Mental health during the COVID-19 pandemic

As the pandemic began, the risks were uncertain. As sick people flooded into hospitals and official advice evolved, the lack of information increased stress and anxiety.[11] Many uncertainties surrounded the beginning of the pandemic, including estimating infection risk, symptom overlap between COVID-19 and other health problems.[12]

During the first wave of the epidemic, critical supplies were quickly exhausted. The most prominent items were personal protective equipment (PPE) for hospital workers and ventilators for treatment.[11] At the onset of the pandemic in early 2020, a national survey found that many medical facilities were running out of PPE supplies, including one third of the surveyed medical facilities reporting being out of face masks and a quarter reporting a shortage or almost shortage of gowns.[13] Another study reported that 63.3% of nurses agreed with the statement, “I am worried about inadequate personal protective equipment for healthcare personnel (PPE)”.[14]

As the pandemic began, anyone who interacted with infected people had to address the possibility that they might have been infected themselves and might therefore present an unknown risk to their family and others. In some cases, they were initially stigmatized.[12][15][16]

Many care homes subjected their residents to enforced isolation. They were locked into their rooms around the clock, including at mealtimes when their meals were delivered to their doors. Visitors were not allowed, nor was any socialization among the residents.[17]

Nurses worked longer hours during the pandemic, which increased anxiety in many. Many patients rapidly progressed once in the hospital to the ICU and ultimately, death. The absence of approved therapeutics meant that palliative care (supplemental oxygen, ventilators and extracorporeal membrane oxygenation) were the only options. In some cases, this stimulated frustration and a sense of powerlessness.[18]

Those caring for COVID-19 patients were subject strict biosecurity measures, consigned to wearing gowns, uncomfortable masks and face shields at work. After returning home, many changed clothes before entering and isolated themselves, in an attempt to protect their families. Their jobs demanded constant awareness and vigilance, reduced their autonomy, reduced access to social support, reduced self-care, uncertainty about the effects of long-term exposure to COVID-19 patients, and fear of infecting others.[19][20]

In some jurisdictions, schools were closed during the early months of the pandemic. Such closures increased anxiety, loneliness, stress, sadness, frustration, indiscipline, and hyperactivity among children.[21]

WHO and CDC issued guidelines for minimizing mental health issues during the pandemic. The summarized guidelines are:[24][25][26]

• Be empathetic to affected individuals.
• Use people-first language while describing infected individuals. (for example, instead of saying "a schizophrenic person, say "a person with schizophrenia").[27]
• Minimize watching the news to reduce anxiety. Seek information only from trusted sources, preferably once or twice a day.
• Protect yourself and be supportive to others.
• Amplify positive stories of local infected people.
• Honor healthcare workers who are caring for those with COVID-19.
• Implement positive thinking.
• Engage in hobbies.
• Avoid negative coping strategies, such as avoidance of crowds and pandemic news coverage.

What are health care workers experiencing?

• Feeling pressure is normal in a crisis. Mental health is as important as physical health.
• Nurses face higher rates of fatigue, sleep problems, depressive disorders, PTSD, and anxiety.
• Personal Protective Equipment shortages leaving nurses feeling unsafe.
• Frontline health care works experience higher levels of stress
• Nurses expressed elevated stress. Hands-on patient care increasresed risk perception. Vaccinated nurses were less fatigued than others.[11] Nurses working with infected patients faced more anxiety, depression, and distress. Non-frontline nurses exhibited less depression.[14]

What actions can healthcare workers take?

