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The coronavirus ( COVID ‐19) pandemic's impact on mental health

Bilal javed.

1 Faculty of Sciences, PMAS Arid Agriculture University, Rawalpindi Pakistan

2 Roy & Diana Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, Philadelphia Pennsylvania, USA

Abdullah Sarwer

3 Nawaz Sharif Medical College, University of Gujrat, Gujrat Pakistan

4 Department of General Medicine, Allama Iqbal Memorial Teaching Hospital, Sialkot Pakistan

Erik B. Soto

5 Graduate School of Public Health, University of Pittsburgh, Pittsburgh Pennsylvania, USA

Zia‐ur‐Rehman Mashwani

Throughout the world, the public is being informed about the physical effects of SARS‐CoV‐2 infection and steps to take to prevent exposure to the coronavirus and manage symptoms of COVID‐19 if they appear. However, the effects of this pandemic on one's mental health have not been studied at length and are still not known. As all efforts are focused on understanding the epidemiology, clinical features, transmission patterns, and management of the COVID‐19 outbreak, there has been very little concern expressed over the effects on one's mental health and on strategies to prevent stigmatization. People's behavior may greatly affect the pandemic's dynamic by altering the severity, transmission, disease flow, and repercussions. The present situation requires raising awareness in public, which can be helpful to deal with this calamity. This perspective article provides a detailed overview of the effects of the COVID‐19 outbreak on the mental health of people.

1. INTRODUCTION

A pandemic is not just a medical phenomenon; it affects individuals and society and causes disruption, anxiety, stress, stigma, and xenophobia. The behavior of an individual as a unit of society or a community has marked effects on the dynamics of a pandemic that involves the level of severity, degree of flow, and aftereffects. 1 Rapid human‐to‐human transmission of the SARS‐CoV‐2 resulted in the enforcement of regional lockdowns to stem the further spread of the disease. Isolation, social distancing, and closure of educational institutes, workplaces, and entertainment venues consigned people to stay in their homes to help break the chain of transmission. 2 However, the restrictive measures undoubtedly have affected the social and mental health of individuals from across the board. 3

As more and more people are forced to stay at home in self‐isolation to prevent the further flow of the pathogen at the societal level, governments must take the necessary measures to provide mental health support as prescribed by the experts. Professor Tiago Correia highlighted in his editorial as the health systems worldwide are assembling exclusively to fight the COVID‐19 outbreak, which can drastically affect the management of other diseases including mental health, which usually exacerbates during the pandemic. 4 The psychological state of an individual that contributes toward the community health varies from person‐to‐person and depends on his background and professional and social standings. 5

Quarantine and self‐isolation can most likely cause a negative impact on one's mental health. A review published in The Lancet said that the separation from loved ones, loss of freedom, boredom, and uncertainty can cause a deterioration in an individual's mental health status. 6 To overcome this, measures at the individual and societal levels are required. Under the current global situation, both children and adults are experiencing a mix of emotions. They can be placed in a situation or an environment that may be new and can be potentially damaging to their health. 7

2. CHILDREN AND TEENS AT RISK

Children, away from their school, friends, and colleagues, staying at home can have many questions about the outbreak and they look toward their parents or caregivers to get the answer. Not all children and parents respond to stress in the same way. Kids can experience anxiety, distress, social isolation, and an abusive environment that can have short‐ or long‐term effects on their mental health. Some common changes in children's behavior can be 8 :

Excessive crying and annoying behavior
Increased sadness, depression, or worry
Difficulties with concentration and attention
Changes in, or avoiding, activities that they enjoyed in the past
Unexpected headaches and pain throughout their bodies
Changes in eating habits

To help offset negative behaviors, requires parents to remain calm, deal with the situation wisely, and answer all of the child's questions to the best of their abilities. Parents can take some time to talk to their children about the COVID‐19 outbreak and share some positive facts, figures, and information. Parents can help to reassure them that they are safe at home and encourage them to engage in some healthy activities including indoor sports and some physical and mental exercises. Parents can also develop a home schedule that can help their children to keep up with their studies. Parents should show less stress or anxiety at their home as children perceive and feel negative energy from their parents. The involvement of parents in healthy activities with their children can help to reduce stress and anxiety and bring relief to the overall situation. 9

3. ELDERS AND PEOPLE WITH DISABILITIES AT RISK

Elderly people are more prone to the COVID‐19 outbreak due to both clinical and social reasons such as having a weaker immune system or other underlying health conditions and distancing from their families and friends due to their busy schedules. According to medical experts, people aged 60 or above are more likely to get the SARS‐CoV‐2 and can develop a serious and life‐threatening condition even if they are in good health. 10

Physical distancing due to the COVID‐19 outbreak can have drastic negative effects on the mental health of the elderly and disabled individuals. Physical isolation at home among family members can put the elderly and disabled person at serious mental health risk. It can cause anxiety, distress, and induce a traumatic situation for them. Elderly people depend on young ones for their daily needs, and self‐isolation can critically damage a family system. The elderly and disabled people living in nursing homes can face extreme mental health issues. However, something as simple as a phone call during the pandemic outbreak can help to console elderly people. COVID‐19 can also result in increased stress, anxiety, and depression among elderly people already dealing with mental health issues.

