Mental health during the COVID-19 pandemic

Source: Wikipedia, the free encyclopedia.

COVID-19 increased the numbers for mental health disorders to the general public.

The COVID-19 pandemic has impacted the mental health of people around the world.[1][2] Similar to the past respiratory viral epidemics, such as the SARS-CoV, MERS-CoV, and the influenza epidemics, the COVID-19 pandemic has caused anxiety, depression, and post-traumatic stress disorder symptoms in different population groups, including the healthcare workers, general public, and the patients and quarantined individuals.[3][4] The Guidelines on Mental Health and Psychosocial Support of the Inter-Agency Standing Committee of the United Nations recommends that the core principles of mental health support during an emergency are "do no harm, promote human rights and equality, use participatory approaches, build on existing resources and capacities, adopt multi-layered interventions and work with integrated support systems."[5] COVID-19 is affecting people's social connectedness, their trust in people and institutions, their jobs and incomes, as well as imposing a huge toll in terms of anxiety and worry.[6]

COVID-19 also adds to the complexity of substance use disorders (SUDs) as it disproportionately affects people with SUD due to accumulated social, economic, and health inequities.[7] The health consequences of SUDs (for example, cardiovascular diseases, respiratory diseases, type 2 diabetes, immunosuppression and central nervous system depression, and psychiatric disorders) and the associated environmental challenges (e.g., housing instability, unemployment, and criminal justice involvement) increase risk for COVID-19. COVID-19 public health mitigation measures (i.e., physical distancing, quarantine and isolation) can exacerbate loneliness, mental health symptoms, withdrawal symptoms and psychological trauma. Women and young people faced the greatest burdens of depression and anxiety.[2][4] Confinement rules, unemployment and fiscal austerity measures during and following the pandemic period can affect the illicit drug market and drug use patterns.

Causes of mental health issues during COVID-19 pandemic

An exhausted anesthesiologist physician in Pesaro, Italy, March 2020
Sign in a gym in Ireland discouraging casual social contact due to the risk of infection. Loss of these kind of interactions has had an impact on many people during the COVID-19 pandemic.

Fear, worry, and stress are normal responses to perceived or real threats, and at times when we are faced with uncertainty or the unknown. So it is normal and understandable that people are experiencing fear in the context of the COVID-19 pandemic.

Added to the fear of contracting the virus in a pandemic such as COVID-19 are the significant changes to our daily lives as our movements are restricted in support of efforts to contain and slow down the spread of the virus. Faced with new realities of working from home, temporary unemployment, home-schooling of children, and lack of physical contact with other family members, friends and colleagues, it is important that we look after our mental, as well as our physical, health. In order to take care of our own health, professionals suggest implementing what they call "psychological PPE" into our lives. These habits include eating healthy foods, developing healthy coping mechanisms, and practicing mindfulness and relaxation methods.[8]

From the beginning, nurses have always had a stressful job of taking care of patients and juggling long shifts in the hospital. Unfortunately, their hours increased even more during COVID-19, in which many nurses had a huge increase in anxiety.[9] Cases of anxiety and depression within healthcare workers that interact with COVID-19 patients has increased by 1.57% and 1.52% respectively.[10] If untreated, anxiety and depression can lead to more severe mental and physical health outcomes.[11] A researcher, named Labrague, discovered that nurses who work in the frontline are more prone to mental and psychological issues, such as higher rates of anxiety, emotional exhaustion, depression, or post-traumatic stress disorder.[12] Some nurses had an increase in stress due to treating multiple patients at once or not having enough personal protective equipment.[12] Consequently, they experienced a 1.5 percent increase in anxiety from COVID-19 than before.[9]

In addition to these problems, COVID-19 can cause additional psychological responses, such as, risk of being infected when the transmission mode of COVID-19 is not 100% clear, common symptoms of other health problems being mistaken for COVID-19, increased worry about children being at home alone (during school shutdowns, etc.) while parents have to be at work, and risk of deterioration of physical and mental health of vulnerable individuals if care support is not in place.[5]

Another researcher named Kim conducted a cross-sectional study by using an online survey in Southern California where the experiment studied stress before and after the pandemic.[13] The study used the 10-item Perceived Stress Scale (PSS) and the Connor-Davidson Resilience Scale to learn psychological stress and resilience in the nurses.[13] The experiment concluded that nurses reported feeling moderate and high levels of stress compared to before the pandemic.

Frontline workers, such as doctors and nurses may experience additional mental health problems. Stigmatization towards working with COVID-19 patients, stress from using strict biosecurity measures (such as physical strain of protective equipment, need for constant awareness and vigilance, strict procedures to follow, preventing autonomy, physical isolation making it difficult to provide comfort to the sick), higher demands in the work setting, reduced capacity to use social support due to physical distancing and social stigma, insufficient capacity to give self-care, insufficient knowledge about the long-term exposure to individuals infected with COVID-19, and fear that they could pass infection to their loved ones can put frontline workers in additional stress.[5][14][15]

These mental health issues may also be due to self-isolating or being in quarantine. Wu et al. explain that after conducting their research they had found that those who have participated in these activities reported more symptoms of depression.[16] In contrast, researchers suspect that the depression and/ or burnout that healthcare workers are experiencing may not be from COVID-19 directly, but as a result of the situation it has put their families in and/or themselves in. It is said that as a result of COVID-19 the workload of healthcare providers has increased tremendously, possibly leaving the worker feeling drained and unable to catch up.[17] Unfortunately, there has not been enough research to pick out just one reason why this may be happening to individuals.