• Adopt coping strategies, get sufficient rest, eat healthy food, be physically active, avoid tobacco, alcohol, or drugs.
• Stay connected with loved ones, including digitally.
• Use understandable ways to share messages with people with disabilities.
• Know how to link people with available resources.
• Online counseling can reduce the risk of insomnia, anxiety, and depression/burnout.[20]

• Focus on long-term occupational capacity rather than short term results.
• Ensure good quality communication and accurate updates.
• Ensure that staff are aware of mental health resources.
• Orient staff on how to provide psychological first aid to the affected.
• Ensure that mental health emergencies are managed in healthcare facilities.
• Ensure availability of essential psychiatric medications at all levels of health care.
• Offset feelings of anxiety and depression using strong leadership and clear, honest, and open communication.[28]
• Use widespread screening to identify workers in need of mental health support.[29]
• Provide organizational support
• Facilitate peer support.[29]
• Rotate work schedules to mitigate stress.[30]
• Implement interventions tailored to local needs and provide positive, supportive environments.[30]

• Role model healthy behaviors, routines, and coping skills.[31][32][33][34][35][36][37]
• Use a positive parenting approach based on communication and respect.[33][34][36]
• Maintain family routines and provide age-appropriate activities to teach children responsibility.[31][35][37][38]
• Explain COVID-19 and required interventions in age-appropriate ways.[32][33][34][36][37][38][39]
• Monitor children's social media.[31][34][38]
• Validate children's thoughts and feelings and help them find positive ways to express emotions.[34][37]
• Avoid separating children from their parents/caregivers as much as possible. Ensure regular contact with parents and caregivers, for children in isolation.[31][39][40]

• Older adults, those especially in isolation or suffering from pre-existing conditions, may become more anxious, angry, or withdrawn. Provide practical and emotional support through caregivers and healthcare professionals.
• Share facts on the crisis and give clear information about how to reduce infection risk.
• Maintain access to current medications.
• Find out in advance where and how to get practical help.
• Learn and perform daily home exercises.
• Keep regular schedules.
• Keep in touch with loved ones.
• Continue hobbies or regular tasks.
• Talk on the phone or online or do a fun online activity with others.
• Help your community, e.g., by providing food/meals to others.

• Stay connected and maintain social networks.
• Pay attention to your needs and feelings. Engage in relaxing activities.
• Avoid listening to rumors.
• Begin new activities.
• Maintain routines.

CDC stated that citizens should "try to do enjoyable activities and return to normal life as much as possible" during a crisis.[41] A peer-reviewed study published in 2021 suggests that playing video games may have a positive effect on players' mental health and well-being, providing opportunities for socialization and connection.[42]

A psychological intervention plan was developed by the Second Xiangya Hospital, the Institute of Mental Health, the Medical Psychology Research Center of the Second Xiangya Hospital, and the Chinese Medical and Psychological Disease Clinical Medicine Research Center. It focused on building an intervention medical team to provide online courses for medical staff, a hotline team, and interventions.[43] Online education and counselling services were created for social media platforms such as WeChat, Weibo, and TikTok. Printed books about mental health and COVID-19 were republished online. Free electronic copies were available through the Chinese Association for Mental Health.[44]

The government loosened Health Insurance Portability and Accountability Act (HIPAA) regulations through a limited waiver. It allowed clinicians to evaluate and treat individuals though video chatting services that were not previously permitted, allowing patients to receive remote care.[45] On October 5, 2020, then-president Donald Trump issued an executive order to address mental and behavioral health issues, establishing a Coronavirus Mental Health Working Group.[46] In the executive order, he cited a CDC report that found that during June 24–30, 2020, 40.9% of more than 5,000 Americans reported at least one adverse mental or behavioral health condition, and 10.7% had seriously considered suicide during the month preceding the survey.[47] On 9 November 2020, a study reported findings from an electronic health record network cohort study using data from nearly 70 million individuals, including 62,354 individuals.[48] Nearly 20% of COVID-19 survivors were diagnosed with a psychiatric condition between 14 and 90 days after diagnosis, including 5.8% first-time psychiatric diagnoses. Among patients without previous psychiatric history, patients hospitalized for COVID-19 had increased incidence of a first psychiatric diagnosis compared to other health events analyzed. Together, these findings suggest that COVID-19 may increase psychiatric sequelae, and those with pre-existing psychiatric conditions may be at increased risk for COVID-19.[49]