Family members may witness any of the following changes to the behavior of older relatives 11 ;

Irritating and shouting behavior
Change in their sleeping and eating habits
Emotional outbursts

The World Health Organization suggests that family members should regularly check on older people living within their homes and at nursing facilities. Younger family members should take some time to talk to older members of the family and become involved in some of their daily routines if possible. 12

4. HEALTH WORKERS AT RISK

Doctors, nurses, and paramedics working as a front‐line force to fight the COVID‐19 outbreak may be more susceptible to develop mental health symptoms. Fear of catching a disease, long working hours, unavailability of protective gear and supplies, patient load, unavailability of effective COVID‐19 medication, death of their colleagues after exposure to COVID‐19, social distancing and isolation from their family and friends, and the dire situation of their patients may take a negative toll of the mental health of health workers. The working efficiency of health professionals may decrease gradually as the pandemic prevails. Health workers should take short breaks between their working hours and deal with the situation calmly and in a relaxed manner. 5

5. STIGMATIZATION

Generally, people recently released from quarantine can experience stigmatization and develop a mix of emotions. Everyone may feel differently and have a different welcome by society when they come out of quarantine. People who recently recovered may have to exercise social distancing from their family members, friends, and relatives to ensure their family's safety because of unprecedented viral nature. Different age groups respond to this social behavior differently, which can have both short‐ and long‐term effects. 1

Health workers trying to save lives and protect society may also experience social distancing, changes in the behavior of family members, and stigmatization for being suspected of carrying COVID‐19. 6 Previously infected individuals and health professionals (dealing pandemic) may develop sadness, anger, or frustration because friends or loved ones may have unfounded fears of contracting the disease from contact with them, even though they have been determined not to be contagious. 5

However, the current situation requires a clear understanding of the effects of the recent outbreak on the mental health of people of different age groups to prevent and avoid the COVID‐19 pandemic.

6. TAKE HOME MESSAGE

Understanding the effects of the COVID‐19 outbreak on the mental health of various populations are as important as understanding its clinical features, transmission patterns, and management.
Spending time with family members including children and elderly people, involvement in different healthy exercises and sports activities, following a schedule/routine, and taking a break from traditional and social media can all help to overcome mental health issues.
Public awareness campaigns focusing on the maintenance of mental health in the prevailing situation are urgently needed.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

AUTHOR CONTRIBUTIONS

B.J. and A.S. devised the study. B.J. collected and analyzed the data and wrote the first draft. E.B.S. edited and revised the manuscript. A.S. and Z.M. provided useful information. All the authors contributed to the subsequent drafts. The authors reviewed and endorsed the final submission.

Javed B, Sarwer A, Soto EB, Mashwani Z‐R. The coronavirus (COVID‐19) pandemic's impact on mental health . Int J Health Plann Mgmt . 2020; 35 :993–996. 10.1002/hpm.3008 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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COVID-19 pandemic and mental health consequences: Systematic review of the current evidence

Affiliations.

1 Copenhagen Research Centre for Mental Health - CORE, Mental Health Centre Copenhagen, Copenhagen University Hospital, Gentofte Hospitalsvej 15, 4. sal, 2900 Hellerup, Denmark; Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
2 Copenhagen Research Centre for Mental Health - CORE, Mental Health Centre Copenhagen, Copenhagen University Hospital, Gentofte Hospitalsvej 15, 4. sal, 2900 Hellerup, Denmark; Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark. Electronic address: [email protected].
PMID: 32485289
PMCID: PMC7260522
DOI: 10.1016/j.bbi.2020.05.048

Background: During the COVID-19 pandemic general medical complications have received the most attention, whereas only few studies address the potential direct effect on mental health of SARS-CoV-2 and the neurotropic potential. Furthermore, the indirect effects of the pandemic on general mental health are of increasing concern, particularly since the SARS-CoV-1 epidemic (2002-2003) was associated with psychiatric complications.

Methods: We systematically searched the database Pubmed including studies measuring psychiatric symptoms or morbidities associated with COVID-19 among infected patients and among none infected groups the latter divided in psychiatric patients, health care workers and non-health care workers.

Results: A total of 43 studies were included. Out of these, only two studies evaluated patients with confirmed COVID-19 infection, whereas 41 evaluated the indirect effect of the pandemic (2 on patients with preexisting psychiatric disorders, 20 on medical health care workers, and 19 on the general public). 18 of the studies were case-control studies/compared to norm, while 25 of the studies had no control groups. The two studies investigating COVID-19 patients found a high level of post-traumatic stress symptoms (PTSS) (96.2%) and significantly higher level of depressive symptoms (p = 0.016). Patients with preexisting psychiatric disorders reported worsening of psychiatric symptoms. Studies investigating health care workers found increased depression/depressive symptoms, anxiety, psychological distress and poor sleep quality. Studies of the general public revealed lower psychological well-being and higher scores of anxiety and depression compared to before COVID-19, while no difference when comparing these symptoms in the initial phase of the outbreak to four weeks later. A variety of factors were associated with higher risk of psychiatric symptoms and/or low psychological well-being including female gender, poor-self-related health and relatives with COVID-19.

