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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 171-178

A review of the mental health effects of the COVID-19 pandemic

Department of Clinical Psychology, Institute of Social Sciences, Üsküdar University, Üsküdar/Istanbul, Turkey

Date of Submission03-Jun-2021
Date of Decision01-Jul-2021
Date of Acceptance11-Jul-2021
Date of Web Publication13-Aug-2021

Correspondence Address:
Gökben Hizli Sayar
Üsküdar University- Altunizade-Üsküdar, İstanbul
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnbs.jnbs_26_21

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COVID-19 virus emerged in Wuhan, China, in December 2019 and spread rapidly all over the world. Its rapid spread was declared as a “pandemic” by the World Health Organization in March 2020. COVID-19 causes many physical, psychological, and social problems. This study aims to reveal the psychological and behavioral effects of the COVID-19 pandemic on different groups with a literature review. It has been observed that the COVID-19 pandemic caused an increase in fear, anxiety, and anger, anxiety disorders in the general population; however, increased stress and life changes caused an increase in posttraumatic stress disorder, depression, insomnia, and even suicidal thoughts. In the studies carried out in this period, it was understood that some special groups such as individuals with previous psychiatric diseases, children and adolescents, the elderly and those with chronic diseases, and healthcare workers who struggled with the disease were more affected. It is necessary to ensure that sensitive groups, especially healthcare workers, who are at risk in terms of the adverse mental effects of the epidemic, are effectively screened, and appropriate evaluation methods and forms should be developed for this purpose.

Keywords: Coronavirus, mental health, pandemic, psychological effects

How to cite this article:
Varolan LA, Özdogan B, Sayar GH. A review of the mental health effects of the COVID-19 pandemic. J Neurobehav Sci 2021;8:171-8

How to cite this URL:
Varolan LA, Özdogan B, Sayar GH. A review of the mental health effects of the COVID-19 pandemic. J Neurobehav Sci [serial online] 2021 [cited 2022 Aug 8];8:171-8. Available from: http://www.jnbsjournal.com/text.asp?2021/8/2/171/323809

  Introduction Top

The new coronavirus COVID-19 emerged in Wuhan, China, in December 2019 and spread rapidly worldwide. Its prevalence was declared “epidemic” by the World Health Organization in March 2020.[1]

The COVID-19 pandemic causes many physical problems, having a death risk of up to 3%, trying to improve the diagnosis and treatment possibilities of the virus simultaneously with the epidemic, not knowing the danger and risks precisely, as the situation could not be controlled and the pandemic brought many unknowns, it soon turned into a global trauma. The COVID-19 pandemic caused by the new coronavirus has affected the physical health of individuals and had a profound and diverse psychosocial impact on communities and people at international levels, as in past infectious disease outbreaks.[2],[3]

The need to develop effective psychological interventions to protect, control, and treating mental health, which can minimize the anxiety, depression, and stress brought about by negative situations such as the changing lifestyle with the pandemic, the fear of getting sick and death, despair, and stigmatization, is apparent.[4] It is essential to reveal the psychosocial problems caused by the pandemic to find solutions. This review aims to reveal the psychological and behavioral effects of the COVID-19 pandemic on different groups with a literature review. At the same time, it is aimed to evaluate what needs to be done about treatment and prevention.

  Coronaviruses Top

Coronaviruses (CoV), which are the disease agents, are single-stranded RNA viruses with protein protrusions on their surface. Although these viruses belonging to the coronavirus family are usually self-limiting mild respiratory diseases, they are more severe and even more severe such as “Middle East Respiratory Syndrome (MERS)” and “Severe Acute Respiratory Syndrome (SARS).” It can cause fatal infections.[5]

This new outbreak was noticed due to an increase in pneumonia cases of unknown cause in Wuhan, China, and was first reported by the World Health Organization China Country Office on December 31, 2019.[5] Although this epidemic was defined as an “international public health emergency” on January 30, 2020, as a result of the rapid spread of the disease with its severity and high transmission ability, a global epidemic was reported by the World Health Organization on March 11, 2020, with cases in many countries, including the European continent. It has been declared as a “pandemic.”[6]