Due to a lack of pre-COVID comparative data and non-representative sampling, few research were able to clearly identify changes in mental health caused by the COVID-19 environment. According to research, the early years of 2020 saw an upsurge in mental health problems. Young people, people with pre-existing mental health disorders, and people who are financially disadvantaged have been found to face an increase in declining mental health. Some demographics appear to have been under researched (e.g., culturally and linguistically diverse populations and indigenous peoples), while some research methodologies have not been utilised (e.g. there was a lack of qualitative and mixed-methods studies). [50]

Obsessive-compulsive disorder (OCD), perceived as a medical disease, is extremely common in developing and developed countries alike.[51] The social and collective perception of OCD as an illness albeit, is subjective and varies cross-culturally. As such, data relating to the impact of the COVID-19 pandemic upon sufferers of OCD is skewed because of different cultural influences on behaviour and ‘relationships between beliefs’.[52] Those living with OCD have been subject to socioeconomic, pandemic-related stressors, as COVID-19 has been covered across social media and the 24/7 news cycle since its outbreak. These media outlets emanate fear, and the probability of contamination in conjunction with regulatory quarantines and periods of isolation, trigger precautionary compulsions in OCD patients. Such behaviour is driven by the ‘psychological distress’ of governmental control and social restrictions.[53]

Emotions of high stress and loneliness are contributing factors of Post-Traumatic Stress Disorder (PTSD) and the COVID-19 Pandemic has provided individuals with conditions in which these symptoms foster. COVID-19 has affected social structures across cultures, and for people living with PTSD, global measures that regulate the body by means of school closures, border restrictions, social distancing, mask wearing and hand washing, expose the ‘population to feelings of intense fear and helplessness’.[54] A study on the psychological distress experiences by health care workers across 21 countries reveals a PTSD prevalence of 21.5%. The Middle East and Europe were both countries of interest in this study, indicating the cross-cultural impact that COVID-19 has had upon PTSD. [55]

An increase of mental health issues such as depression and anxiety during the COVID-19 pandemic is a commonly held perception worldwide. Whilst this is true for several western cultures and societies it does not encompass all of the minorities within these cultures. In a study conducted by Giurgescu et al (2022),[56] it was concluded that levels of perceived anxiety and depression had increased for pregnant African American women during the pandemic. Further to this, they also concluded that pregnant African American women experienced higher levels of loneliness that increased their levels of perceived anxiety, stress, and depression. The higher levels anxiety and depression within this minority can be attributed to several social factors they have had to experience in their lifetime. The history of underlying social inequity and oppression may have paved way for a higher mortality and morbidity rate, job loss and food and housing insecurities. Although the COVID-19 pandemic has affected rates of mental health amongst most western cultures, the people within these demographics are likely to be impacted by historical, social and biological factors that have led to high levels of depression and anxiety irrespective of COVID-19.[57]

Studies from previous years and epidemics reported that children who were isolated were much more likely to develop PTSD.[35][38] PTSD in children can have long-term consequences on brain development and affected kids are more likely to develop psychiatric disorders.[32][36][37]

Pandemic lockdowns impacted mental health outcomes for children with special needs, creating challenges including the lack of understanding about the pandemic and the ability to complete school work.[37] Children on the autism spectrum were more likely to become agitated by the changing environment.[37]

Adolescents and children with attention deficit hyperactivity disorder (ADHD) struggled with staying confined in only one space, creating difficulties for caregivers to find activities that were engaging/meaningful to them.[37]

The impact of COVID-19 restrictions and isolation impacted on children's abilities to use successful coping mechanisms and management techniques for ADHD. Issues of diagnosis and treatment were also prevalent. Primarily, clinicians faced the problem of differentiating between situational and persistent ADHD symptoms in children and adolescents, who did not have the same environmental triggers (i.e. social spheres) which allowed their symptoms to be best evaluated.[62] Those wanting to be evaluated for expression of ADHD symptoms were subject to extensive wait lists for clinical analysis as a result of staff shortages during the pandemic. Those that were offered a positive diagnosis were then further restricted by the limited non-medication based treatment options, such as behavioural and educational therapies. [62] Those children and adolescents already living with diagnosed ADHD were also facing substantial challenges. Studies conducted during the pandemic showed that social isolation and homestay directives led to an increased reliance on screen-time to manage attention problems. A 75% increase in online gaming participation was observed. [63] In some instances, gaming may represent an unhealthy coping mechanism for ADHD youth and has already been demonstrated to exacerbate poor management of symptoms. [63] Furthermore, this excessive screen-time was prolonged by the use of Zoom for learning. Children with ADHD were required to simultaneously process auditory and visual cues during these online classes, leading to 'distracted connection' [63] and mental overstimulation.