WHO, together with partners, is providing guidance and advice during the COVID-19 pandemic for health workers, managers of health facilities, people who are looking after children, older adults, people in isolation and members of the public more generally, to help us look after our mental health.

Further materials relating to looking after our mental health during the COVID pandemic will be added to this page as they become available.[5][18][19]

Prevention and management of mental health conditions

Coping with bipolar disorder and other mental health issues during COVID-19 infographic

World Health Organization and Centers for Disease Control guidelines

The WHO and the CDC have issued guidelines for preventing mental health issues during the COVID-19 pandemic. The summarized guidelines are as follows:[20][21]

For general population

  • Be empathetic to all the affected individuals, regardless of their nationality or ethnicity.
  • Use people-first language while describing individuals affected with COVID-19.
  • Minimize watching the news if that makes one anxious. Seek information only from trusted sources, preferably once or twice a day.
  • Protect yourself and be supportive to others, such as your neighbors.
  • Find opportunities to amplify positive stories of local people who have experienced COVID-19.
  • Honor healthcare workers who are supporting those affected with COVID-19.
  • Implement positive thinking.[22]
  • Engage in personal hobbies.[22]
  • Avoid negative coping strategies, such as avoidance of crowds and pandemic news coverage.[22]

For healthcare workers

What are health care workers experiencing? 
  • Feeling under pressure is normal during the times of a crisis. Managing one's mental health is as important as managing physical health.
  • Nurses face higher rates of fatigue, sleep problems, depressive disorders like PTSD, and anxiety emerged.
  • Personal Protective Equipment Shortages
  • COVID-19 led to PPE shortages within hospitals leaving nurses feeling unsafe and fearful when working. Supported in Kamberi’s study with 63.3% of nurses agreed with the statement, “I am worried about inadequate personal protective equipment for healthcare personnel (PPE)”.[23]
  • Frontline health care works experience higher levels of stress
  • Nurses expressed elevated levels of stress, especially those that are working directly with COVID-19 patients. Hands-on direct patient care towards the sick patients creates a high level of risk perception for the nurses. Nurses who received the COVID-19 vaccine were far less fatigued than those who had yet to receive it.[24] Nurses who did not work on the frontline exhibited lower levels of depression.[23] On the other hand, nurses working with patients who tested positive for COVID-19 were more vulnerable to levels of anxiety, depression, and distress.[23]
What resources are available to help healthcare workers? 
  • Follow coping strategies, ensure sufficient rest, eat good food, engage in physical activity, avoid using tobacco, alcohol, or drugs. Use the coping strategies that have previously worked for you under stressful situations.
  • If one is experiencing avoidance by the family or the community, stay connected with loved ones, including digital methods.
  • Use understandable ways to share messages to people with disabilities.
  • Know how to link people affected with COVID-19 with available resources.
  • Technology (online counseling) can provide physiological support in order to reduce the risk of insomnia, anxiety, and depression/burnout.[17]

For team leaders in health facilities

  • Keep all staff protected from poor mental health. Focus on long-term occupational capacity rather than short term results.
  • Ensure good quality communication and accurate updates.
  • Ensure that all staff are aware of where and how mental health support can accessed.
  • Orient all staff on how to provide psychological first aid to the affected.
  • Emergency mental health conditions should be managed in healthcare facilities.
  • Ensure availability of essential psychiatric medications at all levels of health care.
  • Strong leadership and clear, honest, and open communication is needed to offset these feelings of anxiety and depression.[25]
  • Conduct widespread screening to identify healthcare workers in need of mental health support.[26]
  • Provide organizational support and facilitate peer support.[26]
  • Establish organizational interventions that promote mental wellbeing among healthcare workers.[27]
  • Rotate work schedules to mitigate stress.[27]
  • Implement interventions tailored to the local needs of the hospital and provide positive, supportive environments for healthcare workers.[27]

For carers of children

  • Role model healthy behaviors, routines, and coping skills.[28][29][30][31][32][33][34]
  • Use a positive parenting approach based on communication and respect.[30][31][33]
  • Maintain family routines as much as possible and provide age-appropriate engaging activities for children to teach responsibility.[28][32][34][35]
  • Explain COVID-19 and the preventive measures in age-appropriate ways that children can understand to help them process what is happening.[29][30][31][33][34][35][36]
  • Monitor children's social media for safety.[28][31][35]
  • Validate children's thoughts and feelings and help them find positive ways to express emotions.[31][34]
  • Avoid separating children from their parents/carers as much as possible. Ensure that regular contact with parents and carers is maintained, should the child be placed in isolation.[28][36][37]

For older adults, people with underlying health conditions, and their carers

  • Older adults, those especially in isolation or suffering from pre-existing neurological conditions, may become more anxious, angry, or withdrawn. Provide practical and emotional support through caregivers and healthcare professionals.
  • Share simple facts on the crisis and give clear information about how to reduce the risk of infection.
  • Have access to all the medications that are currently being used.
  • Know in advance where and how to get practical help.
  • Learn and perform simple daily exercises to practice at home.
  • Keep regular schedules as much as possible and keep in touch with loved ones.
  • Indulge in a hobby or task that helps focus the mind on other aspects.
  • Reach out to people digitally or telephonically to have normal conversations or do a fun activity together online.
  • Try and do good for the community with social distancing measures in place. It could be providing meals to the needy, dry rations, or coordination.