Conclusion: Research evaluating the direct neuropsychiatric consequences and the indirect effects on mental health is highly needed to improve treatment, mental health care planning and for preventive measures during potential subsequent pandemics.

Keywords: COVID-19; Mental health; Mental health disorders; Psychiatry; SARS-CoV-2.

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Open access
Published: 11 April 2023

Effects of the COVID-19 pandemic on mental health, anxiety, and depression

Ida Kupcova 1 ,
Lubos Danisovic 1 ,
Martin Klein 2 &
Stefan Harsanyi 1

BMC Psychology volume 11 , Article number: 108 ( 2023 ) Cite this article

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The COVID-19 pandemic affected everyone around the globe. Depending on the country, there have been different restrictive epidemiologic measures and also different long-term repercussions. Morbidity and mortality of COVID-19 affected the mental state of every human being. However, social separation and isolation due to the restrictive measures considerably increased this impact. According to the World Health Organization (WHO), anxiety and depression prevalence increased by 25% globally. In this study, we aimed to examine the lasting effects of the COVID-19 pandemic on the general population.

A cross-sectional study using an anonymous online-based 45-question online survey was conducted at Comenius University in Bratislava. The questionnaire comprised five general questions and two assessment tools the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS). The results of the Self-Rating Scales were statistically examined in association with sex, age, and level of education.

A total of 205 anonymous subjects participated in this study, and no responses were excluded. In the study group, 78 (38.05%) participants were male, and 127 (61.69%) were female. A higher tendency to anxiety was exhibited by female participants (p = 0.012) and the age group under 30 years of age (p = 0.042). The level of education has been identified as a significant factor for changes in mental state, as participants with higher levels of education tended to be in a worse mental state (p = 0.006).

Conclusions

Summarizing two years of the COVID-19 pandemic, the mental state of people with higher levels of education tended to feel worse, while females and younger adults felt more anxiety.

Peer Review reports

Introduction

The first mention of the novel coronavirus came in 2019, when this variant was discovered in the city of Wuhan, China, and became the first ever documented coronavirus pandemic [ 1 , 2 , 3 ]. At this time there was only a sliver of fear rising all over the globe. However, in March 2020, after the declaration of a global pandemic by the World Health Organization (WHO), the situation changed dramatically [ 4 ]. Answering this, yet an unknown threat thrust many countries into a psycho-socio-economic whirlwind [ 5 , 6 ]. Various measures taken by governments to control the spread of the virus presented the worldwide population with a series of new challenges to which it had to adjust [ 7 , 8 ]. Lockdowns, closed schools, losing employment or businesses, and rising deaths not only in nursing homes came to be a new reality [ 9 , 10 , 11 ]. Lack of scientific information on the novel coronavirus and its effects on the human body, its fast spread, the absence of effective causal treatment, and the restrictions which harmed people´s social life, financial situation and other areas of everyday life lead to long-term living conditions with increased stress levels and low predictability over which people had little control [ 12 ].

Risks of changes in the mental state of the population came mainly from external risk factors, including prolonged lockdowns, social isolation, inadequate or misinterpreted information, loss of income, and acute relationship with the rising death toll. According to the World Health Organization (WHO), since the outbreak of the COVID-19 pandemic, anxiety and depression prevalence increased by 25% globally [ 13 ]. Unemployment specifically has been proven to be also a predictor of suicidal behavior [ 14 , 15 , 16 , 17 , 18 ]. These risk factors then interact with individual psychological factors leading to psychopathologies such as threat appraisal, attentional bias to threat stimuli over neutral stimuli, avoidance, fear learning, impaired safety learning, impaired fear extinction due to habituation, intolerance of uncertainty, and psychological inflexibility. The threat responses are mediated by the limbic system and insula and mitigated by the pre-frontal cortex, which has also been reported in neuroimaging studies, with reduced insula thickness corresponding to more severe anxiety and amygdala volume correlated to anhedonia as a symptom of depression [ 19 , 20 , 21 , 22 , 23 ]. Speaking in psychological terms, the pandemic disturbed our core belief, that we are safe in our communities, cities, countries, or even the world. The lost sense of agency and confidence regarding our future diminished the sense of worth, identity, and meaningfulness of our lives and eroded security-enhancing relationships [ 24 ].

Slovakia introduced harsh public health measures in the first wave of the pandemic, but relaxed these measures during the summer, accompanied by a failure to develop effective find, test, trace, isolate and support systems. Due to this, the country experienced a steep growth in new COVID-19 cases in September 2020, which lead to the erosion of public´s trust in the government´s management of the situation [ 25 ]. As a means to control the second wave of the pandemic, the Slovak government decided to perform nationwide antigen testing over two weekends in November 2020, which was internationally perceived as a very controversial step, moreover, it failed to prevent further lockdowns [ 26 ]. In addition, there was a sharp rise in the unemployment rate since 2020, which continued until July 2020, when it gradually eased [ 27 ]. Pre-pandemic, every 9th citizen of Slovakia suffered from a mental health disorder, according to National Statistics Office in 2017, the majority being affective and anxiety disorders. A group of authors created a web questionnaire aimed at psychiatrists, psychologists, and their patients after the first wave of the COVID-19 pandemic in Slovakia. The results showed that 86.6% of respondents perceived the pathological effect of the pandemic on their mental status, 54.1% of whom were already treated for affective or anxiety disorders [ 28 ].

