Consequences of the SARS-CoV-2 Pandemic on Mental Health: Integrative Review

The lack of specific treatment and knowledge about the exact pathophysiology of the 2019 Coronavirus disease (COVID-19) and its vaccines makes the organic aspects of the pandemic a concern and puts the psychiatric consequences and psychological effects of SARS-CoV-2, COVID-19, in second place. Hence, the psychiatric impacts of the COVID-19 pandemic have not been well established yet. We have performed an integrative literature review in three electronic databases: Medline, PsycINFO, and Published International Literature on Traumatic Stress (PILOTS). The findings were then divided into five subcategories: impacts of COVID-19 on the mental health of psychiatric patients; use of technology as an ally in combating impacts on mental health in the context of the COVID-19 pandemic; mental health promotion measures in the context of the COVID-19 pandemic for the population; mental health promotion measures in the context of the COVID-19 pandemic for health professionals; and mental health in specific groups in the context of the COVID-19 pandemic. This study has showed that the situation and measures proposed to fight the COVID-19 pandemic cause stress, anxiety, fear, and uncertainty in the population. Psychiatric patients, the elderly, refugees, and migrant workers are more vulnerable due to the stigmatization and lack of specialized support in health services and reduced access to medications. Therefore, they require care from governments and health authorities. In addition, measures to promote hospital health for health professionals seem to be essential to improve care and reduce the psychologic/psychiatric impacts on professionals. Thus, technology is a valuable ally in this process.


Introduction
A pandemic creates its own objective reality as a backdrop for all forms of psychopathology. There are economic downturns, job layoffs, prolonged school and business closings, and threatened supply chain disruptions during such period [1][2][3][4][5]. It also compromises the care and mental health of individuals who already have diseases.

Literature review
We have performed an integrative literature review in three electronic databases: Medline, PsycINFO, and Published International Literature on Traumatic Stress (PILOTS). The electronic searches used variants of the following research terms with a syntax adjusted to each database: #1 "COVID-19" OR "Coronavirus Infections" (Medical Subject Headings -[MeSH term] AND #2 ("Health Personnel" OR "Health Care Provider" [MeSH] term); and "Mental Health" [keyword].

Data collection
Manuscripts were selected primarily through the analysis of their titles and abstracts. Two researchers collected data individually in order to ensure trustworthiness of the findings, and divergences were solved by a third senior researcher. Each sample article was thoroughly read, and the information was inserted in a spreadsheet ( Table 1) that included the author, publishing year, journal, and main findings.

Eligibility criteria
Papers were analyzed based on the following eligibility criteria: at least one combination of the terms described in the search strategy in the title; written in English, Portuguese or Spanish; addressing the psychiatric impact of COVID-19 pandemic; original articles with the full text available through the Journal Portal of the Brazilian Coordination of Personal Improvement of Higher Level (CAPES), which is a virtual library created by the Brazilian Department of Health where content is restricted to authorized users. Monographs, dissertations, and thesis were excluded.
Manuscripts repeated in more than one of the databases were counted only once. Some papers were excluded because they approached other viruses/pandemics.

Ethical issue
Considering this is an integrative literature review, Resolution 510/16 of the Brazilian National Health Council (CNS, acronym in Portuguese) ensures the dismissal of submission to an Ethics Committee on Research (Human Beings).

Results
The findings were then divided into five subcategories: impacts of COVID-19 on the mental health of psychiatric patients; use of technology as an ally in combating mental health impacts in the context of COVID-19 pandemic; mental health promotion measures in the context of the COVID-19 pandemic for the population; mental health promotion measures in the context of the COVID-19 pandemic for health professionals; and mental health in specific groups in the context of the COVID-19 pandemic ( Table 1).

Impacts of COVID-19 on the mental health of psychiatric patients
Patients with confirmed or suspected COVID-19 may experience fear of the consequences of being infected by a potentially harmful virus, and those in quarantine Rolim-Neto et al. [10] Psychiatry Res.
Importance of recognizing how to combat stress, anxiety, and negative symptoms such as depression in the face of death figures as a mental health strategy for healthcare workers.
In China, the lack of psychiatrists' training in the management of infectious diseases in pandemics is a major challenge to mental health and an impasse to health promotion in the pandemic.