For people in isolation

  • Stay connected and maintain social networks.
  • Pay attention to your own needs and feelings. Engage in activities that you find relaxing.
  • Avoid listening to rumors that make you uncomfortable.
  • Begin new activities if you can.
  • Find new ways to exactly stay connected, use other instant messaging clients to have multiple chats with friends and family.
  • Be sure to keep routine.

The Centers for Disease Control and Prevention also state that citizens should "try to do enjoyable activities and return to normal life as much as possible" during a crisis.[38] A peer-reviewed study published in 2021 suggests that playing video games may have had a positive effect on players' mental health and well-being, providing opportunities for socialization and a connection with normal life.[39]

Countries

China

A detailed 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 a psychological intervention medical team to provide online courses for medical staff, a psychological assistance hotline team, and psychological interventions.[40] Online mental health education and counselling services were created for social media platforms such as WeChat, Weibo, and TikTok that were widely used by medical staff and the public. Printed books about mental health and COVID-19 were republished online with free electronic copies available through the Chinese Association for Mental Health.[41]

United States

Due to the increase in telecommunication for medical and mental health appointments, the United States government loosened the Health Insurance Portability and Accountability Act (HIPAA) through a limited waiver. This allows clinicians to evaluate and treat individuals though video chatting services that were not previously compliant, allowing for patients to socially distance and receive care.[42] On October 5, 2020, President Donald Trump issued an executive order to address the mental and behavioral health consequences of the COVID-19 pandemic and its mitigation, including the establishment of a Coronavirus Mental Health Working Group.[43] In the executive order, he cited a report from the United States Centers for Disease Control and Prevention, which 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 considering suicide during the month preceding the survey.[44] On 9 November 2020, a peer-reviewed paper published in Lancet Psychiatry reported findings from an electronic health record network cohort study using data from nearly 70 million individuals, including 62,354 who had a diagnosis of COVID-19.[45] Nearly 20% of COVID-19 survivors were diagnosed with a psychiatric condition between 14 and 90 days after diagnosis with COVID-19, including 5.8% first-time psychiatric diagnoses. Among all patients without previous psychiatric history, patients hospitalized for COVID-19 also had increased incidence of a first psychiatric diagnosis compared to other health events analyzed. Together, these findings suggest that those with COVID-19 may be more susceptible to psychiatric sequelae of COVID-19, and those with pre-existing psychiatric conditions may be at increased risk for SARS-CoV-2 infection and COVID-19.[citation needed]

Impact on individuals with anxiety disorders

Obsessive–compulsive disorder

There has been a heightened concern for individuals suffering from obsessive–compulsive disorder, especially in regards to long-term consequences.[46][47] Fears regarding infection by the virus, and public health tips calling for hand-washing and sterilization are triggering related compulsions in some OCD sufferers, with some sufferers with cleanliness obsessions seeing these fears realized.[48][49][50] Amid guidelines of social-distancing, quarantine, and feelings of separation, some sufferers are seeing an increase in intrusive thoughts, unrelated to contamination obsessions.[51][52]

Post-traumatic stress disorder

There has been a particular concern for sufferers of post-traumatic stress disorder, as well as the potential for medical workers and COVID–19 patients to develop PTSD-like symptoms. In late March 2020, researchers in China found that, based on a PTSD checklist questionnaire provided to 714 discharged COVID–19 patients, 96.2% had serious prevalent PTSD symptoms. Additionally, there is a significant increase in PTSD symptoms and diagnosis among nurses who are regularly working with COVID-19 patients.[53][11]

Anxiety and Depression

From the start, nurses have always had a stressful job of taking care of patients and juggling long shifts in the hospital. Unfortunately, their hours increased even more during COVID-19, in which many nurses had a huge increase in anxiety.[9] Cases of anxiety and depression within healthcare workers that interact with COVID-19 patients has increased by 1.57% and 1.52% respectively.[10] If untreated, anxiety and depression can lead to more severe mental and physical health outcomes.[11]

Impact on children

Academics have reported that for many children who were separated from caregivers during the pandemic, it may place them into a state of crisis, and those who were isolated or quarantined during past pandemic disease are more likely to develop acute stress disorders, adjustment disorders and grief, with 30% of children meeting the clinical criteria for PTSD.[54]

School closures also caused anxiety for students with special needs as daily routines are suspended or changed and all therapy or social skills groups also halted. Others who have incorporated their school routines into coping mechanisms for their mental health have had an increase in depression and difficulty in adjusting back into normal routines. An additional concern has been shown towards children being placed in social isolation due to the pandemic, as rates of child abuse, neglect, and exploitation increased after the Ebola outbreak.[55] The closures have also limited the amount of mental health services that some children have access to, and some children are only identified as having a condition due to the training and contact by school authorities and educators.[42] A meta-analysis of 15 studies performed by Panda et al. (2020) showed that 79.4% of children and teenagers around the world suffered negative consequences as a result of COVID-19 and quarantine. The calculations showed that 42.3% were irritable, 41.7% had symptoms of depression, 34.5% struggled with anxiety, and 30.8% had problems with inattention. Many young people also struggled with boredom, fear, and sleep problems.[31] In an October 2020 global study (Aristovnik et al., 2020), the negative emotions experienced by the students were boredom (45.2%), anxiety (39.8%), frustration (39.1%), anger (25.9%), hopelessness (18.8%), and shame (10.0%). The highest levels of anxiety were found in South America (65.7%) and Oceania (64.4%), followed by North America (55.8%) and Europe (48.7%). The least anxious were students from Africa (38.1%) and Asia (32.7%). A similar order of continents was found for frustration as the second-most devastating emotion.[56]