In this study, we aimed to examine the lasting effects of the COVID-19 pandemic on the general population. This study aimed to assess the symptoms of anxiety and depression in the general public of Slovakia. After the end of epidemiologic restrictive measures (from March to May 2022), we introduced an anonymous online questionnaire using adapted versions of Zung Self-Rating Anxiety Scale (SAS) and Zung Self-Rating Depression Scale (SDS) [ 29 , 30 ]. We focused on the general public because only a portion of people who experience psychological distress seek professional help. We sought to establish, whether during the pandemic the population showed a tendency to adapt to the situation or whether the anxiety and depression symptoms tended to be present even after months of better epidemiologic situation, vaccine availability, and studies putting its effects under review [ 31 , 32 , 33 , 34 ].

Materials and Methods

This study utilized a voluntary and anonymous online self-administered questionnaire, where the collected data cannot be linked to a specific respondent. This study did not process any personal data. The questionnaire consisted of 45 questions. The first three were open-ended questions about participants’ sex, age (date of birth was not recorded), and education. Followed by 2 questions aimed at mental health and changes in the will to live. Further 20 and 20 questions consisted of the Zung SAS and Zung SDS, respectively. Every question in SAS and SDS is scored from 1 to 4 points on a Likert-style scale. The scoring system is introduced in Fig. 1 . Questions were presented in the Slovak language, with emphasis on maintaining test integrity, so, if possible, literal translations were made from English to Slovak. The questionnaire was created and designed in Google Forms®. Data collection was carried out from March 2022 to May 2022. The study was aimed at the general population of Slovakia in times of difficult epidemiologic and social situations due to the high prevalence and incidence of COVID-19 cases during lockdowns and social distancing measures. Because of the character of this web-based study, the optimal distribution of respondents could not be achieved.

Categories of Zung SAS and SDS scores with clinical interpretation

During the course of this study, 205 respondents answered the anonymous questionnaire in full and were included in the study. All respondents were over 18 years of age. The data was later exported from Google Forms® as an Excel spreadsheet. Coding and analysis were carried out using IBM SPSS Statistics version 26 (IBM SPSS Statistics for Windows, Version 26.0, Armonk, NY, USA). Subject groups were created based on sex, age, and education level. First, sex due to differences in emotional expression. Second, age was a risk factor due to perceived stress and fear of the disease. Last, education due to different approaches to information. In these groups four factors were studied: (1) changes in mental state; (2) affected will to live, or frequent thoughts about death; (3) result of SAS; (4) result of SDS. For SAS, no subject in the study group scored anxiety levels of “severe” or “extreme”. Similarly for SDS, no subject depression levels reached “moderate” or “severe”. Pearson’s chi-squared test(χ2) was used to analyze the association between the subject groups and studied factors. The results were considered significant if the p-value was less than 0.05.

Ethical permission was obtained from the local ethics committee (Reference number: ULBGaKG-02/2022). This study was performed in line with the principles of the Declaration of Helsinki. All methods were carried out following the institutional guidelines. Due to the anonymous design of the study and by the institutional requirements, written informed consent for participation was not required for this study.

In the study, out of 205 subjects in the study group, 127 (62%) were female and 78 (38%) were male. The average age in the study group was 35.78 years of age (range 19–71 years), with a median of 34 years. In the age group under 30 years of age were 34 (16.6%) subjects, while 162 (79%) were in the range from 31 to 49 and 9 (0.4%) were over 50 years old. 48 (23.4%) participants achieved an education level of lower or higher secondary and 157 (76.6%) finished university or higher. All answers of study participants were included in the study, nothing was excluded.

In Tables 1 and 2 , we can see the distribution of changes in mental state and will to live as stated in the questionnaire. In Table 1 we can see a disproportion in education level and mental state, where participants with higher education tended to feel worse much more than those with lower levels of education. Changes based on sex and age did not show any statistically significant results.

In Table 2 . we can see, that decreased will to live and frequent thoughts about death were only marginally present in the study group, which suggests that coping mechanisms play a huge role in adaptation to such events (e.g. the global pandemic). There is also a possibility that living in times of better epidemiologic situations makes people more likely to forget about the bad past.

Anxiety and depression levels as seen in Tables 3 and 4 were different, where female participants and the age group under 30 years of age tended to feel more anxiety than other groups. No significant changes in depression levels based on sex, age, and education were found.