At the time of pregnancy, women who undergo mental distress negatively impact themselves and their child, therefore the Covid-19 pandemic plays a role in affecting women and their child through increased feelings of anxiety and depression.[67]

Covid-19 increases fear and worries of vulnerability due to the unclear understanding of how Covid-19 impacts pregnancy. A 2020 study in China of 4,124 pregnant women found that after they learned that Covid-19 could be spread from human to human their scores on the Edinburgh Postnatal Depression Scale were much higher. They showed increased anxiety levels, depression levels, and suicidal thoughts.[64]

A 2020 study in Canada of 1,987 pregnant women showed results that 37% of the women showed depression symptoms, 46.3% showed high anxiety levels, and 67.6% showed an increase in pregnancy-correlated anxiety.[64]

Pregnant women that tested positive for Covid-19 faced complications including preterm birth, premature rupture of membranes, fetal distress, stillbirth, and placental infections.[64]

More than one third of Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) scores in pregnant women were above normal during the pandemic in a study conducted by Durankus.[67]

The possible threats that Covid-19 put on the mother and child's life and how it could possibly impact proper prenatal care correlated to higher levels of stress, depression and anxiety.[68] Anxiety in pregnant women increased as they thought about the possibility of being infected, changing birth plans, running out of food or essentials, and the uncertainty of how Covid would impact their labor process.[68]

A 2018-2020 study found that Latina immigrants declared facing discrimination and stigma from others who believed that they had the Covid-19 disease. This kind of treatment impacted or even worsened their mental health.[69] Latina immigrants were given an increase in caregiving roles with little support from others during the pandemic which played a role in their poor mental health and wellbeing.[69]

Studies have shown higher levels of depression and anxiety in Latina immigrants compared to before the pandemic. Latina immigrants already dealt with economic stress before the pandemic but Covid-19 escalated their stress through isolation, fear, lack of support, services and resources.[69]

A 2020 study of Barcelona women compared their anxiety and depression levels during the initial days of lockdown and then 5 weeks after lockdown during the Covid-19 pandemic. Results showed that their anxiety levels went from 8.5% to 17.6% and their depression levels went from 7.7% to 22.5%.[70]

Their results showed a correlation of higher risks of anxiety and depression with women who have unstable personalities and women who can't easily control negative emotions. The pandemic increased stress which impacted those vulnerable to handling stressful situations.[70]

Women who dealt with economic issues, and unemployment during the pandemic showed poor mental health but women with the neuroticism trait were most vulnerable to mental health issues during pandemic.[70]

A survey conducted in Turkey in 2020 concluded that younger women and women who are in school showed higher mental burnout. The shift from in-person learning to online learning negatively affected women's mental health.[66]

Women had to balance school, work, and caregiving during the pandemic which caused them to burnout and have an increase in stress. They also worried about testing positing and possibly spreading the disease since they were working and coming home during the pandemic.[66]

Staying at home while being restricted from socializing created a negative impact on women's mental wellbeing; they become exhausted, lonely, stressed, and worried.[66]

Schools have been able to play the role of a safety net in many cases where adults look out for the mental health status of their students. In schools teachers and adults are able to be on the look out and recognize physical/emotional distress, signs of physical abuse, and/or sudden significant or subtle changes in behavior.[77] Should they recognize any apparent disruptions, teachers are able to intervene and provide their students with the necessary resources to help them.[77] However, during the COVID-19 pandemic, with students and teachers out, this system has not been in place. When schools shut down, teachers had to resort to online learning where they were no longer able to see how students were doing physically/mentally and weren't able to provide them with the help they needed. With the lack of resources to help students, it resulted in a drastic increase in depression and anxiety rates, increasing by over 20%. Since students were suffering mentally, it became challenging for them to have the motivation to do their school work.[78]

