essay about covid 19 mental health

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• Review Article
• Published: 03 October 2022

How COVID-19 shaped mental health: from infection to pandemic effects

• Brenda W. J. H. Penninx   ORCID: orcid.org/0000-0001-7779-9672 1 , 2 ,
• Michael E. Benros   ORCID: orcid.org/0000-0003-4939-9465 3 , 4 ,
• Robyn S. Klein 5 &
• Christiaan H. Vinkers   ORCID: orcid.org/0000-0003-3698-0744 1 , 2  

Nature Medicine volume  28 ,  pages 2027–2037 ( 2022 ) Cite this article

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• Epidemiology
• Infectious diseases
• Neurological manifestations
• Psychiatric disorders

The Coronavirus Disease 2019 (COVID-19) pandemic has threatened global mental health, both indirectly via disruptive societal changes and directly via neuropsychiatric sequelae after SARS-CoV-2 infection. Despite a small increase in self-reported mental health problems, this has (so far) not translated into objectively measurable increased rates of mental disorders, self-harm or suicide rates at the population level. This could suggest effective resilience and adaptation, but there is substantial heterogeneity among subgroups, and time-lag effects may also exist. With regard to COVID-19 itself, both acute and post-acute neuropsychiatric sequelae have become apparent, with high prevalence of fatigue, cognitive impairments and anxiety and depressive symptoms, even months after infection. To understand how COVID-19 continues to shape mental health in the longer term, fine-grained, well-controlled longitudinal data at the (neuro)biological, individual and societal levels remain essential. For future pandemics, policymakers and clinicians should prioritize mental health from the outset to identify and protect those at risk and promote long-term resilience.

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In 2019, the COVID-19 outbreak was declared a pandemic by the World Health Organization (WHO), with 590 million confirmed cases and 6.4 million deaths worldwide as of August 2022 (ref. 1 ). To contain the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across the globe, many national and local governments implemented often drastic restrictions as preventive health measures. Consequently, the pandemic has not only led to potential SARS-CoV-2 exposure, infection and disease but also to a wide range of policies consisting of mask requirements, quarantines, lockdowns, physical distancing and closure of non-essential services, with unprecedented societal and economic consequences.

As the world is slowly gaining control over COVID-19, it is timely and essential to ask how the pandemic has affected global mental health. Indirect effects include stress-evoking and disruptive societal changes, which may detrimentally affect mental health in the general population. Direct effects include SARS-CoV-2-mediated acute and long-lasting neuropsychiatric sequelae in affected individuals that occur during primary infection or as part of post-acute COVID syndrome (PACS) 2 —defined as symptoms lasting beyond 3–4 weeks that can involve multiple organs, including the brain. Several terminologies exist for characterizing the effects of COVID-19. PACS also includes late sequalae that constitute a clinical diagnosis of ‘long COVID’ where persistent symptoms are still present 12 weeks after initial infection and cannot be attributed to other conditions 3 .

Here we review both the direct and indirect effects of COVID-19 on mental health. First, we summarize empirical findings on how the COVID-19 pandemic has impacted population mental health, through mental health symptom reports, mental disorder prevalence and suicide rates. Second, we describe mental health sequalae of SARS-CoV-2 virus infection and COVID-19 disease (for example, cognitive impairment, fatigue and affective symptoms). For this, we use the term PACS for neuropsychiatric consequences beyond the acute period, and will also describe the underlying neurobiological impact on brain structure and function. We conclude with a discussion of the lessons learned and knowledge gaps that need to be further addressed.

Impact of the COVID-19 pandemic on population mental health

Independent of the pandemic, mental disorders are known to be prevalent globally and cause a very high disease burden 4 , 5 , 6 . For most common mental disorders (including major depressive disorder, anxiety disorders and alcohol use disorder), environmental stressors play a major etiological role. Disruptive and unpredictable pandemic circumstances may increase distress levels in many individuals, at least temporarily. However, it should be noted that the pandemic not only resulted in negative stressors but also in positive and potentially buffering changes for some, including a better work–life balance, improved family dynamics and enhanced feelings of closeness 7 .

Awareness of the potential mental health impact of the COVID-19 pandemic is reflected in the more than 35,000 papers published on this topic. However, this rapid research output comes with a cost: conclusions from many papers are limited due to small sample sizes, convenience sampling with unclear generalizability implications and lack of a pre-COVID-19 comparison. More reliable estimates of the pandemic mental health impact come from studies with longitudinal or time-series designs that include a pre-pandemic comparison. In our description of the evidence, we, therefore, explicitly focused on findings from meta-analyses that include longitudinal studies with data before the pandemic, as recently identified through a systematic literature search by the WHO 8 .

Self-reported mental health problems

Most studies examining the pandemic impact on mental health used online data collection methods to measure self-reported common indicators, such as mood, anxiety or general psychological distress. Pooled prevalence estimates of clinically relevant high levels of depression and anxiety symptoms during the COVID-19 pandemic range widely—between 20% and 35% 9 , 10 , 11 , 12 —but are difficult to interpret due to large methodological and sample heterogeneity. It also is important to note that high levels of self-reported mental health problems identify increased vulnerability and signal an increased risk for mental disorders, but they do not equal clinical caseness levels, which are generally much lower.

Three meta-analyses, pooling data from between 11 and 61 studies and involving ~50,000 individuals or more 13 , 14 , 15 , compared levels of self-reported mental health problems during the COVID-19 pandemic with those before the pandemic. Meta-analyses report on pooled effect sizes—that is, weighted averages of study-level effect sizes; these are generally considered small when they are ~0.2, moderate when ~0.5 and large when ~0.8. As shown in Table 1 , meta-analyses on mental health impact of the COVID-19 pandemic reach consistent conclusions and indicate that there has been a heterogeneous, statistically significant but small increase in self-reported mental health problems, with pooled effect sizes ranging from 0.07 to 0.27. The largest symptom increase was found when using specific mental health outcome measures assessing depression or anxiety symptoms. In addition, loneliness—a strong correlate of depression and anxiety—showed a small but significant increase during the pandemic (Table 1 ; effect size = 0.27) 16 . In contrast, self-reported general mental health and well-being indicators did not show significant change, and psychotic symptoms seemed to have decreased slightly 13 . In Europe, alcohol purchase decreased, but high-level drinking patterns solidified among those with pre-pandemic high drinking levels 17 . When compared to pre-COVID levels, no change in self-reported alcohol use (effect size = −0.01) was observed in a recent meta-analysis summarizing 128 studies from 58 (predominantly European and North American) countries 18 .

What is the time trajectory of self-reported mental health problems during the pandemic? Although findings are not uniform, various large-scale studies confirmed that the increase in mental health problems was highest during the first peak months of the pandemic and smaller—but not fully gone—in subsequent months when infection rates declined and social restrictions eased 13 , 19 , 20 . Psychological distress reports in the United Kingdom increased again during the second lockdown period 15 . Direct associations between anxiety and depression symptom levels and the average number of daily COVID-19 cases were confirmed in the US Centers for Disease Control and Prevention (CDC) data 21 . Studies that examined longer-term trajectories of symptoms during the first or even second year of the COVID-19 pandemic are more sparse but revealed stability of symptoms without clear evidence of recovery 15 , 22 . The exception appears to be for loneliness, as some studies confirmed further increasing trends throughout the first COVID-19 pandemic year 22 , 23 . As most published population-based studies were conducted in the early time period in which absolute numbers of SARS-CoV2-infected individuals were still low, the mental health impacts described in such studies are most likely due to indirect rather than direct effects of SARS-CoV-2 infection. However, it is possible that, in longer-term or later studies, these direct and indirect effects may be more intertwined.

The extent to which governmental policies and communication have impacted on population mental health is a relevant question. In cross-country comparisons, the extent of social restrictions showed a dose–response relationship with mental health problems 24 , 25 . In a review of 33 studies worldwide, it was concluded that governments that enacted stringent measures to contain the spread of COVID-19 benefitted not only the physical but also the mental health of their population during the pandemic 26 , even though more stringent policies may lead to more short-term mental distress 25 . It has been suggested that effective communication of risks, choices and policy measures may reduce polarization and conspiracy theories and mitigate the mental health impact of such measures 25 , 27 , 28 .

In sum, the general pattern of results is that of an increase in mental health symptoms in the population, especially during the first pandemic months, that remained elevated throughout 2020 and early 2021. It should be emphasized that this increase has a small effect size. However, even a small upward shift in mental health problems warrants attention as it has not yet shown to be returned to pre-pandemic levels, and it may have meaningful cumulative consequences at the population level. In addition, even a small effect size may mask a substantial heterogeneity in mental health impact, which may have affected vulnerable groups disproportionally (see below).

Mental disorders, self-harm and suicide

Whether the observed increase in mental health problems during the COVID-19 pandemic has translated into more mental disorders or even suicide mortality is not easy to answer. Mental disorders, characterized by more severe, disabling and persistent symptoms than self-reported mental health problems, are usually diagnosed by a clinician based on the International Classification of Diseases, 10th Revision (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria or with validated semi-structured clinical interviews. However, during the COVID-19 pandemic, research systematically examining the population prevalence of mental disorders has been sparse. Unfortunately, we can also not strongly rely on healthcare use studies as the pandemic impacted on healthcare provision more broadly, thereby making figures of patient admissions difficult to interpret.