Mental health in specific groups in the COVID-19 pandemic context
Zhai and Du [12] Lancet Exchange students may have their mental health affected due to stigmatization, bullying and mistreatment in the countries where they are studying because they could be classified as potential transmitters of the virus.
Bao et al. [13] Lancet Triggering of mental disorders, post-traumatic stress disorder, depression, and anxiety in healthcare workers.
Perlis [14] JAMA Chronic shess of COVID-19 pandemic can cause anxiety and major depression in healthcare workers.
Jawaid [15] Science Encouraging the spread of news with mental health benefits; mental health supports with hotline; and maintaining regular phone contact are possible measures to deal with the mental health consequences of elderly people with COVID-19.
Brasil [16] -List of a series of measures to promote childreifs mental health in the COYID-19 pandemic context.
Liem et al. [17] Lancet Impasses of the communities of intemational mi grant workers, since their pre-exposure condition is more fragile, and they are more exposed to psychiatric diseases in pandemics than the general population.
The outbreak of COVID-19 has raised great challenges regarding mental health semces for older adults in the community. There seems to be insufficient and inadequate attention paid to this vulnerable population in the recently established crisis of psychological services in China.
Populations as refugees have a much greater risk of developing mental disorders compared to the general population due to the precarious hygienicsanitary conditions, nutrition, housing and access to information that they have.

Source:
Authors.  [20]. In a Chinese study with 263 participants, the majority (53.3%) of individuals did not feel helpless due to the COVID-19 pandemic. However, 52.1% of the participants felt horrified and apprehensive due to the pandemic. Additionally, most participants (57.8 to 77.9%) received more support from friends and family members, more shared feeling and caring with family [21]. Indeed, a pandemic causes profound changes in social dynamics. One example is supermarkets, which were clear of essential items and faced a rationing procedure at the beginning of the pandemic. Schools and other educational institutions have been affected, with compulsory examinations postponed and most children remaining at home. The financial implications are profound, even though governments have implemented various supportive measures [22]. This situation causes stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear [23].
This impact is more dangerous and worrying in psychiatric patients. Schizophrenia, bipolar, depression and anxiety disorders or autism have an increased risk for infection due to immunogenetic vulnerability. The elderly psychiatric patients are the most vulnerable group, and there is a high exacerbation risk of psychic disorders and an aggravation of existing psychiatric symptoms, cognitive disorders, and loss of autonomy. The elderly may have difficulties adopting "barrier measures" (behavioral measures to protect oneself and others from the virus) and complying with confinement instructions. Severe social isolation, precarious housing, restricted solidarity networks for the informal monitoring of these patients' health condition complicate this population's situation [26].
Furthermore, people with mental disorders can be exposed to more barriers in accessing timely health services due to discrimination associated with patients who have mental illness in health care settings. The elderly could be more substantially influenced by emotional responses brought on by the COVID-19 pandemic, resulting in relapses or worsening of an already existing mental health condition due to high susceptibility to stress compared with the general population. The treatment for mental disease could make that of COVID-19 more challenging [27].