One of the preventive measures taken in most countries during COVID-19 is quarantining anybody who exhibits symptoms or is in contact with somebody diagnosed with COVID-19. Studies from previous years and epidemics have shown that children who were isolated were much more likely to develop PTSD from the experience.[32][35] PTSD in children can have long-term consequences on brain development and affected kids are more likely to develop psychiatric disorders.[29][33][34]

Impact on students

A infographic students can use to stay connected to better their mental health

The COVID-19 pandemic has had considerable impact on students through direct effects of the pandemic, but also through the implementation of stay-at-home orders.[18] 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 being infected were associated with higher scores of depression in students.[18] Higher scores of depression were also associated with higher levels of frustration and boredom, inadequate supplies of resources, inadequate information from public health authorities, insufficient financial resources and perceived stigma.[18] Being in a steady relationship and living together with others were associated with lower depressive scores.[18] Research demonstrated that the psychological stress following strict social confinement was moderated by levels of the pre-pandemic stress hormone cortisol and individual abilities of resilient coping. The stay-at-home orders worsened self-reports of perceived stress but also led to an increase in cognitive abilities like perspective taking and working memory.[57] However, research has shown that greater emotion regulation ability (measured pre-pandemic) was associated with lower acute stress (measured by the Impact of Event Scale-Revised) in response to the early stage of the COVID-19 pandemic in the US during shelter-in-place orders (local lockdowns).[58]

The Higher Education Policy Institute conducted a report which discovered that around 63% of student's claimed that their mental health had been worsened as a result of the COVID-19 pandemic, and alongside this 38% demonstrated satisfaction with the accessibility of mental health services. Despite this, the director for policy and advocacy at the institute has explained that it is still unclear as to how and when normality will resume for students regarding their education and living situation.[59]

Due to the COVID-19 pandemic student's mental health has been impacted significantly due to students being isolated from others and not having contact with the mental health services available to them with in-person schools.[60] The specific level of impact on students varies by demographic backgrounds however, students from low-income households and students of color have experienced a higher level of impact.[60] Students from these demographics are also suffering academically from the pandemic due to them not having access to many of the vital things used in virtual learning environments. This disadvantage that they have correlates with a decrease in academic performance and achievement increasing the impact on their learning and growth.[60] The effects on student's mental health from the pandemic will continue even when the pandemic is over. Due to the connection between academic achievement and a student's mental health, students who struggle with mental health during the pandemic will also struggle academically.[60]

This impact on a student's education will not disappear when the pandemic is over but will take a significant amount of time to catch all students up to the same place.[60] This creates an even bigger disadvantage between certain groups of students and others. Students who come from high-income households and those in certain school districts will most likely have continued access even during the pandemic to these mental health resources and other resources lessening the impact to the academic achievement and learning while those who are low income will most likely not have access to the same mental health resources and other resources during the pandemic.[61]

These issues and impacts are not only evident in K-12 students but also in higher education students. Due to the pandemic, many students who had planned to enroll in college in the fall of 2020 ended up not due to various circumstances and issues related to the pandemic.[62] These students along with those who did attend will still have to deal with the impacts on their mental health and education during the pandemic. Those who did attend whether virtually or in-person might still not have access to the mental health resources they previously might have had with in-person instruction and that coupled with the significant stress that comes with the transition to college can have a drastic impact on their academic performance and learning.[60] Students can still feel isolated even with virtual learning happening because there may be a lack of connection between students and their instructors and their peers due to everything happening virtually and there being a lack of direct communication between students and between their instructors. This continued feeling of isolation can decrease a student's overall mental health and well-being and lead to worse academic performance. Students in higher education also have many other stressors involved such as difficult classwork, living expenses, and the higher education environment. These stressors are only being made worse during the pandemic impacting student's mental health even more. Students who come from low-income households might feel these impacts even more than other students because these stressors might be even worse for them.[60]

Overall, the COVID-19 pandemic has had a significant impact not only on students educationally but also on their mental health. The students that have been most affected by the COVID-19 pandemic have been those who come from low-income families and students of color.[60] The effects of the pandemic on student's mental health and educational development will still be present even after the pandemic has ended due to how significant of an impact it has had on students.[60]

Impact on essential workers and medical personnel

Before COVID-19, healthcare workers already had a lot of stressors. They have a difficult time managing their time with such a busy schedule, they have to make sure to provide for their family, they have to deal with unsatisfied patients, as well as already having a difficult job by itself. It is important for health care workers to know how to tackle their stressors because they are more susceptible to medical errors. The physical and emotional burden of working with COVID-19 impacted medical personnel severely by causing higher rates of anxiety, depression, and burnout which eventually lead to poor sleep, poor quality work/empathy towards patients, and even higher suicide rates.[63]