On a global scale and based on imputations and modeling from survey data of self-reported mental health problems, the Global Burden of Disease (GBD) study 29 estimated that the COVID-19 pandemic has led to a 28% (95% uncertainty interval (UI): 25–30) increase in major depressive disorders and a 26% (95% UI: 23–28) increase in anxiety disorders. It should be noted that these estimations come with high uncertainty as the assumption that transient pandemic-related increases in mental symptoms extrapolate into incident mental disorders remains disputable. So far, only four longitudinal population-based studies have measured and compared current mental (that is, depressive and anxiety) disorder prevalence—defined using psychiatric diagnostic criteria—before and during the pandemic. Of these, two found no change 30 , 31 , one found a decrease 32 and one found an increase in prevalence of these disorders 33 . These studies were local, limited to high-income countries, often small-scale and used different modes of assessment (for example, online versus in-person) before and during the pandemic. This renders these observational results uncertain as well, but their contrast to the GBD calculations 29 is striking.

Time-series analysis of monthly suicide trends in 21 middle-income to high-income countries across the globe yielded no evidence for an increase in suicide rates in the first 4 months of the pandemic, and there was evidence of a fall in rates in 12 countries 34 . Also in the United States, there was a significant decrease in suicide mortality in the first pandemic months but a slight increase in mortality due to drug overdose and homicide 35 . A living systematic review 36 also concluded that, throughout 2020, there was no observed increase in suicide rates in 20 studies conducted in North America, Europe and Asia. Analyses of electronic health record data in the primary care setting showed reduced rates of self-harm during the first COVID-19 pandemic year 37 . In contrast, emergency department visits for self-harm behavior were unchanged 38 or increased 39 . Such inconsistent findings across healthcare settings may reflect a reluctance in healthcare-seeking behavior for mental healthcare issues. In the living systematic review, eight of 11 studies that examined service use data found a significant decrease in reported self-harm/suicide attempts after COVID lockdown, which returned to pre-lockdown levels in some studies with longer follow-up (5 months) 36 .

In sum, although calculations based on survey data predict a global increase of mental disorder prevalence, objective and consistent evidence for an increased mental disorder, self-harm or suicide prevalence or incidence during the first pandemic year remains absent. This observation, coupled with the only small increase in mental health symptom levels in the overall population, may suggest that most of the general population has demonstrated remarkable resilience and adaptation. However, alternative interpretations are possible. First, there is a large degree of heterogeneity in the mental health impact of COVID-19, and increased mental health in one group (for example, due to better work–family balance and work flexibility) may have masked mental health problems in others. Various societal responses seen in many countries, such as community support activities and bolstering mental health and crisis services, may have had mitigating effects on the mental health burden. Also, the relationship between mental health symptom increases during stressful periods and its subsequent effects on the incidence of mental disorders may be non-linear or could be less visible due to resulting alternative outcomes, such as drug overdose or homicide. Finally, we cannot rule out a lag-time effect, where disorders may take more time to develop or be picked up, especially because some of the personal financial or social consequences of the COVID pandemic may only become apparent later. It should be noted that data from low-income countries and longer-term studies beyond the first pandemic year are largely absent.

Which individuals are most affected by the COVID-19 pandemic?

There is substantial heterogeneity across studies that evaluated how the COVID pandemic impacted on mental health 13 , 14 , 15 . Although our society as a whole may have the ability to adequately bounce back from pandemic effects, there are vulnerable people who have been affected more than others.

First, women have consistently reported larger increases in mental health problems in response to the COVID-19 pandemic than men 13 , 15 , 29 , 40 , with meta-analytic effect sizes being 44% 15 to 75% 13 higher. This could reflect both higher stress vulnerability or larger daily life disruptions due to, for example, increased childcare responsibilities, exposure to home violence or greater economic impact due to employment disruptions that all disproportionately fell to women 41 , thereby exacerbating the already existing pre-pandemic gender inequalities in depression and anxiety levels. In addition, adolescents and young adults have been disproportionately affected compared to younger children and older adults 12 , 15 , 29 , 40 . This may be the result of unfavorable behavioral and social changes (for example, school closure periods 42 ) during a crucial development phase where social interactions outside the family context are pivotal. Alarmingly, even though suicide rates did not seem to increase at the population level, studies in China 43 and Japan 44 indicated significant increases in suicide rates in children and adolescents.

Existing socio-cultural disparities in mental health may have further widened during the COVID pandemic. Whether the impact is larger for individuals with low socio-economic status remains unclear, with contrasting meta-analyses pointing toward this group being protected 15 or at increased risk 40 . Earlier meta-analyses did not find that the mental health impact of COVID-19 differed across Europe, North America, Asia and Oceania 13 , 14 , but data are lacking from Africa and South America. Nevertheless, a large-scale within-country comparison in the United States found that the mental health of Black, Hispanic and Asian respondents worsened relatively more during the pandemic compared to White respondents. Moreover, White respondents were more likely to receive professional mental healthcare during the pandemic, and, conversely, Black, Hispanic, and Asian respondents demonstrated higher levels of unmet mental healthcare needs during this time 45 .

People with pre-existing somatic conditions represent another vulnerable group in which the pandemic had a greater impact (pooled effect size of 0.25) 13 . This includes people with conditions such as epilepsy, multiple sclerosis or cardiometabolic disease as well as those with multiple comorbidities. The disproportionate impact may reflect this groupʼs elevated COVID-19 risk and, consequently, more perceived stress and fear of infection, but it could also reflect disruptions of regular healthcare services.

Healthcare workers faced increased workload, rapidly changing and challenging work environments and exposure to infections and death, accompanied by fear of infecting themselves and their families. High prevalences of (subthreshold) depression (13% 46 ), depressive symptoms (31% 47 ), (subthreshold) anxiety (16% 46 ), anxiety symptoms (23% 47 ) and post-traumatic stress disorder (~22% 46 , 47 ) have been reported in healthcare workers. However, a meta-analysis did not find a larger mental health impact of the pandemic as compared to the general population 40 , and another meta-analysis (of 206 studies) found that the mental health status of healthcare workers was similar to or even better than that of the general population during the first COVID year 48 . However, it is important to note that these meta-analyses could not differentiate between frontline and non-frontline healthcare workers.

Finally, individuals with pre-existing mental disorders may be at increased risk for exacerbation of mental ill-health during the pandemic, possibly due to disease history—illustrating a higher genetic and/or environmental vulnerability—but also due to discontinuity of mental healthcare. Already before the pandemic, mental health systems were under-resourced and disorganized in most countries 6 , 49 , but a third of all WHO member states reported disruptions to mental and substance use services during the first 18 months of the pandemic 50 , with reduced, shortened or postponed appointments and limited capacity for acute inpatient admissions 51 , 52 . Despite this, there is no clear evidence that individuals with pre-existing mental disorders are disproportionately affected by pandemic-related societal disruptions; the effect size for pandemic impact on self-reported mental health problems was similar in psychiatric patients and the general population 13 . In the United States, emergency visits for ten different mental disorders were generally stable during the pandemic compared to earlier periods 53 . In a large Dutch study 22 , 54 with multiple pre-pandemic and during-pandemic assessments, there was no difference in symptom increase among patients relative to controls (see Fig. 1 for illustration). In absolute terms, however, it is important to note that psychiatric patients show much higher symptom levels of depression, anxiety, loneliness and COVID-fear than healthy controls. Again, variation in mental health changes during the pandemic is large: next to psychiatric patients who showed symptom decrease due to, for example, experiencing relief from social pressures, there certainly have been many patients with symptom increases and relapses during the pandemic.

Trajectories of mean depressive symptoms (QIDS score), anxiety symptoms (BAI score), loneliness (De Jong questionnaire score) and Fear of COVID-19 score before and during the first year of the COVID-19 pandemic in healthy controls (blue line, n  = 378) and in patients with depressive and/or anxiety disorders (red line, n  = 908). The x -axis indicates time with one pre-COVID assessment (averaged over up to five earlier assessments conducted between 2006 and 2019) and 11 online assessments during April 2020 through February 2021. Symbols indicate the mean score during the assessment with 95% CIs. As compared to pre-COVID assessment scores, the figure shows a statistically significant increase of depression and loneliness symptoms during the first pandemic peak (April 2020) in healthy controls but not in patients (for more details, see refs. 22 , 54 ). Asterisks indicate where subsequent wave scores differ from the prior wave scores ( P  < 0.05). The figure also illustrates the stability of depressive and anxiety symptoms during the first COVID year, a significant increase in loneliness during this period and fluctuations of Fear of COVID-19 score that positively correlate with infection rates in the Netherlands. Raw data are from the Netherlands Study of Depression and Anxiety (NESDA), which were re-analyzed for the current plots to illustrate differences between two groups (healthy controls versus patients). BAI, Beck Anxiety Inventory; QIDS, Quick Inventory of Depressive Symptoms.

Impact of COVID-19 infection and disease on mental health and the brain

Not only the pandemic but also COVID-19 itself can have severe impact on the mental health of affected individuals and, thus, of the population at large. Below we describe acute and post-acute neuropsychiatric sequelae seen in patients with COVID-19 and link these to neurobiological mechanisms.