Compared to the estimated global prevalence of depression in 2017 (3.44%), in 2021 it was approximately 7 times higher (25%) [ 14 ]. Our study did not prove an increase in depression, while anxiety levels and changes in the mental state did prove elevated. No significant changes in depression levels go in hand with the unaffected will to live and infrequent thoughts about death, which were important findings, that did not supplement our primary hypothesis that the fear of death caused by COVID-19 or accompanying infections would enhance personal distress and depression, leading to decreases in studied factors. These results are drawn from our limited sample size and uneven demographic distribution. Suicide ideations rose from 5% pre-pandemic to 10.81% during the pandemic [ 35 ]. In our study, 9.3% of participants experienced thoughts about death and since we did not specifically ask if they thought about suicide, our results only partially correlate with suicidal ideations. However, as these subjects exhibited only moderate levels of anxiety and mild levels of depression, the rise of suicide ideations seems unlikely. The rise in suicidal ideations seemed to be especially true for the general population with no pre-existing psychiatric conditions in the first months of the pandemic [ 36 ]. The policies implemented by countries to contain the pandemic also took a toll on the population´s mental health, as it was reported, that more stringent policies, mainly the social distancing and perceived government´s handling of the pandemic, were related to worse psychological outcomes [ 37 ]. The effects of lockdowns are far-fetched and the increases in mental health challenges, well-being, and quality of life will require a long time to be understood, as Onyeaka et al. conclude [ 10 ]. These effects are not unforeseen, as the global population suffered from life-altering changes in the structure and accessibility of education or healthcare, fluctuations in prices and food insecurity, as well as the inevitable depression of the global economy [ 38 ].

The loneliness associated with enforced social distancing leads to an increase in depression, anxiety, and posttraumatic stress in children in adolescents, with possible long-term sequelae [ 39 ]. The increase in adolescent self-injury was 27.6% during the pandemic [ 40 ]. Similar findings were described in the middle-aged and elderly population, in which both depression and anxiety prevalence rose at the beginning of the pandemic, during the pandemic, with depression persisting later in the pandemic, while the anxiety-related disorders tended to subside [ 41 ]. Medical professionals represented another specific at-risk group, with reported anxiety and depression rates of 24.94% and 24.83% respectively [ 42 ]. The dynamic of psychopathology related to the COVID-19 pandemic is not clear, with studies reporting a return to normal later in 2020, while others describe increased distress later in the pandemic [ 20 , 43 ].

Concerning the general population, authors from Spain reported that lockdowns and COVID-19 were associated with depression and anxiety [ 44 ]. In January 2022 Zhao et al., reported an elevation in hoarding behavior due to fear of COVID-19, while this process was moderated by education and income levels, however, less in the general population if compared to students [ 45 ]. Higher education levels and better access to information could improve persons’ fear of the unknown, however, this fact was not consistent with our expectations in this study, as participants with university education tended to feel worse than participants with lower education. A study on adolescents and their perceived stress in the Czech Republic concluded that girls are more affected by lockdowns. The strongest predictor was loneliness, while having someone to talk to, scored the lowest [ 46 ]. Garbóczy et al. reported elevated perceived stress levels and health anxiety in 1289 Hungarian and international students, also affected by disengagement from home and inadequate coping strategies [ 47 ]. Wathelet et al. conducted a study on French University students confined during the pandemic with alarming results of a high prevalence of mental health issues in the study group [ 48 ]. Our study indicated similar results, as participants in the age group under 30 years of age tended to feel more anxious than others.

In conclusion, we can say that this pandemic changed the lives of many. Many of us, our family members, friends, and colleagues, experienced life-altering events and complicated situations unseen for decades. Our decisions and actions fueled the progress in medicine, while they also continue to impact society on all levels. The long-term effects on adolescents are yet to be seen, while effects of pain, fear, and isolation on the general population are already presenting themselves.

The limitations of this study were numerous and as this was a web-based study, the optimal distribution of respondents could not be achieved, due to the snowball sampling strategy. The main limitation was the small sample size and uneven demographic distribution of respondents, which could impact the representativeness of the studied population and increase the margin of error. Similarly, the limited number of older participants could significantly impact the reported results, as age was an important risk factor and thus an important stressor. The questionnaire omitted the presence of COVID-19-unrelated life-changing events or stressors, and also did not account for any preexisting condition or risk factor that may have affected the outcome of the used assessment scales.

Data Availability

The datasets generated and analyzed during the current study are not publicly available due to compliance with institutional guidelines but they are available from the corresponding author (SH) on a reasonable request.

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Kupcova, I., Danisovic, L., Klein, M. et al. Effects of the COVID-19 pandemic on mental health, anxiety, and depression. BMC Psychol 11 , 108 (2023). https://doi.org/10.1186/s40359-023-01130-5

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impact of covid 19 on mental health research paper pdf

Research article
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Published: 09 January 2021

A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being

Johannes H. De Kock ORCID: orcid.org/0000-0002-2468-5572 1 , 2 ,
Helen Ann Latham 3 ,
Stephen J. Leslie 4 ,
Mark Grindle 1 ,
Sarah-Anne Munoz 1 ,
Liz Ellis 1 ,
Rob Polson 1 &
Christopher M. O’Malley 1

BMC Public Health volume 21 , Article number: 104 ( 2021 ) Cite this article

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Health and social care workers (HSCWs) have carried a heavy burden during the COVID-19 crisis and, in the challenge to control the virus, have directly faced its consequences. Supporting their psychological wellbeing continues, therefore, to be a priority. This rapid review was carried out to establish whether there are any identifiable risk factors for adverse mental health outcomes amongst HSCWs during the COVID-19 crisis.

We undertook a rapid review of the literature following guidelines by the WHO and the Cochrane Collaboration’s recommendations. We searched across 14 databases, executing the search at two different time points. We included published, observational and experimental studies that reported the psychological effects on HSCWs during the COVID-19 pandemic.

