The spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), has generated a pandemic that forced governments around the world to take unprecedented measures to limit it. On April 8th, 2020, the United Nations Educational, Scientific and Cultural Organization (UNESCO) stated that 188 countries had their schools suspended nationwide, an unprecedented measure that left at least 1.5 million young people out of formal education(1). Furthermore, many businesses suspended or drastically reduced their activities, causing an economic contraction that is estimated to reach around 12% in the Eurozone alone, and characterized as “unprecedented in peacetime” by representatives of the European Central Bank(2). Apart from probable economic (i.e., unemployment) and financial implications, the measures taken generated drastic changes in lifestyle for many individuals that are now under pressure to fulfill their job roles from home while also caring for their children. In addition, instrumental social support has become very difficult to provide because of the imposed travel restrictions. Thus, we can state that this situation generated major changes in the lifestyle of most individuals and that many of them will find it impossible to adapt by using their familiar coping strategies. It is therefore reasonable to consider this situation a social crisis, as it will cause numerous individuals to go through “a period of psychological disequilibrium, experienced as a result of a hazardous event or situation that constitutes a significant problem that cannot be remedied by using familiar coping strategies” – the very definition of a crisis, as Roberts formulated it in 2000(3).
A social crisis can lead to increased symptoms and prevalence of major depressive disorder, anxiety disorders, stress-related disorders (i.e., including posttraumatic stress disorder), and mental and behavioral disorders due to psychoactive substance use. Furthermore, stress is a factor that increases the risk of relapse in other mental and behavioral disorders as well. The resolution of any crisis and the efficient management of stressful situations are dependent upon factors related to the event (e.g., severity, localization) and factors related to the individual (e.g., the perception of the traumatic event, social support and coping and defense mechanisms)(4). However, promoting adaptation is dependent upon knowledge about the stressor, its direct consequences and putative mitigating factors (e.g., demographic, socioeconomical, cultural etc.). Thus, this study aimed at reviewing the currently available empirical results on mental health in the context of COVID-19 pandemic. For this, a PubMed search was conducted using the terms “COVID-19” and “mental health”. All abstracts were reviewed and all papers that contained empirical evidence were further processed. Opinion papers were excluded. Full-text versions were obtained for all included studies.
Epidemiological data on general population
All papers identified started from the assumption that an increase in the frequency and severity of symptoms related to stress, anxiety and depression is expected(5,6), but the magnitude of this increase is unknown and nearly impossible to predict. Furthermore, the extent to which these symptoms will add up to cause an increase in the prevalence of stress-related disorders, anxiety disorders, major depressive disorder, posttraumatic stress disorder (PTSD) and other mental and behavioral disorders and problems (e.g., psychoactive substance use disorders, self-harm or suicide attempts) is yet unknown and needs to be researched(5). Studies that include diagnosis are however more elaborate and difficult to implement during the crisis. Thus, all published papers used screening tools and reported prevalence rates based on these.
Both Asian and European studies report higher rates for clinically significant depressive symptoms in the general population, varying between 16.5% and 48.3%(7-10), values that are significantly higher than the 12-month prevalence of 7% reported in the United States for major depressive disorder(11).
The prevalence of clinically significant anxiety symptoms in the general population varied between 21.6% and 35.1%(7-10), again higher than the 12-month prevalence of 17.7% reported in general(12).
The prevalence of PTSD symptoms was found to be 15.8%(8).
Risk and protective factors for the general population
The risk for developing a mental and behavioral disorder or worsening of a preexisting one relies in the intensity and nature of the stress reaction, which is influenced by the objective nature of the stressor, the perception of the event, the available social support and the coping strategies(4).
The COVID-19 pandemic is objectively a particular type of stressor in the sense that it is poorly localized and yet generalized, giving individuals little chance for avoidance or control.