Use of technology as an ally in combating impacts on mental health in the COVID-19 pandemic context
Health services around the world have been mobilized and reinvented in an attempt to meet the population's mental health demands during the COVID-19 pandemic. The literature states that technology to reduce risk is a way out of proper pandemic management [28].
In France [29], there has been a 90% shift in outpatient activity with the use of telepsychiatry. There is a hotline for psychiatry teleconsultation, and meetings with more than five people became virtual. In addition, psychiatrists alternately present themselves in the department or teleworking. According to Starace and Serrara [30], during phone check-ins, the professional provides information of open hours, changes in access to services, and public health recommendations about limiting social contacts. DOI: http://dx.doi.org /10.5772/intechopen.96816 In Siena, Italy, more than 90% of the outpatient consultations were transformed into telemedicine consultations, which also made use of cell phones. Hence, health workers may benefit from social contact provided via the Internet, in a group setting, at the end of a working day, from their houses, without wearing the protective garments they wore all day long. They believe that offering a space to talk electronically, to share experiences, and to provide comfort to each other can be helpful, especially for those who live alone [31].
In Croatia, the use of digital technologies in post-traumatic stress disorder (PTSD) mitigation was the main topic of the researches carried out by Cosic et al. [32]. According to the authors, based on their experience, the development of computer tools and methods for emotion elicitation, estimation and regulation, cognitive-behavioral therapy, stress inoculation/resilience training, prevention of stress-related disorders and soldiers' ability strength to cope with highly stressful situations, as well as assessments of individual and group stress resilience features, created the NATO research and development project "Multidisciplinary Metrics for Soldier Resilience Prediction and Training" with researches from Turkey, Croatia, and Austria. It can use these expertise's origin strategies to face the COVID-19 psychology and psychiatric impact.
Increasing the communication with friends, family members and loved ones, even if from a distance, from video-chats or group calls with family members, may help to reduce loneliness and precariousness. In case of insufficient social network, professional helplines are particularly useful, if managed by qualified trained professionals [33].
Mainstream media, such as television and radio, may play an important role by including content that promotes quality information and safety for the population [15]. They should get ahead and educate people about the importance and existence of not only physical health issues, but also mental health ones during a pandemic, along with medical and mental health professionals in order to sustain scientificand fact-based presentation and suggestions while addressing the importance of COVID-19 control practices [34].
In Singapore, the government have kept the public abreast on the progress of the outbreak with regular broadcasts of news and announcements on social media. These include daily updates, such as the number of new and current infections, patients who are at critical condition or have been discharged, and preventive measures. Social media channels have also been set up by the state to curb the spread of false information and "fake news." Regular dialog with Cabinet Ministers and infectious diseases physicians is aired to clear questions [35].

Mental health promotion measures in the COVID-19 pandemic context for the population
A significant distress decrease has been associated with the nationwide quarantine, medical supports and resources from all over the country, public education, individual protection strength, medical isolation, population mobility control, reduction of gatherings to stop the virus spread, and social and spiritual support. These are very important elements of community resilience and anti-fragility during COVID-19 crisis periods [3,36].
During the COVID-19 pandemic, the National Institutes of Health in the USA and other funders must provide administrative supplements and notifications that encourage researchers to go fully remote; assess the mental health impact of COVID-19; prioritize repurposing of psychiatric human and pharmacologic resources for COVID-19 research efforts; and continue working, leveraging the unique clinical research resources in psychiatry to help as many people as possible through the crisis [28].

Fighting the COVID-19 Pandemic
China created 26 protocols and guidelines regarding mental health promotion between January and February in 2020 [37]. In these protocols, psychological crisis interventions have included three key points: understanding the mental health condition in different populations influenced by the COVID-19 outbreak, identifying people that are at high risk of suicide and aggression, and providing appropriate psychological interventions for those in need [37].
Based on Fiorillo and Gorwood [33] in Italy, some measures to face the mental impacts of the pandemic are: limiting the sources of stress, i.e. decrease of access to unofficial channels and uncontrolled sources; breaking isolation, by increasing communication of family and friends via social media; maintaining the usual routine rhythm; focusing on the isolation benefits and asking for professional help when needed. According to Ho, Che and Ho [35], the integration of hospital and community resources, more support for frontline health workers, accurate dissemination of health and related information to the public, identification of high-risk groups, improved screening of psychiatric morbidities, mode and content of psychological intervention encourage the use of a psychodynamic approach as a way to improve the population's adherence to preventive measures [38]. A Chinese study that evaluated 1,304 people showed that cognitive therapy can provide information or evidence to enhance confidence in the doctor's ability to diagnose COVID-19 [39].
Measures for a better health promotion and for combating the COVID-19 include the use of personal protective equipment, mainly of fluid-resistant surgical masks, telemedicine, avoiding crowds/visits, offering individual educational sessions to patients admitted at the unit, providing printed materials, and encouraging hand hygiene [30].