A five-part questionnaire was conducted among health care workers in Ghana to know the statistics/correlation between COVID-19 and mental health. The first part of this questionnaire was to record the demographics of the medical personnel. The second part would be the results of the Fear of COVID-19 Scale in which participants would mark statements from a range “completely disagree” through “strongly agree.” The lowest category would be worth 1 point, while the highest category (strongly agree) would be worth 5 points. At the end of this part of the questionnaire, surveyors would add up the scores and place them in one of the following scales: No fear, mild fear, moderate fear, and extreme fear. The higher the number, the higher level of concern for the COVID-19 Pandemic. For the third part of the questionnaire, participants answered the Depression Anxiety Stress Scale in which they answered questions and ranked them similar to the Fear of COVID-19 Scale; however, the difference is that for the DASS-21 Assessment, participants ranked the statements from zero (does not apply to me at all) through three (applied to me most of the time). Because the DASS-21 assessment is split up into three categories, (Depression, Anxiety and Stress), surveyors would calculate three different numbers, one for each category. This scale is very similar to the Fear of COVID-19 Scale; the only difference is that the scale has 5 categories ranging from normal to extremely severe. Just like the COVID-19 Scale, the higher the number, the more psychological effect on staff. The fourth part includes a series in questions in which participants strongly agree, are neutral or strongly disagree in whether or not they are provided with a good psychological environment. Lastly, the fifth part is also categorized just like part four, however, the questions ask whether or not participants are coping in a healthy way.

This study resulted in over 40% of health staff having mild to extreme fear of COVID-19. The highest percentage of the three subcategories from the DASS-21 assessment was Depression with 15.8%. However, only 29.78% receive the salary that the government provided to them for relief, and only 39.71 are insured in case they are infected with the deadly virus.[64]

A study in South Africa did not show a difference in anxiety (scored on the GAD-7) or depression (scored on the PHQ-9) among health workers active during the pandemic compared to the general population.[65]

Hospitals in China such as The Second Xiangya Hospital (Psychology Research Center), and the Chinese Medical and Psychological Disease Clinical Medicine Research Center noticed the signs of psychological distress very quickly and had set up a plan to help the staff with their struggling mental health. They suggested interventions to help with coping with stress in a healthy way, a hotline, and several courses to become educated on how to cope with stress. Health care workers disagreed because they stated that all they needed was uninterrupted rest as well as more supplies. 42.28% of respondents in Ghana proved that their hospitals do not provide sufficient protective equipment.[64] Moreover, medical staff in China did agree to use the psychologists’ skills to help them deal with noncompliant and/or emotionally distressed patients. In addition, they also suggested possibly having mental health specialists ready when a patient becomes emotionally distressed.[66]

Along with the personal protective equipment (PPE) shortage affecting medical professionals, there are multiple additional effectors that have caused such an increase in mental wellness. Health care professionals are experiencing fear towards possible Coronavirus exposure, as well as likely disease transmission to acquaintances if infection were to occur.[67][68] This fear has correlated to a significant decrease in nurse mental health.

An increased patient workload has also contributed to the mental health decline. Patient counts in hospitals are increasing astronomically, causing severe hospital overload. Due to this, the majority of the medical professionals have each experienced a higher patient workload on average.Supporting nurses' mental health during the pandemic[69][70] In addition, nurses have had to step into the role of family proxy due to new guide lines set in place preventing family visitation, in order to decrease viral transmission rates.

As a result of COVID-19, anxiety in healthcare workers has been on the rise. Anxiety is a big part of mental health and it directly correlates with how workers' perform in healthcare. Since the peak of COVID-19, many studies have been conducted to answer the question of just how much COVID has affected the mental health of individuals in health care. Since the COVID outbreak that started on March 11,  2020, the virus has rapidly and uncontrollably spread to over 200 countries, and millions of healthcare workers around the world have been putting their lives at risk in order to nurture and save the lives of people exposed. A study done by Di Mattei et al. revealed that 12.63% of COVID nurses and 16.28% of other COVID healthcare workers reported extremely severe anxiety symptoms at the peak of the pandemic.[71] In addition, another study was conducted on 1,448 full time employees in Japan.[72] The participants were surveyed at baseline in March 2020 and then again in May of 2020. The result of the study showed that psychological distress and anxiety had increased more among healthcare workers during the COVID-19 outbreak.[72] Similarly, studies have also shown that following the pandemic, at least one in five healthcare professionals report symptoms of anxiety.[73] Specifically, the aspect of “anxiety was assessed in 12 studies, with a pooled prevalence of 23.2%” following COVID.[73] When considering all  1,448 participants that percentage makes up about 335 people.

Although the mental health of medical staff as a result of COVID has not been commonly talked about, the findings of author Woon et al. reveal just how drastically things have changed in a couple of months.[25] His study conducted on 399 participants from two universities suggest that the prevalence rates of anxiety post COVID were about 31.6%. Even so, “participants with moderate to extremely severe anxiety made up  25.8% of the sample”.[25] Combined accounting for over 50% of those who were surveyed. The results concluded that individuals who worked during the COVID-19 pandemic reported higher rates of anxiety. As research supports, healthcare workers may experience a significant amount of psychological distress as a result of COVID-19 due to providing direct patient care. In addition, according to a study conducted by three doctors from Texas, "41.5% of respondents had significantly more anxiety than providers who did not care directly for patients."[16] Even still, the effects of COVID-19 on healthcare providers is very evident when evaluating symptoms of anxiety.