Approximately 145 million COVID-19 confirmed cases and 3 million deaths were reported in April 2021, when all-world data, especially the United States, Brazil, Russia, India, and European countries, were most affected by the pandemic. In Turkey, 4.5 million confirmed cases, deaths due to COVID-19 were reported in 37,500 people.[1]

  The Clinical Course of COVID-19 Top

When we look at the clinical course of the disease, the symptoms are often in respiratory tract diseases. In symptomatic patients, fever, cough, shortness of breath (dyspnea), weakness, sore throat, runny nose, muscle pain, inability to taste smell, and diarrhea can be seen most. Although most patients exposed to the virus can experience asymptomatic disease, it can be fatal with severe system disorders such as pneumonia and renal failure in patients with more severe disease. The clinical course may be different in patients with symptoms. In mild cases, the symptoms are milder, and no pathology is detected in imaging studies. In moderate cases, imaging findings that will diagnose pneumonia and respiratory tract infection symptoms such as fever and cough, and sputum are positive. In cases with severe disease, increased respiratory rate, or decreased oxygen saturation (≤%93) or the radiological image deteriorates within 1–2 days.[7],[8]

Data obtained to date show that 80% of the infections have a mild or asymptomatic course. Studies show that 15% of those with the disease experience serious infections that require oxygen, and 5% experience critical processes requiring respiratory support. To prevent the spread of the disease in sick or suspected infected people, an isolation process called “quarantine” is applied. In addition to physical symptoms, intense anxiety, depression, sleep disorders, helplessness, feelings of anger, and suicidal ideation are also observed in these individuals. Symptoms of infection such as fever, cough, and shortness of breath also aggravate the mental effects of this period. This situation can similarly be seen in healthcare workers.[9],[10]

  Prolonged Symptoms and Psychiatric Morbidity after COVID-19 Top

It is essential to know the psychiatric and neuropsychiatric effects of COVID-19 infection to regulate the diagnosis and treatment of patients with infection. Although studies on the effects of the COVID-19 pandemic on neuropsychiatric complications and psychopathologies have started to be published, the long-term effects are not yet known. Symptoms in patients with severe disease; manifest as headaches, imbalance, shaky, confusion, balance difficulty, epilepsy, ischemic stroke, neuropathic pain, and myopathy.[11]

In studies examining psychiatric symptoms in patients who recovered after COVID-19; it has been reported that these individuals show high rates of insomnia, posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in the 1 month after infection.[12],[13]

These initial findings and previous studies conducted after the coronavirus epidemics of MERS and SARS indicate that psychiatric illness will be seen after COVID-19 infection no small measure.[14],[15],[16]

Recently, prolonged findings are emerging in patients recovering from acute COVID-19 infection, which may result in significant inadequacy such as chronic fatigue, widespread muscle aches, shortness of breath, headache, and difficulty concentrating.[17],[18]

  The Effects of the COVID-19 Pandemic on Mental Health Top

In addition to all these physiological effects of the COVID-19 pandemic, the effects such as the anxiety of getting sick and dying, the uncertainties regarding the process, the inability to find an effective treatment method, the limitation of social interactions, and the sudden and rapid change in the philosophy of life affected individuals psychosocially. With the rapid spread and fatal course of the disease, it was perceived as a life-threatening threat and became a trauma with intense distressing emotions. The impact of trauma will vary according to the cultural and social characteristics of the society, economic well-being, and the physical and mental well-being of the individual. The difference in psychological reactions in this period may vary from person to person and in different social classes. Some people can adapt to the traumatic situation during this period. However, some may show different reactions to this life-threatening, such as extreme fear reaction or fatalism, negligence.[19],[20]

In the COVID-19 Turkey Study conducted by Hızlı Sayar et al., individuals' anxieties, fears, and maturity levels were investigated. The research was carried out with 6318 people from 81 provinces. According to the study results, 57% of women and 37% of men stated that they were afraid when watching the news about coronavirus or seeing news on social media. Being uncomfortable when thinking about COVID is 51% for women, while this rate is 37% for men. While those who express that they are terrified of coronavirus are 41% for women, this rate is 35% for men. When looking at the level of fear of losing his life due to COVID, this rate is 42% for women and 29% for men.[21]