As COVID-19 mitigation efforts began to ease up and students return to the classroom, teachers have noticed an increase in crying and disruptive behavior in this population of students and also increased occurrences in violence and bullying.[79] Mental health professionals call for schools and education institutions everywhere to implement a number of health promotion programs in their schools that may teach students how to prevent succumbing to adverse mental health issues and how to cope with the reality and continuing effects of COVID-19 so that it does not get in the way of their education and future endeavours.[80]

The Higher Education Policy Institute conducted a study that reported that 63% of students claimed that their mental health had worsened, and that 38% demonstrated satisfaction with the mental health service access.[81] Physical harm such as overdose, suicide and substance abuse reached an all-time high. Academic stress, dissatisfaction with the quality of teaching and fear of infection were associated with higher depression scores.

Involvement in a steady relationship and living with others were associated with lower depressive scores. Research reported that psychological stress following strict confinement was moderated by levels of the pre-pandemic stress hormone cortisol and individual coping skills. Stay-at-home orders that worsened self-reports of stress also increased cognitive abilities including perspective taking and working memory.[82] However, that greater emotion regulation (measured pre-pandemic) was associated with lower acute stress (measured by the Impact of Event Scale-Revised) in response to the early pandemic in the US during lockdown.[83] Students who experienced a death of a close family member, a known stressor, were more likely to decide to stay home and attend college virtually.[84]

Isolation from others and lack of contact with mental health services worsened symptoms. The specific level of impact on students reflected their demographic backgrounds: students from low-income households and students of color experienced greater mental health and academic impacts. Students who struggle with mental health also struggled academically.[85] Students from high-income households and those in successful school districts were more likely to have to mental health (and other) resources.[86]

Those already living with psychopathology were more vulnerable to experience heightened levels of distress during lockdown measures.[87] Specifically, researchers saw an increase in the amount of eating disorders related vulnerabilities.[88] Social isolation that accompanies lockdown and stay at home measures for many resulted in a decrease in physical movement and activity, an increased amount of food in the home, and an increased time spent with a screen. There was an increase of 10% of student's perception of their body and the description of their weight as a risk factor for acquiring an eating disorder and exhibiting symptoms during the months between January 2020 and April 2020.[88] After lockdown ended, student's levels of physical activity remained below their pre-pandemic levels, even for those attending colleges that resumed in-person instruction.[84]

Studies showed that although college students did not have significant increases in their BMI, the rates in which college students were concerned about gaining weight and subsequent increases in their BMI significantly increased.[88]

An international survey conducted in Norway, USA, UK, and Australia at the end of 2020 found that university students in higher education had poorer mental health than non-students.[89]

Damage to the economy is associated with higher suicide rates. The pandemic put many businesses on hold, led to reduced employment, and triggered a major stock market drop.[122]

Stigma is a primary cause. Frontline workers, the elderly, the homeless, migrants, and daily wage workers were more vulnerable.[121] Stigma led to reported suicides in infected individuals in Bangladesh and India.[123]

Studies reported that the outbreak had a significant impact on mental health, with an increase in health anxiety, acute stress reactions, adjustment disorders, depression, panic attacks, and insomnia. Relapses and increased hospitalization rates are occurring in cases of severe mental disorders, obsessive-compulsive disorder, and anxiety disorders. All of which increase suicide risks.[121] National surveys in China (and Italy) revealed a high prevalence of depression and anxiety, both of which increase suicide risks.[121]

One Shanghai district reported 14 cases of suicides among primary and secondary school students as of June 2020, more than annual averages.[124] Domestic media reported additional suicides by young people even though topics like suicide are usually avoided in Chinese society.[124]

In September 2021, mental health organizations and an advisor to the government urged the government to address suicide prevention, although suicides in 2020 were lower than in 2019, as they warned that Fiji was beginning to suffer from a "mental health epidemic."[125]

Alcohol bans during the pandemic reportedly led to suicides in India.[126]