Neuropsychiatric sequelae in individuals with COVID-19

Common symptoms associated with acute SARS-CoV-2 infection include headache, anosmia (loss of sense of smell) and dysgeusia (loss of sense of taste). The broader neuropsychiatric impact is dependent on infection severity and is very heterogeneous (Table 2 ). It ranges from no neuropsychiatric symptoms among the large group of asymptomatic COVID-19 cases to milder transient neuropsychiatric symptoms, such as fatigue, sleep disturbance and cognitive impairment, predominantly occurring among symptomatic patients with COVID-19 (ref. 55 ). Cognitive impairment consists of sustained memory impairments and executive dysfunction, including short-term memory loss, concentration problems, word-finding problems and impaired daily problem-solving, colloquially termed ‘brain fog’ by patients and clinicians. A small number of infected individuals become severely ill and require hospitalization. During hospital admission, the predominant neuropsychiatric outcome is delirium 56 . Delirium occurs among one-third of hospitalized patients with COVID-19 and among over half of patients with COVID-19 who require intensive care unit (ICU) treatment. These delirium rates seem similar to those observed among individuals with severe illness hospitalized for other general medical conditions 57 . Delirium is associated with neuropsychiatric sequalae after hospitalization, as part of post-intensive care syndrome 58 , in which sepsis and inflammation are associated with cognitive dysfunction and an increased risk of a broad range of psychiatric symptoms, from anxiety to depression and psychotic symptoms with hallucinations 59 , 60 .

A subset of patients with COVID-19 develop PACS 61 , which can include neuropsychiatric symptoms. A large meta-analysis summarizes 51 studies involving 18,917 patients with a mean follow-up of 77 days (range, 14–182 days) 62 . The most prevalent neuropsychiatric symptom associated with COVID-19 was sleep disturbance, with a pooled prevalence of 27.4%, followed by fatigue (24.4%), cognitive impairment (20.2%), anxiety symptoms (19.1%), post-traumatic stress symptoms (15.7%) and depression symptoms (12.9%) (Table 2 ). Another meta-analysis that assessed patients 12 weeks or more after confirmed COVID-19 diagnosis found that 32% experienced fatigue, and 22% experienced cognitive impairment 63 . To what extent neuropsychiatric symptoms are truly unique for patients with COVID remains unclear from these meta-analyses, as hardly any study included well-matched controls with other types of respiratory infections or inflammatory conditions.

Studies based on electronic health records have examined whether higher levels of neuropsychiatric symptoms truly translate into a higher incidence of clinically overt mental disorders 64 , 65 . In a 1-year follow-up using the US Veterans Affairs database, 153,848 survivors of SARS-CoV-2 infection exhibited an increased incidence of any mental disorder with a relative risk of 1.46 and, specifically, 1.35 for anxiety disorders, 1.39 for depressive disorders and 1.38 for stress and adjustment disorders, compared to a contemporary group and a historical control group ( n  = 5,859,251) 65 . In absolute numbers, the incident risk difference attributable to SARS-CoV-2 for mental disorders was 64 per 1,000 individuals. Taquet et al. 64 analyzed electronic health records from the US-based TriNetX network with over 81 million patients and 236,379 COVID-19 survivors followed for 6 months. In absolute numbers, 6-month incidence of hospital contacts related to diagnoses of anxiety, affective disorder or psychotic disorder was 7.0%, 4.5% and 0.4%, respectively. Risks of incident neurological or psychiatric diagnoses were directly correlated with COVID-19 severity and increased by 78% when compared to influenza and by 32% when compared to other respiratory tract infections. In contrast, a medical record study involving 8.3 million adults confirmed that neuropsychiatric disorders were significantly elevated among COVID-19 hospitalized individuals but to a similar extent as in hospitalized patients with other severe respiratory disease 66 . In line with this, a study using language processing of clinical notes in electronic health records did not find an increase in fatigue, mood and anxiety symptoms among COVID-19 hospitalized individuals when compared to hospitalized patients for other indications and adjusted for sociodemographic features and hospital course 67 . It is important to note that research based only on hospital records might be influenced by increased health-seeking behavior that could be differential across care settings or by increased follow-up by hospitals of patients with COVID-19 (compared to patients with other conditions).

Consequently, whether PACS symptoms form a unique pattern due to specific infection with SARS-CoV-2 remains debatable. Prospective case–control studies that do not rely on hospital records but measure the incidence of neuropsychiatric symptoms and diagnoses after COVID-19 are still scarce, but they are critical for distinguishing causation and confounding when characterizing PACS and the uniqueness of neuropsychiatric sequalae after COVID-19 (ref. 68 ). Recent studies with well-matched control groups illustrate that long-term consequences may not be so unique, as they were similar to those observed in patients with other diseases of similar severity, such as after acute myocardial infarction or in ICU patients 56 , 66 . A first prospective follow-up study of COVID-19 survivors and control patients matched on disease severity, age, sex and ICU admission found similar neuropsychiatric outcomes, regarding both new-onset psychiatric diagnosis (19% versus 20%) and neuropsychiatric symptoms (81% versus 93%). However, moderate but significantly worse cognitive outcomes 6 months after symptom onset were found among survivors of COVID-19 (ref. 69 ). In line with this, a longitudinal study of 785 participants from the UK Biobank showed small but significant cognitive impairment among individuals infected with SARS-CoV-2 compared to matched controls 70 .

Numerous psychosocial mechanisms can lead to neuropsychiatric sequalae of COVID-19, including functional impairment; psychological impact due to, for example, fear of dying; stress of being infected with a novel pandemic disease; isolation as part of quarantine and lack of social support; fear/guilt of spreading COVID-19 to family or community; and socioeconomic distress by lost wages 71 . However, there is also ample evidence that neurobiological mechanisms play an important role, which is discussed below.

Neurobiological mechanisms underlying neuropsychiatric sequelae of COVID-19

Acute neuropsychiatric symptoms among patients with severe COVID-19 have been found to correlate with the level of serum inflammatory markers 72 and coincide with neuroimaging findings of immune activation, including leukoencephalopathy, acute disseminated encephalomyelitis, cytotoxic lesions of the corpus callosum or cranial nerve enhancement 73 . Rare presentations, including meningitis, encephalitis, inflammatory demyelination, cerebral infarction and acute hemorrhagic necrotizing encephalopathy, have also been reported 74 . Hospitalized patients with frank encephalopathies display impaired blood-brain barrier (BBB) integrity with leptomeningeal enhancement on brain magnetic resonance images 75 . Studies of postmortem specimens from patients who succumbed to acute COVID-19 reveal significant neuropathology with signs of hypoxic damage and neuroinflammation. These include evidence of BBB permeability with extravasation of fibrinogen, microglial activation, astrogliosis, leukocyte infiltration and microhemorrhages 76 , 77 . However, it is still unclear to what extent these findings differ from patients with similar illness severity due to acute non-COVID illness, as these brain effects might not be virus-specific effects but rather due to cytokine-mediated neuroinflammation and critical illness.

Post-acute neuroimaging studies in SARS-CoV-2-recovered patients, as compared to control patients without COVID-19, reveal numerous alterations in brain structure on a group level, although effect sizes are generally small. These include minor reduction in gray matter thickness in the various regions of the cortex and within the corpus collosum, diffuse edema, increases in markers of tissue damage in regions functionally connected to the olfactory cortex and reductions in overall brain size 70 , 78 . Neuroimaging studies of post-acute COVID-19 patients also report abnormalities consistent with micro-structural and functional alterations, specifically within the hippocampus 79 , 80 , a brain region critical for memory formation and regulating anxiety, mood and stress responses, but also within gray matter areas involving the olfactory system and cingulate cortex 80 . Overall, these findings are in line with ongoing anosmia, tremors, affect problems and cognitive impairment.

Interestingly, despite findings mentioned above, there is little evidence of SARS-CoV-2 neuroinvasion with productive replication, and viral material is rarely found in the central nervous system (CNS) of patients with COVID-19 (refs. 76 , 77 , 81 ). Thus, neurobiological mechanisms of SARS-CoV-2-mediated neuropsychiatric sequelae remain unclear, especially in patients who initially present with milder forms of COVID-19. Symptomatic SARS-CoV-2 infection is associated with hypoxia, cytokine release syndrome (CRS) and dysregulated innate and adaptive immune responses (reviewed in ref. 82 ). All these effects could contribute to neuroinflammation and endothelial cell activation (Fig. 2 ). Examination of cerebrospinal fluid in patients with neuroimaging findings revealed elevated levels of pro-inflammatory, BBB-destabilizing cytokines, including interleukin-6 (IL-6), IL-1, IL-8 and mononuclear cell chemoattractants 83 , 84 . Whether these cytokines arise from the periphery, due to COVID-19-mediated CRS, or from within the CNS, is unclear. As studies generally lack control patients with other severe illnesses, the specificity of such findings to SARS-CoV-2 also remains unclear. Systemic inflammatory processes, including cytokine release, have been linked to glial activation with expression of chemoattractants that recruit immune cells, leading to neuroinflammation and injury 85 . Cerebrospinal fluid concentrations of neurofilament light, a biomarker of neuronal damage, were reportedly elevated in patients hospitalized with COVID-19 regardless of whether they exhibited neurologic diseases 86 . Acute thromboembolic events leading to ischemic infarcts are also common in patients with COVID-19 due to a potentially increased pro-coagulant process secondary to CRS 87 .

(1) Elevation of BBB-destabilizing cytokines (IL-1β and TNF) within the serum due to CRS or local interactions of mononuclear and endothelial cells. (2) Virus-induced endotheliitis increases susceptibility to microthrombus formation due to platelet activation, elevation of vWF and fibrin deposition. (3) Cytokine, mononuclear and endothelial cell interactions promote disruption of the BBB, which may allow entry of leukocytes expressing IFNg into the CNS (4), leading to microglial activation (5). (6) Activated microglia may eliminate synapses and/or express cytokines that promote neuronal injury. (7) Injured neurons express IL-6 which, together with IL-1β, promote a ‘gliogenic switch’ in NSCs (8), decreasing adult neurogenesis. (9) The combination of microglial (and possibly astrocyte) activation, neuronal injury and synapse loss may lead to dysregulation of NTs and neuronal circuitry. IFNg, interferon-g; NSC, neural stem cell; NT, neurotransmitter; TJ, tight junction; TNF, tumor necrosis factor; vWF, von Willebrand factor.