The perception of a stressful situation is based on the appraisals individuals perform when faced with it. In general, persons will perform two types of appraisals when faced with a stressor, and these appraisals then determine how they will cope with that stressor. The primary appraisal evaluates the nature of the stressor per se in terms of severity, certainty, predictability etc. The secondary appraisal is focused on their own ability to deal with the situation (e.g., controllability, agency)(13).
In the case of COVID-19 pandemic, several factors concurred to create an image of severity. First, the nature of the stressor is still somewhat unclear in respect to the severity of the illness, speed of spread, prognosis etc. Conflicting messages from the authorities made the situation even worse, in many cases, by creating even more uncertainty. Secondly, looming shortages of resources, both for basic needs and for prevention and treatment, high financial losses and impaired ability to get social support due to self-isolation and travel restrictions created an image of poor controllability of the situation for many people(14).
In the general population, the most important risk factors associated with psychopathology were: inadequate information, loneliness, duration of quarantine, female gender, younger age, previous diagnosis of mental and behavioral disorders, fear of infection, having symptoms associated with COVID-19, having a close relative with COVID-19, frustration and boredom, inadequate supplies, financial problems and stigma(8,10,15).
On the other hand, the most important protective factors were: the belief that information has been provided, perceived survival likelihood and low risk of contracting SARS‑CoV‑2, older age, economic stability, personal precautionary measures, spirituality and high level of confidence in doctors(7,8,10).
Data on special population groups
The COVID-19 pandemic per se and the measures taken to limit it affect vulnerable populations even more(16).
Youth has been impacted more severely by the pandemic, causing significant disruption in routine, peer contact, skills acquisition and putting significant strain on their relationship with adults/caretakers. Students were further impacted by the suspension of classes, examinations, with little remedy put in place by the authorities in many cases. Graduating students faced even more uncertainty regarding graduation and entering the work market(17). In a cross-sectional study from China, nearly 40.4% of young adults were found at risk for psychological problems, with lower educational attainment and using negative coping styles among the most important risk factors(18).
The measures taken by authorities worldwide have had a major impact on the elderly due to their biopsychosocial vulnerabilities(19,20). Older persons are especially vulnerable to loneliness, an independent risk factor for depression, anxiety disorders and suicide(20), especially through worsening their perception of risk of death or disease(19). Furthermore, because most of them are not familiar with modern communication technologies, they have a poorer access to quality information and even limits their ability to secure proper healthcare(20). Also, cognitive impairment and other mental disorders due to brain damage and dysfunction can make it difficult for these patients to follow proper preventive measures(20).
The patients with mental and behavioral disorders are another high-risk population since stress can precipitate a relapse of their preexisting condition and because isolation measures limit the availability of resources for them(21).
Medical staff is also considered a high-risk population, and available data show very high rates of clinically significant depressive symptoms (50-51%) and of anxiety symptoms (45%)(22,23). Furthermore, the medical staff seems to be the professional category most affected by poor sleep quality(10), with insomnia rates affecting more than one in three individuals in this group(22).
Moreover, the isolation and quarantine measures imposed by authorities have led to a grim situation for the victims of domestic violence – a phenomenon that is thought to have increased during the pandemic – because they can no longer escape their abusers(24).
An increase in complicated grief prevalence is also expected because of the limitations imposed on normal familial care for terminally ill patients and on burial customs(25).
The situation created by the COVID-19 pandemic is a social crisis that has led to a notable increase in the prevalence of clinically significant depressive, anxiety and stress-related symptoms, which can thus generate and increase the prevalence of related mental and behavioral disorders. Furthermore, various social groups – i.e., young adults, patients, medical staff, domestic violence victims, the elderly – are at an even higher risk for developing such conditions or for the relapse or worsening of their preexisting conditions.
Therefore, authorities should also be concerned with limiting the psychological impact of this situation by providing adequate, noncontradictory information, facilitating social support and spirituality, and limiting the economic impact on individuals, as these are currently considered the most efficient protective factors against developing a mental or behavioral disorder in the pandemic context.