When looking at possible concerns about the pandemic or post-process, individuals; 49.6% due to the uncertainty of the process, 40.9% from staying away from social relations, 35.3% about the future of family members in case of death, 31.3% due to not getting adequate health care, 31.1% not having access to protective equipment, 30.8% due to economic problems, 28.4% due to disruption of their own or their child's education, from home 28.8% worry about not being able to leave when they want, and 27.6% worry about the mental status of family members.[21]

The pandemic has not only caused adverse consequences for individuals' psychology. Within the scope of the study, the participants were also directed to suggestions about psychological maturation, and the participants were asked how long they lived these propositions during the pandemic process. According to the results of the research, the most frequently reported psychological maturation proposition in both women (77%) and men (66%) was “I better understood the value of what I have during the pandemic process.” Later, the statement “The things that I care about in life have changed” became the second-most frequently reported proposition, with 61% of women and 50% of men. In general, these two propositions are followed by the statement “I understand that I can face the difficulties” and “I can accept the events as they are” with a ratio of 56%. The frequency of all items related to psychological maturation was higher in women than in men.[21]

When we look at the psychological effects seen in the process; fear of getting sick and dying, not applying to hospitals and health institutions even when necessary, experiencing economic concerns such as losing their job, being in quarantine for suspicion of illness, and being separated from loved ones due to quarantine, fear of not being able to protect loved ones and losing relatives due to the epidemic and social isolation We come across situations such as feeling depressed, remedy and lonely due to.[22]

The new living conditions caused by the pandemic may prepare an environment for some psychological disorders in healthy individuals and cause an increase in preexisting pathologies. It has been shown that the epidemic does not only cause illness, fear of death, feelings of inadequacy in individuals in the general society, and freedom-restrictive measures such as social isolation can have psychological effects.[23]

It has been reported that quarantine applied to sick people and federal restrictions applied to prevent the spread of the disease cause acute panic, anxiety, fear, paranoia, obsessive behavior, depression, and PTSD with somatic symptoms.[24]

During this period, many studies have been conducted to examine the psychological, behavioral, and social effects of COVID-19, which is caused by the new coronavirus. It has been revealed that the disease causes many changes in societies' living conditions and habits, and this situation leads to some negative psychological consequences. For example, in a study conducted with 1200 participants in China during the COVID-19 epidemic process, 53.8% of the participants expressed the negative effect on the psychology of this epidemic as severe or average. Again, in the same study, it was found that 17% of the participants had moderate to severe depression symptoms, and 29% had moderate-to-severe anxiety symptoms.[4]

In a meta-analysis study that examines the prevalence of stress, anxiety, and depression in the period following the COVID-19 pandemic and evaluates research studies prepared using appropriate methods in the general population as a result of the pandemic; It was found that 29.6% of stress disorders, 31.9% anxiety, and 33.7% depression.[25]

In a study conducted in Turkey, an evaluation was made regarding anxiety, depression, obsessive-compulsive disorder, and anger symptoms before and after the epidemic. A high difference was found in favor of postcoronavirus symptom scores in all participants. When this change was evaluated in terms of the gender variable, it was found that this difference was much more pronounced in women. In this process, it has been observed that individuals who cannot apply a functional coping style with stress, have negative perceptions and attitudes about the epidemic, and have low psychological resilience, are more vulnerable and need psychological assistance. It has been observed that adults cope with stress more functionally than young people.[26]

The pandemic has not only paved the way for new psychological problems to emerge. It also led to an increase in existing psychopathologies. The importance of hand hygiene in combating the high contagiousness of the virus and pandemic can be added as an additional ritualistic pattern to the behavior of patients with obsessive-compulsive disorder. Patients with some obsessive-compulsive disorder may be more affected by this process, as they have contamination obsessions, cleaning compulsions, or experience suspicious obsessions and control compulsions. Because of the epidemic conditions, patients with obsessive-compulsive disorder increase their anxiety symptoms.[27]