It is also unclear whether hospitalized patients with COVID-19 may develop brain abnormalities due to hypoxia or CRS rather than as a direct effect of SARS-CoV-2 infection. Hypoxia may cause neuronal dysfunction, cerebral edema, increased BBB permeability, cytokine expression and onset of neurodegenerative diseases 88 , 89 . CRS, with life-threatening levels of serum TNF-α and IL-1 (ref. 90 ) could also impact BBB function, as these cytokines destabilize microvasculature endothelial cell junctional proteins critical for BBB integrity 91 . In mild SARS-CoV-2 infection, circulating immune factors combined with mild hypoxia might impact BBB function and lead to neuroinflammation 92 , as observed during infection with other non-neuroinvasive respiratory pathogens 93 . However, multiple studies suggest that the SARS-CoV-2 spike protein itself may also induce venous and arterial endothelial cell activation and endotheliitis, disrupt BBB integrity or cross the BBB via adoptive transcytosis 94 , 95 , 96 .

Reducing neuropsychiatric sequelae of COVID-19

The increased risk of COVID-19-related neuropsychiatric sequalae was most pronounced during the first pandemic peak but reduced over the subsequent 2 years 64 , 97 . This may be due to reduced impact of newer SARS-CoV-2 strains (that is, Omicron) but also protective effects of vaccination, which limit SARS-CoV-2 spread and may, thus, prevent neuropsychiatric sequalae. Fully vaccinated individuals with breakthrough infections exhibit a 50% reduction in PACS 98 , even though vaccination does not improve PACS-related neuropsychiatric symptoms in patients with a prior history of COVID-19 (ref. 99 ). As patients with pre-existing mental disorders are at increased risk of SARS-CoV-2 infection, they deserve to be among the prioritization groups for vaccination efforts 100 .

Adequate treatment strategies for neuropsychiatric sequelae of COVID-19 are needed. As no specific evidence-based intervention yet exists, the best current treatment approach is that for neuropsychiatric sequelae arising after other severe medical conditions 101 . Stepped care—a staged approach of mental health services comprising a hierarchy of interventions, from least to most intensive, matched to the individual’s need—is efficacious with monitoring of mental health and cognitive problems. Milder symptoms likely benefit from counseling and holistic care, including physiotherapy, psychotherapy and rehabilitation. Individuals with moderate to severe symptoms fulfilling psychiatric diagnoses should receive guideline-concordant care for these disorders 61 . Patients with pre-existing mental disorders also deserve special attention when affected by COVID-19, as they have shown to have an increased risk of COVID-19-related hospitalization, complications and death 102 . This may involve interventions to address their general health, any unfavorable socioenvironmental factors, substance abuse or treatment adherence issues.

Lessons learned, knowledge gaps and future challenges

Ultimately, it is not only the millions of people who have died from COVID-19 worldwide that we remember but also the distress experienced during an unpredictable period with overstretched healthcare systems, lockdowns, school closures and changing work environments. In a world that is more and more globalized, connectivity puts us at risk for future pandemics. What can be learned from the last 2 years of the COVID-19 pandemic about how to handle future and longstanding challenges related to mental health?

Give mental health equal priority to physical health

The COVID-19 pandemic has demonstrated that our population seems quite resilient and adaptive. Nevertheless, even if society as a whole may bounce back, there is a large group of people whose mental health has been and will be disproportionately affected by this and future crises. Although various groups, such as the WHO 8 , the National Health Commission of China 103 , the Asia Pacific Disaster Mental Health Network 104 and a National Taskforce in India 105 , developed mental health policies early on, many countries were late in realizing that a mental health agenda deserves immediate attention in a rapidly evolving pandemic. Implementation of comprehensive and integrated mental health policies was generally inconsistent and suboptimal 106 and often in the shadow of policies directed at containing and reducing the spread of SARS-CoV-2. Leadership is needed to convey the message that mental health is as important as physical health and that we should focus specific attention and early interventions on those at the highest risk. This includes those vulnerable due to factors such as low socioeconomic status, specific developmental life phase (adolescents and young adults), pre-existing risk (poor physical or somatic health and early life trauma) or high exposure to pandemic-related (work) changes—for example, women and healthcare personnel. This means that not only should investment in youth and reducing health inequalities remain at the top of any policy agenda but also that mental health should be explicitly addressed from the start in any future global health crisis situation.

Communication and trust is crucial for mental health

Uncertainty and uncontrollability during the pandemic have challenged rational thinking. Negative news travels fast. Communication that is vague, one-sided and dishonest can negatively impact on mental health and amplify existing distress and anxiety 107 . Media reporting should not overemphasize negative mental health impact—for example, putative suicide rate increases or individual negative experiences—which could make situations worse than they actually are. Instead, communication during crises requires concrete and actionable advice that avoids polarization and strengthens vigilance, to foster resilience and help prevent escalation to severe mental health problems 108 , 109 .

Rapid research should be collaborative and high-quality

Within the scientific community, the topic of mental health during the pandemic led to a multitude of rapid studies that generally had limited methodological quality—for example, cross-sectional designs, small or selective sampling or study designs lacking valid comparison groups. These contributed rather little to our understanding of the mental health impact of the emerging crisis. In future events that have global mental health impact, where possible, collaborative and interdisciplinary efforts with well-powered and well-controlled prospective studies using standardized instruments will be crucial. Only with fine-grained determinants and outcomes can data reliably inform mental health policies and identify who is most at risk.

Do not neglect long-term mental health effects

So far, research has mainly focused on the acute and short-term effects of the pandemic on mental health, usually spanning pandemic effects over several months to 1 year. However, longer follow-up of how a pandemic impacts population mental health is essential. Can societal and economic disruptions after the pandemic increase risk of mental disorders at a later stage when the acute pandemic effects have subsided? Do increased self-reported mental health problems return to pre-pandemic levels, and which groups of individuals remain most affected in the long-term? We need to realize that certain pandemic consequences, particularly those affecting income and school/work careers, may become visible only over the course of several years. Consequently, we should maintain focus and continue to monitor and quantify the effects of the pandemic in the years to come—for example, by monitoring mental healthcare use and suicide. This should include specific at-risk populations (for example, adolescents) and understudied populations in low-income and middle-income countries.

Pay attention to mental health consequences of infectious diseases

Even though our knowledge on PACS is rapidly expanding, there are still many unanswered questions related to who is at risk, the long-term course trajectories and the best ways to intervene early. Consequently, we need to be aware of the neuropsychiatric sequelae of COVID-19 and, for that matter, of any infectious disease. Clinical attention and research should be directed toward alleviating potential neuropsychiatric ramifications of COVID-19. Next to clinical studies, studies using human tissues and appropriate animal models are pivotal to determine the CNS region-specific and neural-cell-specific effects of SARS-CoV-2 infection and the induced immune activation. Indeed, absence of SARS-CoV-2 neuroinvasion is an opportunity to learn and discover how peripheral neuroimmune mechanisms can contribute to neuropsychiatric sequelae in susceptible individuals. This emphasizes the importance of an interdisciplinary approach where somatic and mental health efforts are combined but also the need to integrate clinical parameters after infection with biological parameters (for example, serum, cerebrospinal fluid and/or neuroimaging) to predict who is at risk for PACS and deliver more targeted treatments.

Prepare mental healthcare infrastructure for pandemic times

If we take mental health seriously, we should not only monitor it but also develop the resources and infrastructure necessary for rapid early intervention, particularly for specific vulnerable groups. For adequate mental healthcare to be ready for pandemic times, primary care, community mental health and public mental health should be prepared. In many countries, health services were not able to meet the population’s mental health needs before the pandemic, which substantially worsened during the pandemic. We should ensure rapid access to mental health services but also address the underlying drivers of poor mental health, such as mitigating risks of unemployment, sexual violence and poverty. Collaboration in early stages across disciplines and expertise is essential. Anticipating disruption to face-to-face services, mental healthcare providers should be more prepared for consultations, therapy and follow-up by telephone, video-conferencing platforms and web applications 51 , 52 . The pandemic has shown that an inadequate infrastructure, pre-existing inequalities and low levels of technological literacy hindered the use and uptake of e-health, both in healthcare providers and in patients across different care settings. The necessary investments can ensure rapid upscaling of mental health services during future pandemics for those individuals with a high mental health need due to societal changes, government measures, fear of infection or infection itself.

Even though much attention has been paid to the physical health consequences of COVID-19, mental health has unjustly received less attention. There is an urgent need to prepare our research and healthcare infrastructures not only for adequate monitoring of the long-term mental health effects of the COVID-19 pandemic but also for future crises that will shape mental health. This will require collaboration to ensure interdisciplinary and sound research and to provide attention and care at an early stage for those individuals who are most vulnerable—giving mental health equal priority to physical health from the very start.

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Acknowledgements

The authors thank E. Giltay for assistance on data analyses and production of Fig. 1 . B.W.J.H.P. discloses support for research and publication of this work from the European Union’s Horizon 2020 research and innovation programme-funded RESPOND project (grant no. 101016127).

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Penninx, B.W.J.H., Benros, M.E., Klein, R.S. et al. How COVID-19 shaped mental health: from infection to pandemic effects. Nat Med 28 , 2027–2037 (2022). https://doi.org/10.1038/s41591-022-02028-2

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• v.17(6); 2020 Jun

Mental Health Effects of COVID-19 Pandemia: A Review of Clinical and Psychological Traits

Konstantinos kontoangelos.