The 24 studies included in this review reported data predominantly from China (18 out of 24 included studies) and most sampled urban hospital staff. Our study indicates that COVID-19 has a considerable impact on the psychological wellbeing of front-line hospital staff. Results suggest that nurses may be at higher risk of adverse mental health outcomes during this pandemic, but no studies compare this group with the primary care workforce. Furthermore, no studies investigated the psychological impact of the COVID-19 pandemic on social care staff. Other risk factors identified were underlying organic illness, gender (female), concern about family, fear of infection, lack of personal protective equipment (PPE) and close contact with COVID-19. Systemic support, adequate knowledge and resilience were identified as factors protecting against adverse mental health outcomes.

Conclusions

The evidence to date suggests that female nurses with close contact with COVID-19 patients may have the most to gain from efforts aimed at supporting psychological well-being. However, inconsistencies in findings and a lack of data collected outside of hospital settings, suggest that we should not exclude any groups when addressing psychological well-being in health and social care workers. Whilst psychological interventions aimed at enhancing resilience in the individual may be of benefit, it is evident that to build a resilient workforce, occupational and environmental factors must be addressed. Further research including social care workers and analysis of wider societal structural factors is recommended.

Peer Review reports

Health and social care workers (HSCWs) continue to play a vital role in our response to the COVID-19 pandemic. It is known that HSCWs exhibit high rates of pre-existing mental health (MH) disorders [ 1 , 2 , 3 ] which can negatively impact on the quality of patient care [ 4 ].

Studies from previous infectious outbreaks [ 5 , 6 ] suggest that this group may be at risk of experiencing worsening MH during an outbreak. Current evidence examining the psychological impact on similar groups [ 7 , 8 , 9 ], suggest that this group may be at risk of experiencing poor MH as a direct result of the COVID-19 pandemic. Compounding the concerns about these data are that HSCWs will be likely to not only be at a higher risk for experiencing MH problems during the pandemic, but also in its aftermath [ 5 ].

There are some specific features of the COVID-19 pandemic that may specifically heighten its potential to impact on the MH of HSCWs.

Firstly, the scale of the pandemic in terms of cases and the number of countries affected has left all with an impression that ‘no-one is safe’. Media reporting of the pandemic has repeatedly focused on the number of deaths in HSCWs and the spread of the disease within health and social care facilities which is likely to have amplified the negative effects on the MH of HSCWs.

Secondly, usual practice has been significantly disrupted and many staff have been asked to work outside of their usual workplace and have been redeployed to higher risk front line jobs.

Finally, the intense focus on personal protective equipment (PPE) is likely to have specifically heightened the impact of COVID-19 on the MH of HSCWs due to the uncertainty surrounding the quantity and quality of equipment, the frequently changing guidance on what PPE is appropriate in specific clinical situations and the uncertainty regarding the absolute risk of transmission posed. While other workers will have been impacted by COVID-19, it is highly likely that the above factors will have disproportionately affected the MH of HSCWs [ 9 , 10 ]. Indeed a British Medical Association survey on the 14th May 2020 during the pandemic showed that 45% of UK doctors are suffering from depression, anxiety, stress, burnout or other mental health conditions relating to, or made worse by, the COVID-19 crisis [ 11 ].

Although evidence based psychological interventions are available for this population [ 12 ], there is a paucity of evidence about interventions for the MH of HSCWs during pandemics. Recent calls to action mandated the need to provide high quality data on the psychological impacts of the COVID-19 pandemic [ 13 , 14 ]. This pandemic has rapidly changed the functioning of society at many levels which suggests that these data are not only needed swiftly, but also with caution and scientific rigour [ 13 , 14 ].

These data are needed in order to equip HSCWs to do their job effectively – high levels of stress and anxiety have been shown to decrease staff morale, increase absenteeism, lower levels of work satisfaction and quality of care [ 6 , 15 ]. It is therefore a priority to understand the psychological needs of our HSCWs in order to provide them with the appropriate tools to mitigate the negative effects of dealing with the COVID-19 pandemic.

While HSCWs have been identified as vulnerable to the negative psychological impact from the current pandemic, they do not form a homogeneous population. It may therefore be appropriate to identify particularly vulnerable groups within the larger population of HSCWs and target psychological support to them. This review seeks to understand whether any group of HSCWs could be confidently excluded from psychological support interventions because they are deemed to be at a low risk. Holmes et al. [ 14 ] have warned that a one-size-fits-all approach to supporting HSCWs might not be effective. This, together with the lack of evidence around tailoring psychological interventions during pandemics [ 1 ], highlights the importance of identifying vulnerable groups, to ensure appropriately personalised interventions are made available.

Aim of the review

The aim of this review is to identify the psychological impact of the COVID-19 pandemic on the health and social care professions, more specifically to identify which sub-groups are most vulnerable to psychological distress and to identify the risk and protective factors associated with this population’s mental health.

This review, looking exclusively at the psychological impact of the COVID-19 pandemic on HSCWs will therefore contribute to informing where mental health interventions, together with organisational and systemic efforts to support this population’s mental health could be focussed in an effort to support psychological well-being [ 14 ]. Rapid but robust gathering of evidence to inform health decision-makers is vital and in circumstances such as these, the WHO recommends rapid reviews [ 16 ].