Physically separating people is the first thing to do to prevent the COVID-19 epidemic from spreading to large masses.[28]

This practice, which is very effective and necessary in combating the epidemic, can create an unfavorable environment for the psychological health of individuals and become a significant risk factor for mental health by weakening the social ties while protecting the physical health of people. Social relations and psychological well-being are also crucial for maintaining a healthy life, such as the suitability of physical conditions and meeting biological needs. As a result, the absence of social relationships during isolation causes an unfavorable environment for mental health.[29]

Studies conducted with individuals who remain in the quarantine process due to COVID-19 reveal that staying at home increases health and financial concerns, depressive symptoms, and stress more, and brings a feeling of loneliness.[30]

When the quarantine processes of the epidemic diseases experienced in the past were examined, various predisposing factors were identified that caused mental problems. In this period, individuals primarily have concerns about their health, but at the same time, they experience a feeling of isolation along with the fear of making others sick, intense boredom. The inadequacy in providing basic needs such as shelter, food, water, inadequate and accurate information, lack of economic and social support, and concerns on this issue is essential to stress factors. In the meta-analysis made specific to the quarantine period and evaluating the quarantine effect, it has been stated that adverse psychological effects cause PTSD symptoms, confusion, and anger. The stressors of these are long quarantine period, fear of infection, disappointment, distress, insufficient information and inadequate support, economic loss, and stigma. Some researchers point out the long-term effects of this condition. People should not be kept in quarantine for longer than necessary; practical, understandable information should be provided to these people, and adequate support should be provided.[31],[32],[33]

Another critical issue that needs to be studied is stigmatization. Disease-related stigmatization is a problem that should be considered in this epidemic, considering the experiences in previous epidemics such as SARS, which affects the lives of individuals who have experienced difficulties for a long time. All healthcare professionals, including those who test positive for COVID-19 themselves, their family members, acquaintances, and general practitioners, face more discrimination and stigma. The adverse psychological effects of this situation continue for a long time, even if people exposed to stigmatization such as corona-positive people or individuals who are not sick with symptoms similar to their symptoms, contacts, healthcare workers recover physically. In societies prone to stigmatizing behavior, people with symptoms of illness tend to delay receiving health care or hide health information in critical situations such as travel. Unfortunately, this situation increases the spread of the disease in society. It has been reported that anxiety and depressive symptoms increase in patients with the stigma.[24],[31],[34]

During the epidemic period, all of the psychological reactions expected after trauma were observed step by step in the risk groups related to the disease and the society, especially healthcare workers. Along with the feeling of uncertainty brought about by the epidemic, emotions such as fear of getting sick, helplessness, hopelessness, and unhappiness have become almost epidemic.[2],[3]

  The Effects of the Pandemic on the Elderly and the Groups with Chronic Diseases Top

Due to advances in technology and their positive reflections on healthcare, and the controllability of infectious diseases, the proportion of the elderly population is increasing worldwide. In parallel with this, a similar change is happening in Turkey, and the proportion of the elderly population has been increasing gradually over the years. For example, while the proportion of the elderly population in the total population was 8.2% in 2015, this rate was 9.5% in 2020.[35]

There is a relationship between aging and increased mortality in COVID-19 infection. In a report prepared by the Chinese Center for Disease Control and Prevention, this rate was reported as 8% in the age group 70–79 and 15% in people aged 80 and over, versus 2.3% in the general population.[36] Similar data are also valid for Turkey.