Apart from anxiety, higher levels of depression and burnout have been seen in healthcare workers as a direct result of COVID-19. In one experiment scientists reported that “more than 28% of the sample reported high levels of emotional exhaustion, except for other non-COVID healthcare workers”.[71] In addition more than 50% of the sample reported low levels of depersonalization, except for COVID nurses and physicians, who reported high levels of depersonalization in 36.73% of the cases.[71] Depersonalization can be defined as a sense of detachment from oneself and one's identity. Taking this into consideration, it is easy to conclude that as a result of COVID-19 the mental health of health care workers has degraded. In addition, when evaluating the results of another study led by Dr. Woon et al., the prevalence rates of depression as a result of COVID-19 were as high as 21.8% and participants with extremely severe depression made up 13.3% of the sample.[25]

In a cross-sectional survey, the researchers concluded that a high percentage of the resilient nurses surveyed report high-stress levels and/or PTSD symptoms.[74] In the survey eight major themes were identified, “revealed from nurses' free-text responses: (a) working in an isolated environment, (b) PPE shortage and the discomfort of pronged usage, (c) sleep problems, (d) intensity of workload, (e) cultural and language barriers, (f) lack of family support, (g) fear of being infected, and (h) insufficient work experiences with COVID-19”.[74] A lot of these concerns are a direct result or exacerbated by the Covid-19 pandemic. Understaffing can cause issues in any profession, but with nursing, there is a higher risk. This is because it does not only affect the health of one person it has a rippling effect throughout society. Kader’s study found that “71.4% of doctors and 74.4% of nurses experienced moderate-to-severe perceived stress”.[75] The study shows that dealing directly with Covid patients significantly increases stress levels. Without intervention not only would the nursing staff struggle but the patients would as well. The medical field is about helping others and nurses need to be in the right mindset to do that. Future research should be geared towards studying what methods help to reduce the stress on nurses. The nursing field cannot adapt on its own, and it cannot do it in the blink of an eye. That being said, the nursing profession will continue to adapt from the Covid-19 pandemic and will continue to need the public's support. Learning along the way and adapting is how nurses and healthcare workers become successful especially during a health crisis.

Impact on suicides

The COVID-19 pandemic has been followed by a concern for a potential spike in suicides, exacerbated by social isolation due to quarantine and social-distancing guidelines, fear, and unemployment and financial factors.[76][77] As of November 2020, researchers found that suicide rates were either the same or lower than before the pandemic began, especially in higher income countries.[78] It is not unusual for a crisis to temporarily reduce suicide rates.[78]

The number of phone calls to crisis hotlines has increased, and some countries have established new hotlines. For example, Ireland launched a new hotline aimed at older generations which received around 16,000 calls within a month of its launch in March 2020.[79] The Kids Helpline in the Australian state of Victoria has reported a 184% increase in calls from suicidal teenagers between early December 2020 and late May 2021.[80]

After a survey in March 2020 of over 700,000 people in Britain, it was found that 1 in 10 people have had suicidal thoughts as a result of lockdown. Alongside this, charities have been working to provide support for those in need during the difficult time. One example is the Martin Gallier Project which, as of November 2020, had intervened in 1,024 suicides since the beginning of the pandemic.[81]

Suicide cases have remained constant or decreased since the outbreak of the COVID-19 pandemic, although the best-quality evidence on this subject is often delayed.[82] According to a study done on twenty-one high and upper-middle-income countries in April–July 2020, the number of suicides has remained static.[83] These results were attributed to a variety of factors, including the composition of mental health support, financial assistance, having families and communities work diligently to care for at-risk individuals, discovering new ways to connect through the use of technology, and having more time spent with family members which aided in the strengthening of their bonds. Despite this, there has been an increase in isolation, fear, stigma, abuse, and economic fallout as a result of COVID-19.[84] Self-reported levels of depression, anxiety, and suicidal thoughts were elevated during the initial stay-at-home periods, according to empirical evidence from several countries, but this does not appear to have translated into an increase in suicides.[83]

According to surveys conducted across the United States in June 2020 by the Centers for Disease Control and Prevention, 10.7 percent of adults aged 18 and up said they had seriously considered suicide in the previous 30 days. They ranged in age from 18 to 24 and were classified as members of minority racial/ethnic groups, unpaid caregivers, and essential workers.[85]

Few studies have been conducted to examine the impact of suicides on low- and lower-middle-income countries. According to the World Health Organization, “in 2016, low- and middle-income countries accounted for 79 percent of global suicides.” This is because there are not enough high-quality vital registration systems, and even fewer collect real-time suicide data.[83]

Myanmar and Tunisia, two lower-middle-income countries were studied along with one low-income country, Malawi. It was found that: “In Malawi, there was reportedly a 57% increase in January–August 2020, compared with January–August 2019, and in Tunisia, there was a 5% increase in March–May 2020, compared with March–May, 2019. By contrast, in Myanmar, there was a 2% decrease in January–June 2020, compared with January–June 2019.”[83] It was informed that these changes could have been due to a lack of precise information since the beginning.[citation needed]