One study reported that people had been influenced by anxiety- and trauma-related disorders and by adverse societal dynamics relating to work and PPE shortages.[127]

Overall, suicide rates in Japan appeared to decrease 20% at the beginning, partly offset by a rise in August 2020.[114]

Counseling helplines by telephone or text message are provided by many organizations.[128]

On September 20, 2020, Sankei Shimbun reported that the month of July and August saw more suicides than in the previous year due to the pandemic's economic impact. Estimates for suicide deaths include a 7.7% increase or a 15.1% increase in August 2020, compared to August 2019.[114] Sankei Shimbun further reported that rates increased more among women, with the month of August seeing a 40.1% increase in suicide compared to August 2019.[129]

As of November 2020, the rate of deaths from suicide appeared to be unchanged in the US.[114] In Clark County, Nevada, 18 high school students committed suicide over nine months of school closures.[130] In March 2020, the federal crisis hotline, Disaster Distress Helpline, received a 338% increase in calls compared to February and an 891% increase in calls compared to March 2019.[131] Suicide rates increased for African Americans.[132]

South Africa implemented a strict lockdown on 26 March 2020 that lasted until 1 June. Of the 860 respondents to an online questionnaire in May 2020, 46% met the diagnostic criteria of anxiety disorder and 47% met the diagnostic criteria of depressive disorder.[135] The participants who met these criteria reported substantial daily life repercussions, but fewer than 20% consulted a formal practitioner.[135] Distress over lockdown and fear of infection were associated with anxiety and depressive symptoms. Pre-existing mental health conditions, younger age, female sex, and living in a non-rural area were associated with more anxiety and depressive symptoms.[135]

In July 2020, Japan was in "mild lockdown", which was not enforced and was non-punitive.[136] A study of 11,333 individuals across Japan were asked to evaluate the impact of a one-month lockdown, answering questions related to lifestyle, stress management, and stressors. It suggested that psychological distress indices significantly correlated with items relating to COVID-19.[137]

Italy was the first country to enter a nationwide lockdown. According to a questionnaire, 21% of participants reported moderate to extremely high depression, while 19% reported moderate to extremely high anxiety.[138] Moreover, about 41% reported poor sleep before the lockdown, increasing to 52% during the lockdown. A cross-sectional study of 1,826 Italian adults confirmed the lockdown's impact on sleep quality, which was especially prevalent among females, those less educated, and those who experienced financial problems.[139]

Spain's outbreak started at the end of February.[140] On March 14, 2020, the Spanish Government declared the state of alarm to limit viral transmission.[141] However, by 9 April Spain reported the second highest rate of confirmed cases and deaths. 36% of participants reported moderate to severe psychological impact, 25% showed mild to severe levels of anxiety, 41% reported depressive symptoms, and 41% felt stressed.[142] A longitudinal study collected data pre-pandemic and during confinement. It reported direct and indirect effects of pre-pandemic cortisol on the changes in self-reported, perceived self-efficacy during confinement. The indirect effects were mediated by increases in working memory span and cognitive empathy.[82]

As of January 2021, Vietnam had largely returned to everyday life. The government employed effective communication, early development of test kits, contact tracing, and containment based upon epidemiological risk rather than symptoms. By appealing to universal Vietnamese values such as tam giao (Three Teachings), the Vietnamese government encouraged a culture that values public health.[143] However, Vietnamese patients quarantining reported psychological strain associated with the stigma of sickness, financial constraints, and guilt from contracting the virus. Frontline healthcare workers at Bach Mai Hospital in Hanoi who quarantined for greater than three weeks reported comparatively poorer self-image and general attitude when compared to shorter term isolees.[144]

A 2022 study assessed the levels of mental wellbeing and potential for clinical need in a sample of UK university students aged 18–25 during the COVID-19 pandemic. Study has found "higher levels of lockdown severity were prospectively associated with higher levels of depressive symptoms. Nearly all students had at least one mental wellbeing concern at either time point." The results suggest that lockdown has caused "a wellbeing crisis in young people."[145]