In a study by Wang et al., the adverse psychological effects of the epidemic were more pronounced in people with chronic diseases who were in poor general physical condition before the epidemic. It has been reported that these people experience more intense depression, stress, and anxiety.[4]

COVID-19 pandemic prevention measures, leading to social distance rules, maintaining a distance of two meters during social contact, avoiding social contact with family and friends, and decreasing the social environment, which causes more loneliness, especially in the elderly population. This isolation situation can lead to mental and physical dysfunction in the elderly. Social relations; is very important because it helps people regulate their emotions, manage stress, and increase their mental endurance. Increased stress, inactivity, etc., in the process of loneliness and social isolation. It also brings risks such as adverse mental effects and cardiovascular system diseases. Therefore, the elderly need to reach the correct information about how they should follow to protect their mental and physical health. In addition, some barriers such as hearing loss caused by old age should be evaluated well, and strategies should be developed in this direction. For example, considering that those with hearing difficulties may not maintain physical distance, their needs such as necessary equipment and protective masks should be provided.[37],[38],[39]

  Effects of the Pandemic on the Group with Psychiatric Illness Top

Due to the living conditions of the people in the group with psychiatric illness, they are at a higher risk for SARS-CoV-2 infection than individuals without any mental problems. There is a relationship between SARS-CoV-2 infection and the severe course of the disease and the risk factors comorbid to psychological illness, such as the state of the person's current mental illness, alcohol, substance use, etc., poor living conditions.[40]

It is possible to say that the most neglected population during the COVID-19 outbreak is individuals with mental disorders. Stress causes the emergence and development of the symptoms of mental health disorders and an increase in the severity of existing psychiatric diseases. On the other hand, due to the restrictions imposed by the COVID-19 pandemic, there have been some disruptions in the access of individuals with existing psychiatric diseases to treatment and health services since the beginning of the pandemic. Due to the conditions, these people may have difficulties continuing their routine examination, interview, and drug treatment or reaching an appropriate health institution in cases where hospitalization is required.[41],[42],[43]

In many studies conducted in different societies, it has been concluded that individuals with a psychiatric disease have a higher risk of encountering and transmitting infection and that the prognosis of the disease is worse, they are more hospitalized, and the risk of death is higher. Considering the reasons for this situation, it was found that the patients who received psychiatric treatment could not comply with the rules due to personal hygiene and self-care inadequacy, disorders in sleep and eating habits, and impulse behavior control. In addition, many reasons such as cognitive disorders, difficulties in accessing treatment, metabolic diseases due to adverse effects of psychiatric drugs take their place as risk factors. At the same time, this patient group's economic and social levels may be lower than the general population, and the living conditions may be generally worse.[44],[45],[46]

  Effects of the Pandemic on Healthcare Professionals Top

During this vast global epidemic, which carries many unknowns and the course of the disease, inadequacies in diagnosis, and treatment opportunities, many changes have occurred in countries health systems. The effects of the pandemic were more pronounced in healthcare workers who were trying to produce the right job by responding quickly to all these changes compared to many other groups.[47]

In parallel with the increasing need for healthcare services, the workload of healthcare workers has increased. Since they are at risk for the patient group they work with, they are concerned about transmitting the disease to themselves and their loved ones. Physical fatigue due to long working hours, insufficient quality of suitable protective equipment, loneliness, and being separated from loved ones are the main reasons for healthcare professionals to be negatively affected by this epidemic. In addition, among healthcare workers directly dealing with infected patients, emergency room workers, intensive care, and infectious diseases, clinic staff are more affected psychologically than other groups. Secondary traumas can develop in healthcare workers who witness serious traumatic events under pandemic conditions.[48],[49]

Liang et al., found that female and middle-senior health workers had higher stress, anxiety, and depression rates. No significant difference was found between the depression score of healthcare workers under the age of 30 and the depression scores of healthcare workers over the age of 30.[50]

Being in the middle age group, working in risky secondary and tertiary hospitals such as infectious diseases services where the risk of contact with infected patients is higher, performing practices such as injections that require close contact with patients such as nurses, and close relationships such as divorce or loss of a spouse, family It has been determined that the probability of experiencing mental problems increases in cases where the support is decreased.[51] In a study in which 1563 health workers participated in this period in China, the prevalence of traumatic stress symptoms among healthcare workers was 73.4%, depressive symptoms 50.7%, anxiety 44.7%, and sleep disorders 36.1%.[52]

Discrimination and stigmatization are essential factors that strain individuals with their adverse psychological effects during the pandemic process. In addition to individuals diagnosed with the disease in themselves and their families, healthcare workers also face this stigmatization behavior.[53]