Factors of suicide

In spite of the fact that there is no increase in suicidal rates around many countries, mental health is still a prominent issue. COVID-19 has increased the risk of psychiatric disorders, chronic trauma, and stress, all of which can lead to suicide and suicidal behavior.[84] According to studies conducted in China, the outbreak has 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 include high risks of suicide.[84] National surveys in China and Italy revealed a high prevalence of depression and anxiety in relation to COVID-19, both of which can act as independent risk factors for suicide.[84]

When the economy is affected negatively, the suicide rate is higher as compared to periods of prosperity. Since the start of the COVID-19 pandemic, businesses were put on hold, many people have been laid off from work, and the stock market has experienced significant drops in history. All resulting in fear of the financial crisis.[86]

Stigma is also identified as a primary cause of suicide. Frontline workers, the elderly, the homeless, migrants, and daily wage workers face unique challenges, making them more vulnerable.[84] According to Somoy News, located in Bangladesh, a 36-year-old Bangladeshi man (Zahidul Islam, from the village of Ramchandrapur) committed suicide because he and his village mates suspected he was infected with COVID-19 due to his fever and cold symptoms, as well as his weight loss. He committed suicide by hanging himself from a tree because of the social avoidance and attitudes of those around him.[87] A similar case was reported in India, on February 12, 2020, a victim, while returning from a city to his native village, committed suicide by hanging himself to prevent the spread of COVID-19 throughout the village. These cases were a result of xenophobia and stigma.[87]

China

One Shanghai distract reported that there have been 14 cases of suicides by primary and secondary school students as of June 2020, the number of which was more than annual numbers added for the last three years.[88] However, since the central government concern the heightened post-lockdown anxiety as domestic media report a spate of suicides by young people and topic like suicide is usually a taboo in Chinese society,[88] Information about suicide cases in China is limited.[citation needed]

Fiji

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."[89]

India

There are reports of people committing suicide after not being able to access alcohol during the lockdown in India.[90]

Japan

Jun Shigemura and Mie Kurosawa suggested that people has been influenced not only by anxiety- and trauma-related disorders but also by adverse societal dynamics which related to work and the serious shortages of personal protective equipment.[91]

Overall, suicide rates in Japan appeared to decrease 20% during the earlier months of the pandemic, but that reduction was partly offset by a rise in August 2020.[78]

Several counseling helplines by telephone or text message are provided by many organizations, including the Ministry of Health, Labour and Welfare.[92]

On September 20, 2020, the Sankei Shimbun reported that the month of July and August saw more people committing suicide than in the previous year due to the ongoing economical impact of the pandemic. Estimates for suicide deaths include a 7.7% increase or a 15.1% increase in August 2020, compared to August 2019.[78] The Sankei also reported that more women were committing suicide at a higher year than the previous year, with the month of August seeing a 40.1% increase in suicide compared to August 2019.[93]

United States

As of November 2020, the rate of deaths from suicide appears to be the same in the US as before the pandemic.[78] In Clark County, Nevada, 18 high school students committed suicide over nine months of school closures.[94]

In March 2020, the federal crisis hotline, Disaster Distress Helpline, received a 338% increase in calls compared to the previous month (February 2020) and an 891% increase in calls compared to the previous year (March 2019).[95]

In May 2020, the public health group Well Being Trust estimated that, over the coming decade of the 2020s, the pandemic and the related recession might indirectly cause an additional 75,000 deaths of despair (including overdose and suicide) than would otherwise be expected in the United States.[96][97]

Suicide rates have increased for African Americans during the pandemic.[98]

Lockdown and mental health

An infographic from the World Health Organization showing statistics related to the impact of COVID-19 on mental health

The first lockdown was adopted in China and then in some other involved countries.[99] The policy included mandatory use of masks, gloves, and protective eyewear; implementing of social distancing, travel restrictions, closing of majority of workplaces, school, and public places.[100] There is potential risk in the measurement of mental health by lockdown since people may feel fear, despair, and uncertainty during the lockdown.[101] Furthermore, because most mental health centers were closed during the lockdown, patients who already had mental health disorders may have worsened symptoms .[100] According to De Man and colleagues, there are five major stressors during the lockdown: duration of lockdown, fear of infections, feelings of frustration and boredom, worries of inadequate supplies, and lack of information.[18]

South Africa

South Africa implemented a strict stay-at-home order on the 26th of March 2020, which lasted until the 1st of June 2020. People were only allowed to leave their homes to buy food, seek medical help or under extreme circumstances. Non-compliers were subject to heavy fines. Of the 860 respondents to an online questionnaire in May 2020, 46.0% met the diagnostic criteria of anxiety disorder and 47.2% met the diagnostic criteria of depressive disorder.[65] The participants who met these criteria reported substantial daily life repercussions, but less than 20% consulted a formal practitioner.[65] Distress related to containment measures and fear of being infected were associated with more anxiety and depressive symptoms. Having a pre-existing mental health condition, younger age, being female, and living in a non-rural area were also associated with more anxiety and depressive symptoms.[65]

Japan

In July 2020, Japan was still in "mild lockdown", which was not enforceable and non-punitive, with the declaration of a state of emergency.[102] According to a research of 11,333 individuals living across Japan which assigned for evaluate the impact after one-month "mild lockdown" through a questionnaire which asked questions related lifestyle, stress management, and stressors during the lockdown, it suggested that psychological distress indices significantly correlated with several items relating to COVID-19.[103]