1 1st Department of Psychiatry, Eginition Hospital, Medical School National & Kapodistrian University of Athens, Athens, Greece

2 University Mental Health Research Institute, Athens, Greece

Marina Economou

Charalambos papageorgiou.

As the coronavirus (COVID-19) pandemic sweeps across the world, it is causing widespread concern, fear and stress, all of which are natural and normal reactions to the changing and uncertain situation that everyone finds themselves in.

In this general review, we examined the literature about the psychological effects of COVID-19 pandemia. In total 65 papers were reviewed using the Medline computer database. Only publications in English were selected.

Children are likely to be experiencing worry, anxiety and fear and older people are also those with underlying health conditions, having been identified as more vulnerable to COVID-19, can be extremely frightening and very fear-inducing. China and several other countries took strict isolation measures. Medical staff and affiliated healthcare workers (staff) are under both physical and psychological pressure.

The COVID-19 pandemic is exceptional. Its effect will likely be imprinted on each individual involved. Extensive stressors will emerge or become worsened. Many medical staff workers will be harmfully psychologically affected.

INTRODUCTION

In January 2020 the World Health Organization (WHO) declared the outbreak of a new coronavirus disease, COVID-19, to be a Public Health Emergency of International Concern. WHO stated that there is a high risk of COVID-19 spreading to other countries around the world. In March 2020, WHO made the assessment that COVID-19 can be characterized as a pandemic. WHO and public health authorities around the world are acting to contain the COVID-19 outbreak [ 1 ]. However, this time of crisis is generating stress throughout the population. The considerations presented in this document have been developed by the WHO Department of Mental Health and Substance Use as a series of messages that can be used in communications to support mental and psychosocial well-being in different target groups during the outbreak [ 2 ]. COVID-19 pandemic not only affects physical health, but also mental health and well-being. The current pandemic is changing priorities for the general population, but it is also challenging the agenda of health professionals, including that of psychiatrists and other mental health professionals [ 3 ]. Everywhere in the world, psychiatric clinics are modifying their practice in order to guarantee care and support to persons with mental health problems, but also to those who are not mentally ill and are suffering from the psychosocial consequences of the pandemic. The number of those who will need psychiatric help is going to increase in the next weeks or months, requiring a reconsideration of our current practices. From a psychopathological viewpoint, the current pandemic is a relatively new form of stressor or trauma for mental health professionals [ 4 ]. COVID-19, the infection caused by the novel coronavirus detected in December 2019, raising concerns of widespread panic and increasing anxiety and although the effects of the coronavirus on mental health have not been systematically studied, it is anticipated that COVID-19 will have rippling effects, especially based on current public reactions.

This paper aims to review of the latest papers referring to the psychiatric and psychological effects of pandemia in the general population. The literature search was done using the Medline computer database. It focused in all studies concerning COVID-19 pandemia and psychiatry. The keywords were selected from titles, abstract and keywords and they were the following “COVID-19” “psychiatry” and “mental health.” Only publications in English were selected.

Psychological approaches

The coronavirus disease 2019 (COVID-19) pandemic it will cause an extraordinary stressor to patients and health care systems across the globe and people with serious mental illnesses should be provided truthful information about strategies related with the medical treatment for COVID-19. It will also be important to deal with the psychological and social dimensions of this epidemic for patients. Worry could both exacerbate and be exacerbated by existing anxiety and depressive symptoms [ 5 ]. Psychiatrists can play essential role in supporting the well-being of those affected and their families and crucial interventions can be related with the education about the common adverse psychological costs and encouraging health-promoting behaviours, the facilitation of problem solving and finally the empowerment of the patients, their families and health-care providers [ 6 ]. Existing focus on the global transmission of COVID-19 infection might distract public attention from psychosocial cost of the outbreak in the affected individuals and in the general population. The emerging mental health issues related to this epidemic event may develop into long-lasting health problems, isolation and stigma. Global health measures should be employed to address psychosocial stressors, particularly related to the use of isolation/quarantine, fear and vulnerability among the general population. The information from media and social network should be closely controlled and community supportive psychological interventions globally promoted [ 7 ]. Still the most important thing we can do is minimize the transmission of the virus through disciplined hygiene and social distancing. The fewer people who get infected in the general population, the lower the risk of infection for long-term care residents [ 8 ]. Mental health problems associated with the COVID-19 pandemic include high rates of psychiatric symptoms, and mental health considerations are highly relevant because mental health disorders (e.g., depression, anxiety disorders, posttraumatic stress disorder and substance use disorders) are common in patients with chronic pain. Mental health problems associated with the COVID-19 pandemic could exacerbate these pre-existing conditions which, in turn, could adversely impact pain-related treatment outcomes [ 9 ]. If a patient with psychiatric disorders infected with the COVID-19, antiviral drugs must be used in combination with psychotropic drugs, including antipsychotic, antidepressant, and anti anxiety drugs. If antiviral drugs are used without supplemental medication, patients with psychiatric disorders can experience relapses in their mental illness [ 10 ]. From a pharmacological point of view Siskind et al. [ 11 ] focus on specific recommendations correlated with the prescription of clozapine. With the ongoing coronavirus disease (COVID-19) pandemic, psychiatrists find themselves in the clinical situation of being asked by patients, family members and patient advocacy societies to help ensure access to clozapine as a medication critical for ongoing patient care. Clozapine may be associated with a higher risk of pneumonia, likely due to sialorrhea and aspiration rather than neutropenia. Clozapine levels can increase with acute systemic infection, leading to symptoms of acute clozapine toxicity, including sedation, myoclonus and seizures. Despite similarities with previous pandemics and a rapid response by the scientific community to understand COVID-19 and reduce its global impact, there is still much that we do not know, especially given the novel features of COVID-19, and governments varying responses to the crisis worldwide. There is therefore an urgent need for health psychology research and a need to understand the potential physical and psychosocial impact of COVID-19 on front-line health care staff [ 12 ]. There are many reasons for this. It is known that psychological factors play an important role in adherence to public health measures (such as vaccination) and in how people cope with the threat of infection and consequent losses. These are clearly crucial issues to consider in the management of any infectious disease, including COVID-19. Psychological reactions to pandemics include maladaptive behaviours, emotional distress and defensive responses. People who are prone to psychological problems are especially vulnerable [ 13 ]. An online assessment was incorporated to examine the pattern of posttraumatic stress symptoms in clinically stable COVID-19 patients. A total of 730 COVID-19 patients were recruited in this study, of whom, 714 met the inclusion criteria. The mean age of the participants 50.2±12.9 years, men accounted for 49.1% of the sample, and 25.8% lived alone prior to admission. The prevalence of significant posttraumatic stress symptoms was 96.2% (95%CI: 94.8–97.6%). Half of participants (49.8%) considered psycho-educational services helpful [ 14 ]. The rapid transmission rates of COVID-19 alongside with demeaning news coverage in widely used communication programs, and social discrimination towards COVID-19 patients may result in higher prevalence of self-perceived posttraumatic stress symptoms [ 15 ]. Health anxiety occurs when perceived bodily sensations or changes, including but not limited to those related to infectious diseases (e.g., fever, coughing, aching muscles), are interpreted as symptoms of being ill. There are several ways in which high health anxiety may influence behavioural responses to the belief of being infected. On the one hand, some people with high health anxiety may regard hospitals and doctor’s offices as a source of contagion and, therefore, avoid seeking medical assistance. On the other hand, other people with high health anxiety tend to seek out health-related information and reassurance, often from doctors. As such, they may visit multiple doctors or even attend hospital emergency rooms in their pursuit of reassurance that their bodily sensations and changes are not due to infection [ 16 ]. The fear of 2019-nCoV is likely due to its novelty and the uncertainties about how bad the current outbreak might become. Fear of 2019-nCoV is much greater than fear of seasonal influenza, even though the latter has killed considerably more people. According to the Morning Consult (2020) poll, 37% of Americans were very concerned about 2019-nCoV whereas 27% were very concerned about seasonal influenza, and most respondents (62%) were more worried about 2019-nCoV than they were about seasonal influenza. While the nature and impact of 2019-nCoV on mental health remains to be determined, there are clues in the existing literature that may help us begin to understand what to expect. Research on the psychological reactions to previous epidemics and pandemics suggests that various psychological vulnerability factors may play a role in coronaphobia, including individual difference variables such as the intolerance of uncertainty, perceived vulnerability to disease, and anxiety [ 17 ]. During epidemics, the number of people whose mental health is affected tends to be greater than the number of people affected by the infection. Patients infected with COVID-19 (or suspected of being infected) may experience intense emotional and behavioral reactions, such as fear, boredom, loneliness, anxiety, insomnia or anger. It is extremely necessary to implement public mental health policies in combination with epidemic and pandemic response strategies before, during and after the event. Mental health professionals, such as psychologists, psychiatrists and social workers, must be on the front line and play a leading role in emergency planning and management teams [ 18 ]. Given the humanitarian challenges of the ongoing pandemic, we think that COVID-19 needs a public mental health focus. COVID-19 is the first major pandemic of our generation, and we must seek the hidden opportunities to reflect and react as a global society. COVID-19 is as much a challenge of how we are going to frame it from a psychiatric perspective as it is a public health crisis. By merging public health with mental health, the ways that COVID-19 are changing the world could be for better rather than worse ( Table 1 ) [ 19 ].