Search strategy

Planning, conducting and reporting of this study was based on the guidelines for rapid reviews [ 17 ], set by the WHO [ 16 ] and the recent COVID-19 Cochrane Collaboration’s recommendations [ 18 ].

Data sources and searches

Two authors (CoM & RP) searched across a broad range of databases to capture research from potentially relevant fields, including health, mental health and health management. Within the OVID platform of databases Medline, EMBase, HMIC and PsychInfo were searched. Within the EbscoHost platform of databases, CINAHL, Medline, APA PsychInfo, Business Source Elite, Health Source and Academic Search Complete were searched. Beyond the OVID and EbscoHost platforms, SCOPUS, the King’s Fund Library, Social Care Online, PROSPERO and Google Advanced were also searched, making 16 databases searched (14 unique databases and two having been searched twice on separate platforms).

Owing to the rapidly changing landscape of the COVID-19 pandemic, and in an effort to include as many eligible papers as possible, the search strategy was executed on 23 April 2020 and again 2 weeks later on 6 May 2020 using a combination of subject headings and keyword searching (see Additional file 1 ). The bibliographical database was created with EndNote X7™.

Search criteria

The design of the search criteria was intended to draw together research both for this rapid review, and to contribute to the design of a digital mental health intervention to enhance the psychological well-being of HSCWs. The design of the search criteria is discussed in further detail in the Additional file 1 .

Types of participants

Participants were restricted to HSCWs during the COVID-19 pandemic.

Types of studies included

Published observational and experimental studies that reported the psychological effects on HSCWs during the COVID-19 pandemic were included. The study designs included quantitative and qualitative primary studies. Studies relating to previous pandemics and epidemics (such as SARS, MERS, H1N1, H5N1, Zika, Ebola, West Nile Fever) were excluded as these results have been reported elsewhere [ 7 ]. Reviews, theses, position papers, protocol papers, and studies published in languages other than English were excluded.

Screening and selection of studies

Searches were screened according to the selection criteria by JDK. The full text of potentially relevant papers was retrieved for closer examination. The reviewer erred on the side of inclusion where there was any doubt, to ensure no potentially relevant papers were missed. The inclusion criteria were then applied against full text versions of the papers (where available) independently by JDK and HL. Disagreements regarding eligibility of studies were resolved by discussion and consensus. Where the two reviewers were still uncertain about inclusion, the other reviewers (RP, CoM) were asked to provide input to reach consensus.

Data extraction and quality assessment

Relevant data were extracted into structured tables including country, setting, population, study design, number of participants, mental health conditions and their measurement tools and main study results. Where available, we extracted risk factors and protective factors. HL, LE and JDK extracted all the data while JDK checked for accuracy and completeness.

Table 2 presents an overview of the validated tools used per study type to assess study quality and risk of bias. JDK and HL assessed the quality of cross-sectional studies with the Joanna Briggs Institute tool [ 48 ] and JDK assessed their risk of bias using the Evidence Partners [ 49 ] appraisal tool. JDK assessed the risk of bias for the longitudinal study with the Critical Appraisal Skills Programme (CASP) appraisal tool [ 50 ] and the uncontrolled before-after study with the ROBINS – I [ 51 ]. SAM utilised Joanna Briggs Institute tool to assess the qualitative studies [ 38 ] and the Mixed methods appraisal tool (MMAT) [ 41 ] to assess mixed methods studies.

Data synthesis and analysis

Current best practice guided the tabulated and narrative synthesis of the results [ 52 , 53 ]. The studies’ outcomes were categorised according to the psychological impact of COVID-19 on HSCWs of:

general psychological impacts

the risk factors associated with adverse mental health outcomes

the protective factors against adverse mental health outcomes

Previous studies’ logical syntheses [ 6 ] were adapted by organising the risk and protective factors into psychosocial, occupational, sociodemographic and environmental categories. The GRADE method from the Cochrane Collaboration [ 54 ] was used to assess the quality of evidence of outcomes included in this rapid review. Varied study quality, together with study type and outcome heterogeneity precluded performing a meta-analysis.

Patient and public involvement

Some members of the author team are frontline healthcare staff during the COVID-19 pandemic and contributed to the design of the review.

Search results

The 677 records of interest were found from the two searches (429 in search 1 and 529 in search 2). After 148 duplicates were removed, 529 records were screened. Of these, 82 full texts of potentially relevant studies were assessed for eligibility (see Fig. 1 ). Twenty-four published studies met the inclusion criteria for the rapid review.

Prisma Flow Diagram

Study characteristics

The 24 studies included in this review consisted of 18 cross-sectional, 2 mixed methods, 2 qualitative, 1 longitudinal and 1 uncontrolled before-after study. The total number of participants in these studies was 13,731. In the cross-sectional studies, participant numbers ranged between 59 and 2299. Participant numbers in the two mixed method studies were 37 and 222 respectively, whilst the qualitative studies included 10 and 20 participants, respectively. The longitudinal study included 120 participants and the uncontrolled before-after study, 27 participants. See Table 1 for sampling methods within the included papers. The majority of papers utilised non-probability sampling methods, limiting generalisability of findings. One exception was Lai et al., who used region stratified 2-stage cluster sampling.