Italy

Italy was the first country that entered a nationwide lockdown during the COVID-19 pandemic in Europe. According to the questionnaire, the prevalence of participants who report moderate to extremely high levels of depression was 21.2% of the population, while moderate to extremely high levels of anxiety was reported in 18.7%.[104] Moreover, about 40.5% of participants in the same research reported that they were experiencing poor sleep before the lockdown and the prevalence increased to 52.4% during the lockdown. A further cross-sectional study on 1,826 Italian adults confirmed the impact of the lockdown on quality of sleep, that was especially evident among females, those with lower levels of education, and those who experienced financial problems.[105]

Spain

The outbreak of COVID-19 in Spain started at the end of February. By 9 April 2020 Spain was the second country in confirmed cases and in deaths. On March 14, 2020, the Spanish Government declared the state of alarm to limit viral transmission. According to research during the first stages of the outbreak, about 36% of the participants reported moderate to severe psychological impact, 25% showed mild to severe levels of anxiety, 41% reported depressive symptoms, and 41% felt stressed.[106] A longitudinal study done by collecting data pre-pandemic and during confinement observed a direct and indirect effect of pre-pandemic cortisol on the changes in self-reported perceived self-efficacy during confinement. The indirect effects were parallelly mediated by increases in working memory span and cognitive empathy.[57]

Vietnam

As of January 2021, Vietnam has largely returned to everyday life thanks to the government's success in effective communication to citizens, early development of testing kits, a robust contact tracing program, and containment based upon epidemiological risk rather than observable symptoms. By appealing to universal Vietnamese values such as tam giao, or the Three Teachings, the Vietnamese government has managed to encourage a culture that values public health with the utmost importance and maintains a level of fortitude and resolve in fighting the spread of COVID-19.[107] However, Vietnamese patients quarantining due to COVID-19 have 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 quarantined for greater than three weeks reported comparatively poorer self-image and general attitude when compared to shorter term patients.[108]

Mental health aftercare

Academics have theorized that once the pandemic stabilizes or fully ends, supervisors should ensure that time is made to reflect on and learn from the experiences by first responders, essential workers, and the general population to create a meaningful narrative rather than focusing on the trauma. The National Institute for Health and Care Excellence has recommended the active monitoring of staff for issues such as PTSD, moral injuries, and other associated mental illness.[109]

A potential solution to continue mental health care during the pandemic is to provide mental health care through video-conferencing psychotherapy and internet interventions.[110] Although e-mental health has not been integrated as a regular part of mental health care practice due to the lack of its acceptance in the past,[111] this way was reviewed as effective in producing promising results for anxiety and mood disorders.[112]

Long-term consequences of the COVID-19 pandemic on mental health

According to the Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support (IASC), there can be long-term consequences due to the COVID-19 pandemic. Deterioration of social networks and economies, stigma towards survivors of COVID-19, possible higher anger and aggression towards frontline workers and the government, possible anger and aggression against children, and possible mistrust of information provided by official authorities are some of the long-term consequences anticipated by the IASC.[5]

Some of these consequences could be due to realistic dangers, but many reactions could be borne out of lack of knowledge, rumors, and misinformation.[113] It is also possible that some people may have positive experiences, such as pride about finding ways of coping. It is likely that community members show altruism and cooperation when faced with a crisis, and people might experience satisfaction from helping others.[114]

Impact on those with medical challenges

End-stage hip or knee Osteoarthritis

A study was conducted in Europe with sixty-three scheduled arthroplasty patients that had the surgical procedure postponed. They were valued over the phone three times the first week of lockdown, the fourth week, and the end of lockdown.[115] They were rated based on their pain level with four different questionnaires. The visual analogue scale (VAS)  scores and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores provided results of increase while the physical activity decreased.[115] There was seen to be a decrease of the physical aspect of the SF-12 scores. With those same scores the mental piece showed no change. Due to the COVID-19 lockdown mental health did not seem to be affected although there was impacts on physical function and pain.[115]

Patients with HIV

In April 2020 a screening was conducted in New York City HIV cohort. Forty-nine patients were contacted by the phone. After being evaluated physical symptoms were frequently present.[116] There were mild mental/cognitive symptoms commonly presented and there were no serious depression and or anxiety witnessed.[116]

Children and Adolescents with mental challenges

Due to the COVID-19 pandemic, the lockdown has led to short and even long term mental health involvement.[34] During the lockdown those children with special needs had faced challenges. Those children had difficulties in following instruction as well as actually understanding the whole idea of the pandemic, and even doing assigned independent work.[34]

With the impact of closed schools and daycares children and adolescents are not able to get the resources and peer interaction that they were getting before.[34] Before they were given scheduled routines and now due to the lockdown those routines have dramatically changed. With the change of routine it can result in outburst, tantrums, and even conflict with parents/guardians.[34]

Children with autism became agitated with the changing environment and even might have shown an increase in behavioural problems.[34] Adolescents and children with Attention Deficit Hyperactivity Disorder (ADHD) do not like to stay confined in only one space. So, it was hard to find activities that were engaging and even meaningful to them. Children and adolescents with Obsessive-Compulsive Disorder (OCD) were suspected to be one of the most affected during this COVID-19 pandemic lockdown.[34] Those with OCD were also expected to have increased distress.[34]

See also

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