Characteristics of 19 studies reporting psychological parameters

Psychiatric management of the elderly during the pandemia

Older adults are vulnerable at the onset of natural disasters and crisis, and especially those suffering from dementia have limited access to accurate information and facts about the COVID-19 pandemic. They might have difficulties in remembering safeguard procedures, such as wearing masks, or in understanding the public health information. Mental health professionals, social workers, nursing home administrators, and volunteers should deliver mental health care for people living with dementia. Vigilance about the health of the elderly in long-term care is essential not only for their health but also to protect the health care system from being overwhelmed by severe COVID-19 cases [ 20 ]. Mental health problems are common in older Chinese adults (i.e., ≥55 years), with the prevalence of depressive symptoms reported to be 23.6% in this population. The rapid transmission of the severe acute respiratory syndrome corona virus (SARS-CoV-2) and high death rate could exacerbate the risk of mental health problems and worsen existing psychiatric symptoms, further impairing their daily functioning and cognition. Stakeholders and health policy makers should collaborate to resolve this barrier in order to provide high-quality, timely crisis psychological services to community-dwelling older adults ( Table 2 ) [ 21 ].

Publications related with the psychiatric management of the elderly

Psychological effects of Pandemia in children

A particular scientific interest is related with children’s normal psychological development and wellbeing. Separation from caregivers might increase the risk of psychiatric disorders. Children who were isolated or quarantined during pandemic diseases were more likely to develop acute stress disorder, adjustment disorder, and grief 30% of the children who were isolated or quarantined met the clinical criteria for posttraumatic stress disorder [ 22 ]. Children are experiencing substantial changes to their daily routine and social infrastructure, because of COVID-19 pandemic and the information provided needs to take into account the child’s age and level of understanding. Sensitive and effective communication about life-threatening illness has major benefits for children and their family’s long-term psychological wellbeing. Ignoring the immediate and long-term psychological effects of this global situation would be unconscionable, especially for children and young people, who account for 42% of our world’s population [ 23 ]. Another critical issue during this pandemic is that in this situation the handling of young children with special needs such as autism spectrum condition (ASC) could be challenging for families and caregivers. Usually these children have interventions for several hours a week at home with special therapists or in dedicated hospitals and institutes. Parents and Caregivers of Young Children with ASC can be helped handle the children by explaining in the children what COVID-19 is, by the use of serious games, by online therapy for high-functioning children and by weekly online consultations for parents and caregivers [ 24 ]. Coronavirus disease 2019 (COVID-19) is changing family life. Parents and caregivers are attempting to work remotely or unable to work, while caring for children, with no clarity on how long the situation will last. Violence and vulnerability increase for children during periods of school closures associated with health emergencies. Rates of reported child abuse rise during school closures. Parents and children are living with increased stress, media hype, and fear, all challenging our capacity for tolerance and longterm thinking. For many, the economic impact of the crisis increases parenting stress, abuse, and violence against children ( Table 3 ) [ 25 ].

Publication related with the psychological effects of pandemia in children

Psychosocial effects of pandemia in China

The novel coronavirus (COVID-2019) has spread very rapidly all over China and several other countries took strict isolation measures and delays in starting schools, colleges, and universities across the country. Public health emergencies can have many psychological effects on college students, which can be expressed as anxiety, fear, and worry, among others. About 24.9% of college students have experienced anxiety because of this COVID-19 outbreak. Living in urban areas, living with parents, having a steady family income were protective factors for college students against experienced anxiety during the COVID-19 outbreak. However, having a relative or an acquaintance infected with COVID-19 was an independent risk factor for experienced anxiety [ 26 ]. From a medical and psychical approach, stress can be related with severe acute respiratory syndrome coronavirus (SARS-CoV) and critical cardiac lesions [ 27 ]. The COVID-19 epidemic in China has ignited another epidemic of stress, anxiety and depression. Since the outbreak of COVID-19, the Chinese government has taken proactive measures to contain not only the spread of the novel coronavirus but also that of psychological distress in the public. There is intense concern about the provision of online mental health services, with the utilization of these services to a large extent neglected and individuals with lower socioeconomic status (SES) might not have as much access to digital technologies [ 28 ]. Ιn the current home confinement situation due to the COVID-19 outbreak, most individuals are exposed to an unprecedented stressful situation of unknown duration. This may not only increase daytime stress, anxiety and depression levels but also disrupt sleep. Importantly, because of the fundamental role that sleep plays in emotion regulation, sleep disturbance can have direct consequences upon next day emotional functioning. People need adaptions of cognitive behavioral therapy elements that are feasible to implement for those facing changed work schedules and requirements, those with health anxiety and those handling childcare and homeschooling, whilst also recognizing the general limitations imposed on physical exercise and social interaction. Managing sleep problems as best as possible during home confinement can limit stress and possibly prevent disruptions of social relationships [ 29 ]. First-line medical workers and scientists played a leading role in fighting against the COVID-19 outbreak. China sent many medical works from across the country to Hubei province in the virus fight. Mental health care for the frontline medical workers around the word is urgently needed. The frontline medical professionals worked under great psychological stress and faced many challenges and losses. The large number of COVID-19 patients, suspected cases, hospitalizations, and patients in critical condition made the medical work incredibly hard. The transmission of COVID-19 from human-to-human and the increasing number of deaths could elicit their fear about being infected. The bad outcomes of some critical patients, the suffering of patients and their relatives could lead to worsening anxiety and mental distress [ 30 ]. In China to explore the mental health status of medical and nursing staff and the efficacy, or lack of critically connecting psychological needs to receiving psychological care, researchers conducted a quantitative study. Notably, among 994 medical and nursing staff working in Wuhan, 36.9% had subthreshold mental health disturbances, 34.4% had mild disturbances, 22.4% had moderate disturbances, and 6.2% had severe disturbance in the immediate wake of the viral epidemic. The noted burden fell particularly heavily on young women. Of all participants, 36.3% had accessed psychological materials (such as books on mental health), 50.4% had accessed psychological resources available through media (such as online push messages on mental health self help coping methods), and 17.5% had participated in counseling or psychotherapy. Trends in levels of psychological distress and factors such as exposure to infected people and psychological assistance were identified [ 31 ]. The prevalence of posttraumatic stress symptoms (PTSS) in China hardest-hit areas a month after the COVID-19 outbreak was 7% and women reported significant higher PTSS in the domains of re-experiencing, negative alterations in cognition or mood, and hyperarousal [ 32 ]. In China a key recommendation is to shift services from institutions to the community, highlighting the steps required to provide appropriate psychiatric services for patients in the current epidemic of COVID-19. Apart from this, with the development of artificial intelligence techniques in clinical settings, attempts to speed up constructing the framework of online consultation and internet hospitals, as well as carrying out telemedicine, are valuable. As one the fundamental components of mental health service, the large top-class tertiary hospitals-based psychiatric health care professionals are easy to play critical roles in comprehensive health of population with mental disorders. This can be leveraged through big data analyses and harnessed via updated clinical practice guidelines and algorithms to improve policy-making [ 33 ]. In order to reduce the risk of developing mental health problems, simple advices may be provided to the general population 1) limit the sources of stress, 2) break the isolation, 3) maintain your usual rhythm, 4) focus on the benefit of the isolation, 5) ask for professional help. The vulnerability to psychological distress across populations in the COVID-19 pandemic could be attributable to various factors, including gender, social support, specific experiences with COVID-19 infection, length of isolation, and amount of exposure to the media [ 34 ]. In a study about the attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak the results showed that the majority of the respondents (97.1%) had confidence that China can win the battle against COVID-19. Nearly all of the participants (98.0%) wore masks when going out in recent days. In multiple logistic regression analyses, the COVID-19 knowledge score was significantly associated with a lower likelihood of negative attitudes and preventive practices towards COVID-2019. Most Chinese residents of a relatively high socioeconomic status, in particular women, are knowledgeable about COVID-19, hold optimistic attitudes, and have appropriate practices towards COVID-19. Health education programs aimed at improving COVID-19 knowledge are helpful for Chinese residents to hold optimistic attitudes and maintain appropriate practices [ 35 ]. One of the largest community mental health projects globally is the mental health care model in China entitled the “Management and treatment program for severe mental illness.” In order to establish community-based mental health services nationwide, this project integrated the resources in psychiatric hospitals and existing community psychiatric services and trained mental health professionals in the development of individual service plans. The COVID-19 outbreak has raised numerous challenges for psychiatric hospitals in China to safely manage patients’ major psychiatric disorders in addition to preventing and treating COVID-19. In addressing these challenges, future community mental health system reform is necessary to re-balance the system by re-distributing resources from hospital-centric services to community-based and primary care services [ 36 ]. In recent years, Chinese health workers are often confronted with frustrating situations in the health care system including serious workplace violence against clinicians. A meta-analysis found that the overall prevalence of workplace violence was 62.4% among Chinese health workers. Regardless of the unsafe clinical environment, Chinese health workers are always committed to provide timely health services without any hesitation or reservations. For instance, as of February 12, 2020, a total of 189 external expert teams comprising 21,569 health workers from other regions of China have volunteered to work in Hubei province, disregarding the high risk of contracting the infection and the high mortality rate of the COVID-19 among health workers [ 37 ]. Despite the Chinese authorities have announced relevant policies and actuating principles in a strategic manner, the COVID-19 outbreak has posted an emerging serious challenge for the mental health services in China. There are some limitations that need to be addressed. First, several online mental health services have been constructed across different areas, however, unified national management and coordination policies are still inadequate, which could result in uneven distribution and wastage of medical resources, let alone evaluating the efficacy of these services. Second, online mental health services are the predominant assistance measure and therefore, some people (e.g., older adults) who may have limited access to smartphones and the broadband internet, may benefit less from the services. Third, frontline health professionals may have limited time and energy to access to these services due to heavy workload. Fourth, based on experiences of SARS outbreak, some patients and health professionals would be traumatized by the COVID-2019 outbreak and still suffer from persistent psychiatric symptoms even after the outbreak [ 38 ]. In a cross-sectional survey that enrolled 1,257 respondents the results revealed a high prevalence of mental health symptoms among health care workers treating patients with COVID-19 in China. Overall, 50.4%, 44.6%, 34.0%, and 71.5% of all participants reported symptoms of depression, anxiety, insomnia, and distress, respectively. Participants were divided in 3 groups (Wuhan, other regions in Hubei province, and regions outside Wuhan province) to compare interregional differences. Most participants were female, were nurses, were aged 26 to 40 years, were married, and worked in tertiary hospitals with a junior technical title. Nurses, women, those working in Wuhan, and frontline workers reported more severe symptoms on all measurements. The same study further indicated that being a woman and having an intermediate technical title were associated with experiencing severe depression, anxiety, and distress [ 39 ]. Surveying more than 1,200 nurses and physicians in 34 hospitals in the Wuhan region and across mainland China, the authors found striking prevalence rates of symptoms of depression and anxiety; half of those responding identified at least mild depression on a validated screening instrument, and one-third reported insomnia. Approximately 14% of physicians and nearly 16% of nurses described moderate or severe depressive symptoms. Those at greatest risk for depressive and anxious symptoms included women, those with intermediate seniority titles (compared with those with junior roles), and those at the center of the epidemic in Wuhan [ 40 ]. Another phenomenon of pandemia is that many countries in which numerous Chinese students pursue their academic studies announced travel restrictions on foreign nationals to contain COVID-19. International Chinese students are living with the fear that their families in China are susceptible and at risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for COVID-19. They also face discrimination and isolation in some countries due to being deemed as potential SARS-CoV-2 carriers. Some media outlets have used derogatory headlines, perpetuating stereotypes and prejudices about Chinese people [ 41 ]. In China, 173 million people are living with mental health disorders, and neglect and stigma regarding these conditions still prevail in society. When epidemics arise, people with mental health disorders are generally more susceptible to infections for several reasons. Mental health disorders can increase the risk of infections, including pneumonia and once infected with severe acute respiratory syndrome coronavirus which results in COVID-19 people with mental disorders can be exposed to more barriers in accessing timely health services, because of discrimination associated with mental ill-health in health-care settings [ 42 ]. With the progress of the disease in China, clinical symptoms become severe and psychological problems in infected patients will change; therefore, psychological intervention measures should be targeted and adapted as appropriate. Interventions should be based on a comprehensive assessment of risk factors leading to psychological issues, including poor mental health before a crisis, bereavement, injury to self or family members, life threatening circumstances, panic, separation from family and low household income ( Table 4 ) [ 43 ].

