-2.41) were observed among users who were frequently exposed.48 A study conducted in Iran also showed a higher level of anxiety among the people who followed coronavirus-related news the most (p <0.001).10 Therefore, the feeling of distress and panic that takes hold of the population due to the amount of information in the media, or ¨ infodemia¨, is also of concern. Monitor, filter out false information and promote accurate information by means of collaboration between professionals from distinct backgrounds could reduce the impact of this type of distress.48 It is also recommended that MH services be disseminated through various channels, including hotlines, online consultations, online courses and outpatient consultations, with special attention to signs of depression and anxiety.48 The media should aim at reporting the progress of the epidemic and increase publicity for psychological counseling.44