Similar reactions were reflected in public opinion in Turkey. In previous years, Bai et al.'s study investigated the responses of healthcare workers shortly after 330 health workers were quarantined due to the SARS outbreak. Twenty percent of the healthcare personnel participating in the study stated that they felt stigmatized and rejected in their neighborhood because they worked in the hospital, and 9% stated that they were unwilling to work or thought to resign.[54]

The most important way to effectively combat this serious health problem and prevent the spread of the disease is to take the necessary precautions by implementing appropriate strategies to break the transmission and infection chain. In the COVID-19 pandemic, it is necessary to create a mental health team that can act with a multidisciplinary approach, together with psychiatrists, clinical psychologists, and nurses, and plan the practical work of these teams established at a regional or regional national level. In addition, to control the fear and anxiety that may be experienced, it should be ensured that regular and truthful information about the COVID-19 outbreak is shared with the public openly by adopting a correct and calm attitude. For this purpose, all kinds of communication channels should be used, and when people need mental support, they should be provided with spiritual support via telephone and the Internet under telemedicine conditions.[38],[55]

Healthcare workers working in more specific health centers, such as hospitals or infectious diseases services, where the treatment of cases related to this disease continues, are at higher risk of mental health problems and infection risk. In addition to the fear of transmitting the disease to themselves, healthcare professionals also have anxiety about infecting their families and loved ones. Due to these conditions, it is important to screen patients and healthcare professionals regarding depression, anxiety, and suicide risk, primarily and regularly.[56],[57],[58]

It is essential to make the necessary arrangements for the uninterrupted continuation of specific treatments of people diagnosed with psychiatric diseases before the epidemic. However, it should be ensured that people who show severe mental illness symptoms during the epidemic reach treatment as quickly as possible.[59]

Supporting all individuals affected by the pandemic in terms of mental health with timely and effective interventions by applying the right strategies will be an essential control mechanism in preventing the adverse psychological effects of the pandemic.

  Conclusion Top

This review aimed to understand the effects of the COVID-19 pandemic on mental health in light of literature findings. It has been observed that the COVID-19 pandemic caused an increase in fear, anxiety, and anger, anxiety disorders in the general population; however, increased stress and life changes caused an increase in PTSD, depression, insomnia, and even suicidal thoughts. In the studies carried out in this period, it was understood that some special groups such as individuals with previous psychiatric diseases, children and adolescents, the elderly and those with chronic diseases, and healthcare workers who struggled with the disease were more affected.

This research focused on 2019–2020 and Turkey-China. The COVID-19 virus has undergone many mutations since the first day it emerged. The mental effects at the beginning of the pandemic and today are likely to be different, as the virus mutates repeatedly and its physical symptoms change.

Psychological outputs such as denial, anger, anxiety, and stress are experienced more intensely with the emerging pandemic. High-risk groups such as children and adolescents, the elderly, healthcare professionals, and people with existing psychiatric disorders should be given priority.

It is necessary to ensure that sensitive groups, especially healthcare workers, who are at risk in terms of the adverse mental effects of the epidemic, are effectively screened, and appropriate evaluation methods and forms should be developed for this purpose. Awareness training and psychoeducation that can reach large communities should be planned for these conservation efforts. In addition, when professional assistance is required, it is essential to provide systems that will ensure correct and timely intervention, meet the need for telephone, internet, and similar infrastructure, and develop suitable algorithms. Considering that the psychological effects of the epidemic may continue for years, even after the epidemic is taken under control and the biological danger situation has passed, it is essential to invest the necessary resources and follow the correct policies.

Patient informed consent

There is no need for patient informed consent.

Ethics committee approval

There is no need for ethics committee approval

Financial support and sponsorship

No funding was received.

Conflicts of interest

There are no conflicts of interest to declare.

Author contribution subject and rate

  • Leman Atasever Varolan (50%) Data collection and wrote the manuscript
  • Büşra Özdoğan (25%) Designed the review, data collection and supervised the article write up. Wrote the manuscript
  • Gökben Hızlı Sayar (25%) Designed the review, data collection and supervised the article write up. Wrote the manuscript.

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