Publications related with the psychosocial effects of pandemia in China

Psychiatric consequences of pandemia in other countries

In Italy, about the 25% of the overall burden of disease is attributed to neuropsychiatric disorders. The community-based Italian psychiatric assistance is integrated in the National Health System, includes 183 Mental Health Departments and takes care almost 780,000 patients. Currently, patients are continuously followed-up, mainly with the use of internet connections. However, the actual stressful period and social isolation may increase the risk of recurrence and new episodes. In fact, people are forced now to live isolated because social distancing is the most effective strategy to limit the spread of the virus. However, social isolation, especially if protracted, may increase the risk of mental disorders such as anxiety, mood, addictive and thought disorders [ 44 ]. In USA, the crisis has highlighted the extent of interconnectedness of their institutions, including medical, public health, political, economic, and educational. The current pandemic clearly underscores the global nature of their lives today and the limited constructs of nationality, religion, and political leanings in the face of a common threat. They cannot fully anticipate the long-lasting effects of this pandemic on our societies. There they have seen telemedicine set up at record speed to meet the needs of patients. Regulatory barriers to reach many patients were brought down almost overnight. They can use more platforms and cross state lines to deliver care, which are important changes that help us reach as many patients as possible. They are collectively experiencing a stressor that affects segments of the population in different ways [ 45 ]. In Japan, economic impacts and social disruptions have been reported. This is not the first time for the Japanese people to experience imperceptible agent emergencies—often dubbed as CBRNE (chemical, biological, radiological, nuclear, and high-yield explosives). In 1945, two atomic bombings took place; the sarin gas attacks in 1995, H1N1 influenza pandemic in 2009, and the Fukushima nuclear accident in 2011 all carried fear and risk associated with unseen agents. These events provoked social disruptions. Overwhelming and sensational news headlines and images added anxiety and fear to these situations as well as fostered rumors and hyped information as individuals filled in the absence of information with rumors. The affected people were subject to societal rejection, discrimination, and stigmatization ( Table 5 ) [ 46 ].

Articles related with other’s countries experience

The heroic efforts of the health care workers during COVID-19 pandemia

During a pandemic, the demands on healthcare staff are extraordinary and work-related stress disproportionally affects healthcare workers and is linked to excessive workloads working in emotionally charged environments and may increase patient safety incidents, medical errors, lower quality service provision, along with issues regarding staff retention and psychological ill-health follow [ 47 ]. For example, ECT practitioners need to liaise with their senior anaesthetic colleagues to optimise a safe environment for ECT and determine the most appropriate PPE to be used. The COVID pandemic is a rapidly evolving situation and ECT practitioners need to keep abreast of developments and changing policies. Regularly updated information and clinical guidance should be accessed from reputable national and international scientific and medical organisations, e.g., the Health Service Executive in Ireland [ 48 ].

Front-line key workers, such as healthcare providers and emergency first responders but also other non-healthcare related staff (e.g., social workers, prison staff), may be especially vulnerable to experiencing moral injuries during this time. Recommendations for clinicians providing psychological support during and after the COVID-19 Pandemic include: Psychological support for those in front-line roles and affected by the COVID-19 and clinicians should also be aware that individuals who develop moral injury-related mental health disorders are often reticent to speak about guilt or shame and may instead focus on more classically traumatic elements of their presentation. Clinicians offering psychological treatment to patients should continue to do so, taking precautionary measures where needed- such as offering treatment via Skype, Zoom, telephone or similar. Steps should be taken by clinical care teams to ensure that vulnerable groups, such as survivors of domestic violence, and those with serious mental illnesses continue to be able to access treatment and support networks [ 49 ]. Comprehensive survey about the psychological effect of the COVID-19 outbreak on hospital staff of different ranks and positions is needed to provide timely and appropriate interventions. Enhancing the psychological wellbeing of hospital staff during the COVID-19 outbreak is equally important to the fight against the outbreak [ 50 ]. During the current COVID-19 disease emergency, it is not only an ethical imperative but also a public health responsibility to keep the network of community psychiatry services operational, particularly for the most vulnerable ones (subjects with mental illness, disability, and chronic conditions). At the same time, it is necessary to reduce the spread of the COVID-19 disease within the outpatient and inpatient services affiliated with Mental Health Departments [ 51 ]. Facing this large scale infectious public health event, medical staff are under both physical and psychological pressure. Staff worried about the shortage of protective equipment and feelings of incapability when faced with critically ill patients. Many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies. Finally, they suggested training on psychological skills to deal with patients’ anxiety, panic, and other emotional problems and, if possible, for mental health staff to be on hand to directly help these patients ( Table 6 ) [ 52 ].