Mental health promotion measures in the COVID-19 pandemic context for health professionals
As if exposure to the COVID-19 during the global pandemic was not enough, healthcare workers face another risk: burnout due to overstress in an increasingly overloaded healthcare system [10]. Thus, health care professionals have accepted an overwhelming responsibility. They are coping with the psychological distress of losing patients, as well as lack of clarity and unpredictability within their work environments, while trying to protect their own health [22], particularly in countries with limited resources [24]. Health professionals have been dealing with high risk of infection and inadequate protection against contamination, overwork, frustration, discrimination, isolation, patients with negative emotions, lack of family contact, and exhaustion [23].
A study with 1,287 workers in hospitals equipped with fever clinics or wards for patients with COVID-19 in Wuhan and other regions in China reported that health workers have been experiencing psychological burden (depression, anxiety, insomnia, and distress), especially female nurses [40]. After surveying more than 1,200 nurses and physicians in 34 hospitals in the Wuhan region and across mainland China, approximately 14% of the physicians and nearly 16% of the nurses described moderate or severe depressive symptoms. There were also reports of insomnia and anxiety [14].
Some strategies for dealing with COVID-19 impacts include: routine support processes (such as peer support programs) available to the healthcare staff with a briefing on moral injuries, as well as awareness on other causes of mental ill health and what to look out for [10,41]; 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 [42]; formation Consequences of the SARS-CoV-2 Pandemic on Mental Health: Integrative Review DOI: http://dx.doi.org /10.5772/intechopen.96816 of psychological intervention teams and intra hospital support for professionals [43] in public policies that aim to articulate these joint efforts in a centralized and strategic way [11,13].

Mental health in specific groups in the COVID-19 pandemic context
During the COVID-19 pandemic, individuals at age extremes (children and the elderly) also suffer an impact on their mental health. Social isolation by COVID-19 pandemic in elderly people has been associated with increased depression and suicidality, as well as to increased pro-inflammatory and decreased anti-viral immune responses. Virtual solutions may be less comfortable for children and the elderly [15], who may also have limited access to internet services and smartphones to enter in mental health services online. Also, the current mass quarantines and restrictions to public transport make it more difficult for them to acquire medicine from previous psychiatric pathologies, which is common in this age range [18].
Some suggestions for managing mental health in institutionalized elderly people include establishing a contingency plan and strategies to deal with more serious psychiatric symptoms; maintaining transparency and trust with employees that prioritize equity and well-being with adequate training and personal protective equipment; ensuring care for the mental health of family members; reassuring them about feelings of fear, sadness and anxiety; and promoting a healthy climate of communication and empathy [44].
In the case of children, stressful and potentially traumatic situations, such as illness and hospitalization, can trigger the emergence of unusual behaviors, such as sucking finger, enuresis, or desire to sleep with parents. Therefore, encouraging the maintenance of routine and creative activities, such as painting, drawing or playing with family members, is essential to reduce psychological impacts. In the event of hospitalization, children should be maintained with constant contact and communication with the family and belongings that fulfill the function of emotional connection. No one should lie about their diagnosis and treatment, making it clear that the child is not to blame for being sick, providing an open communication channel for them [16].
As for young people in universities, the Chinese, mainly, were denied entry in many countries. They face discrimination and isolation in some countries due to being deemed as potential COVID-19 carriers, consequently, such students are at risk of hate crimes, especially when individuals consider them contagious. This situation can lead to mental health problems, such as denial, stress, anxiety, and fear [12].
Refugees and international migrant workers have a higher burden of common mental disorders (e.g. depression) and a lower quality of life than local populations. Many domestic workers cannot obtain masks from pharmacies because they must stay with employers and adhere to government-recommended self-quarantine [17]. Severe risk factors for COVID-19 are common for mental disorders in this population: overcrowding, disruption of sewage disposal, poor standards of hygiene, poor nutrition, negligible sanitation, and lack of access to shelter, health care, public services and safety [19,[45][46][47][48].

Conclusions
This study has showed that the situation and measures proposed to fight the COVID-19 pandemic cause stress, anxiety, fear, and uncertainty in the population. Psychiatric patients, the elderly, refugees, and migrant workers are more vulnerable *Address all correspondence to: juciergjunior@hotmail.com groups due to stigmatization and lack of specialized support in health services and reduced access to medications. Therefore, they require care from governments and health authorities. In addition, measures to promote hospital health for health professionals seem to be essential to improve care and reduce the psychologic/ psychiatric impacts on professionals, and thus technology is a valuable ally in this process. Finally, the weakness of this study is the absence of more robust studies to compose the sample.
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