Publication on mental health of health care workers

Telemedicine and psychological support during pandemia

Undeniably this is the first pandemic of the digital age and research of social media rumours during crisis events highlights the importance of the release of substantive updates at regular intervals from trusted sources. False information tends to proliferate in the absence of updates from official channels. The COVID-19 pandemic has occurred at a time when the human race is more connected than ever. While physical connectivity, by way of widespread travel, has accelerated the spread of the disease around the planet, electronic connectivity provides a tool that, if utilized responsibly, can mitigate its effects [ 53 ]. An unexpected obstacle of the COVID-19 epidemic is that the university public hospitals have had to take unprecedented measures of containment, including asking non-essential medical staff to stay at home. In fact, medical students practicing in the surgical departments find themselves idle, as non-urgent surgical activity has been canceled, until further notice. Blended-learning, defined as the combination of conventional face-to-face learning and asynchronous or synchronous e-learning, have grown quickly and are now extensively used in medical education [ 54 ]. While the epidemic is active and clinical research continues there is no question that clinical researchers are having to make tough decisions about ongoing clinical trials due to the widespread COVID-19 pandemic. Although some guidance has been offered from local and national organizations, it is still ultimately the responsibility of the principal investigation (PI) to evaluate the risk-benefit ratio of ongoing research. When making research decisions, PIs should consider all factors that affect the risk-benefit ratio of continuing research during this time [ 55 ]. In Paris in s psychiatry department although psychiatrists and psychologists were rather reluctant to embrace telepsychiatry before this crisis, the pandemic has required a shift of 90% of our outpatient activity and liaison psychiatry to telepsychiatry. The good news is that this quick shift is well accepted by patients, psychiatrists, and psychologists. To address the mental health issues of the medical and nonmedical hospital staff exposed to overwork, stress, difficult ethical decisions, and multiple deaths, along with confinement and the fear of contamination for themselves and their families, we have proposed a dedicated hotline for psychiatry teleconsultation, which has been positively received [ 56 ].In Italy in a psychiatric department switched almost all of the outpatients visits to telemedicine sessions. They had very little, if any, experience with telemedicine, but they had no other choice. For most patients, they just used the phone. In their unit instituted a policy in October 2019 that banned handshakes, in order to prevent hospital infections. Each room on their units has a sign inviting everyone to greet one another with a smile instead of shaking hands. They knew that washing hands and avoiding handshakes were necessary, but not sufficient, measures. Indeed, they saw quickly that many people who carefully washed their hands and did not touch anyone or anything became infected regardless [ 57 ]. Regarding delivering services only via telephone, telemedicine, or other technologies. Most clinicians have not used telemedicine as a routine part of their daily work. Among the resources that can help clinicians learn about telemedicine, “BestPracticesinVideoconferencingBasedTelementalHealth” ( https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Telepsychiatry/APA-ATA-Best-Practices-in-Videoconferencing-Based-Telemental-Health.pdf ), a consensus guideline from the American Psychiatric Association and the American Telemedicine [ 58 ]. The COVID-19 crisis and global pandemic may be the defining moment for digital mental health, but what that definition will be remains unknown. Ensuring the right use of telehealth and app tools today in this crisis and investment in people and training to support them tomorrow during the potential mental health fallout of the current crisis as well as readiness for tomorrow can cement the future of digital mental health as simply mental health. Bending the curve in the right direction will require funding, research, policy changes, training, and equity, but these investments will continue to yield higher returns at every step [ 59 ]. “Action at a distance” may be the new model for clinical researchers in the context of the COVID-19 pandemic, which may require social distancing for the next 18 months. Therapists must minimize face-to-face contact with vulnerable populations. But they must also persist, adapt, and help older patients and study participants during the pandemic. Guidance for reduce effects of social isolation on older adults engaged in clinical research the use of clinical research platforms to connect with older adults and chronicle the evolution of this unprecedented public health event [ 60 ]. In the COVID-19 epidemic, a new psychological crisis intervention model was developed through internet technology use. This new model from the West China Hospital integrates physicians, psychiatrists, psychologists, and social workers into Internet platforms to carry out psychological intervention to patients, their families, and medical staff. The central idea is to join Internet technology and the whole intervention process, as well as to combine early intervention with later rehabilitation. It is noteworthy that despite the common mental health problems and disorders found among patients and health workers in such settings, most health professionals working in isolation units and hospitals do not receive any training for providing mental health care [ 61 ]. In order to solve some of the psychological and mental problems that quarantine may bring, a new type of psychological and mental problem intervention strategy that is feasible and accessible is urgently needed. In addition to the face-to-face routine psychological counseling mode, remote written counseling may become a new type of psychological counseling mode in the context of public health emergencies. Structured letter therapy is a kind of feasible psychological intervention approach. Structured letter therapy should have the following characteristics: Includes Patient Page, Intervention Page, and Continuation Page [ 62 ]. Online psychological self-help intervention systems, including online cognitive behavioral therapy for depression, anxiety, and insomnia (e.g., on WeChat), have also been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for psychological crises during the epidemic. In general, online mental health services being used for the COVID-19 epidemic are facilitating the development of Chinese public emergency interventions, and eventually could improve the quality and effectiveness of emergency interventions [ 63 ]. The psychological assistance hotline teams composed of volunteers who have received psychological assistance training in dealing with the 2019-nCoV epidemic provide telephone guidance to help deal with mental health problems. Hundreds of medical workers are receiving these interventions, with good response, and their provision is expanding to more people and hospitals. Understanding the mental health response after a public health emergency might help medical workers and communities prepare for a population’s response to a disaster [ 64 ]. Many of the research papers about COVID-19 in international journals were written by researchers in China, which led to great concerns because these findings cannot directly benefit frontline health professionals and policy makers because of the language barrier. It is critical for health science to be published in English-language journals to facilitate communication and enable global coordination and timely epidemic response. However, some media were concerned that Chinese researchers within academic organizations concentrated on publishing papers in prestigious international journals but paid inadequate attention to epidemic prevention of COVID-19 and neglected to disseminate their findings within Chinese-language journals ( Table 7 ) [ 65 ].

Publications on telemedicine

Pandemia and social psychiatry

With the advent of the COVID-19 pandemic, stigma and xenophobia have become major elements of the public discourse and a regrettable, but everyday reality. We have been witnessing increased antagonism toward specific groups with high infection rate that in turn has led to patients presenting with both enacted and felt stigma and associated increased anxiety and depression. Combining the stigma associated with mental illness with the stigma now shown toward certain COVID-positive patients may lead to double stigma, a barrier to psychiatric treatment adherence with resultant increased morbidity. Reducing stigma requires both national and international interventions. To successfully address all these challenges and research themes in a manner that acknowledges the truly global nature and impact of the crisis we are witnessing, we see an urgent need for collaboration and consensus guidelines from psychiatric organizations and their members (task forces, treatment and education guidelines, multi-site /multicountry research, etc.) [ 66 ]. In response to the COVID-19 pandemic, Jails pose a unique set of challenges to COVID-19 prevention, detection, and management mitigation that deserves immediate attention. Social distancing to reduce the rate of disease transmission is not feasible in jails, where people are confined to small living spaces and institutions are often overcapacity. Hand-washing can be undermined by policies limiting soap access or requiring individual purchase of soap. Many jails restrict access to hand sanitizer, which contains alcohol, fearing individuals will ingest it. Along with structural barriers to disease prevention, there are administrative challenges that impede timely access to healthcare professionals when sick. This is especially concerning because jails have a high proportion of people with underlying health conditions, making them more susceptible to severe COVID-19 infection [ 67 ]. It is probable that coronavirus disease (COVID-19) will be transmitted to people experiencing homelessness, which will become a major problem in particular in North America. If cities impose a lockdown to prevent COVID-19 transmission, there are few emergency preparedness plans to transport and provide shelter for the large number of people experiencing homelessness. In lockdowns, public spaces are closed, movement outside homes are restricted, and major roads of transport might be closed, all of which might negatively affect people experiencing homelessness. It is unclear how and where unsheltered people experiencing homelessness will be moved to if quarantines and lockdowns are implemented [ 68 ]. Sub standard implementation of appropriate infection prevention and control measures could influence COVID-19 global spread. These include early recognition, source control and additional precautions at point-of-care for persons under investigation or with confirmed COVID-19. The myriad factors influencing the COVID-19 pandemic are not unique. High population density, unsanitary conditions and aninade-quate health care infrastructure were also at the core of the Zika epidemic. As with any infectious disease emergency, public health officials need also to address the epidemic of fear. In appropriate prevention and treatment strategies such as herbal remedies and exaggerated numbers of persons affected by COVID-19 cases have circulated on social media. The COVID-19 pandemic, rapid spread and magnitude unleashed panic and episodes of racism against people of Asian descent [ 69 ]. Trust encourages social interactions and cooperation among health professionals. Trust has been shown to help improve retention, motivation, performance and quality of care. One way to promote trust among organizations and health professionals is through the frequent provision of information. A medical officer in Beijing, who had experienced SARS, proposed that regular and timely provision of information was useful in alleviating anxiety to some degree. Additionally, frequent communication with and encouragement to health workers from governors and employers leads to them feeling protected. If a health professional does become infected, compensation may also be another incentive to work. It is important to provide physical protective material. However, psychological support should also be made available. Trust may also be a key element [ 70 ]. Of the 150 million international migrant workers (IMWs) worldwide, 95% reside in the five WHO regions in which cases of coronavirus disease 2019 (COVID-19) have been confirmed. The absence of a coordinated response for IMWs highlights a key deficiency in public health planning. During the epidemic, IMWs should be provided more accessible health care. Public health campaigns should be available in multiple languages and diffused through various communication channels and networks of IMWs as soon as possible. In addition, more countries should ratify the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families to provide global health equity and ensure that migrant workers’ health is not neglected in future epidemics and disasters ( Table 8 ) [ 71 ].

Publications related with social psychiatry

Assessing and analyzing the overall content of the publications there is a greater need for research paper which will explore with greater scientific approach the psychiatric factors and consequences of this sudden and terrible pandemia. The COVID-19 pandemic will create unprecedented health and social challenges globally. People with serious mental illnesses will be at uniquely high risk during this period, as will be the public mental health care system central to delivering their care. Constructive peer-support, supportive therapy and early mental health interventions will improve their quality of care, both for themselves and the patients. It is also important for us to stay away from misinformation ourselves and be responsible for what we share on media platforms. It is imperative to remember that mass mayhem and panic due to uncertainty of an illness can cause more damage than the virus itself. With the scare of COVID-19 pandemic on the rise, it is time that as psychiatrists will try to incorporate the healthcare services keeping mental health at the epicenter. Early identification of distress and timely psychological interventions can, not only prevent crisis at times of pandemics but also help in containing its extend. The specific response to the mental distress of children who are quarantined should also be considered when designing psychological intervention strategies in response to COVID-19. Vigilance about the health of the elderly in long-term care is essential not only for their health but also to protect the health care system from being overwhelmed by severe COVID-19 cases. The information from media and social network should be closely controlled and community supportive psychological interventions globally promoted. Psychological support for those in front-line roles and affected by the COVID-19 should be prioritized and made more readily accessible.

The authors have no potential conflicts of interest to disclose.

Author Contributions

Conceptualization: Konstantinos Kontoangelos. Data curation: Marina Economou. Formal analysis: Marina Economou. Investigation: Konstantinos Kontoangelos. Methodology: Marina Economou. Project administration: Marina Economou. Resources: Marina Economou. Software: Konstantinos Kontoangelos. Supervision: Charalambos Papageorgiou. Validation: Charalambos Papageorgiou. Visualization: Konstantinos Kontoangelos. Writing—original draft: Konstantinos Kontoangelos. Writing—review & editing: Konstantinos Kontoangelos.