Eighteen of the studies were from China, of which 8 were based in Wuhan, where the COVID-19 outbreak began. The rest were from America (1), Israel (1), UK (1), Singapore (1), Pakistan (1), multicentre - Singapore & India (1), Global (1). Several validated measures were used to assess anxiety, depression, insomnia, stress and burnout. Table 1 provides an overview of the included studies.

Risk of bias assessment

The quality of the cross-sectional studies was fair, with 16 studies scoring 6 or higher on the JBI appraisal tool and eleven scoring 7 or higher (a score of 7 and above is an indicator of study quality). The majority of the studies indicated a low risk of bias when assessed with the Evidence Partners’ appraisal tool. The uncontrolled before-after study indicated a high risk of bias. The qualitative studies indicated a good level of quality (JBI scores of 9 & 10 respectively) while mixed methods studies showed varied quality. In the cross sectional studies, the most common problem affecting study quality was failure to deal with confounding factors. Failure to locate the researcher culturally or theoretically affected the qualitative papers, whilst the two mixed methods papers’ study quality was affected by lack of explicitly articulated research questions. A summary of the risk of bias and quality assessments are provided in Table 2 .

Psychological toll on healthcare workers

Of the 24 studies included, 22 directly assessed the psychological toll on healthcare workers and all found levels of anxiety, depression, insomnia, distress or Obsessive Compulsive Disorder (OCD) symptoms [ 24 , 25 , 26 , 27 , 29 , 30 , 31 , 33 , 34 , 35 , 36 , 37 , 39 , 40 , 42 , 43 , 44 , 46 , 47 , 58 , 59 , 60 ].

Psychological symptoms were assessed using various validated measures as outlined in Table 3 – the summary of included studies. The most common outcomes assessed were sleep, anxiety and depression. The prevalence of depressive symptoms varied greatly, ranging between 8.9% [ 39 ] to 50.4% [ 31 ]. These findings suggest marked differences in the prevalence of depressive symptoms across the studies. The prevalence of anxiety in cross-sectional studies ranged between 14.5% [ 39 ] to 44.6% [ 31 ]. Sleep was also assessed in several studies. Lai et al. [ 31 ] found the prevalence of sleep disturbances to be 34%, whilst another, nationwide survey in China found that HCWs had significantly worse sleep than the general population [ 29 ].

Risk factors associated with adverse mental health outcomes

Table 3 provides the GRADE evidence profile of the certainty of evidence for the risk factors associated with adverse MH outcomes during the COVID-19 pandemic identified through the review. These risk factors can be grouped into the three thematic areas of i) occupational, ii) psychosocial, iii) environmental.

Occupational factors

Medical hcws.

Two studies showed that medical HCWs (nurses and doctors) had significantly higher levels of MH risk in comparison to non-medical HCWs [ 34 , 47 ]. Zhang et al. [ 47 ] found that medical HCWs had significantly higher levels of insomnia, anxiety, depression, somatization and OCD symptoms in comparison to non-medical HCWs. This was also reflected in a large study in Fujian province, China, in which medical staff had significantly higher anxiety than admin staff [ 34 ]. In contrast, Tan et al. [ 39 ] found that in a population of 470 HCWs in Singapore, the prevalence of anxiety was significantly higher among non-medical HCWs than medical.

Healthcare groups

In three studies nurses were found to be at risk of worse MH outcomes than doctors [ 24 , 26 , 31 ]. One large study in China found nurses were at significant risk of more severe depression and anxiety than doctors [ 31 ]. Another found that nurses had significantly higher financial concerns than doctors and felt significantly more anxious on the ward when compared with other groups. There was no significant difference between professionals regarding stopping work or work overload [ 24 ]. A mixed method paper also showed that nurses had a higher rate of depressive symptoms than doctors. Whilst this was a small sample size, it echoes the findings from larger studies [ 26 ].

With regard to other HCWs, there were two studies which assessed dentists and other dental workers and found them to be at risk of anxiety and elevated distress. Neither study found any difference based on gender or educational level [ 36 , 59 ]. There were no studies comparing dental workers to other HCWs. We did not find any studies that focussed on the primary care workforce or that assessed social care workers.

With regard to seniority, one paper found that having an intermediate technical title was associated with more severe MH symptoms [ 31 ].

Frontline staff/direct contact with COVID-19

Four high-quality studies found being in a ‘frontline’ position or having direct contact with COVID-19 patients was associated with higher levels of psychological distress [ 30 , 31 , 34 , 42 ].

Increased direct exposure to COVID-19 patients increased the mental health risks in health care workers in one study in Wuhan [ 30 ]. This finding is backed by Lai et al. [ 31 ], who found that being a frontline worker was independently associated with more severe depression, anxiety and insomnia scores. In addition, a cross sectional survey of staff in a paediatric centre found that contact with COVID-19 patients was independently associated with increased risk of sleep disturbance [ 42 ]. Lu et al. [ 34 ] found that medical HCWs in direct contact with COVID-19 patients had almost twice the risk of anxiety and depression than non-medical staff with low risk of contact with COVID-19.

There were conflicting results found in two studies. A study in a cancer hospital in Wuhan found burnout frequency to be lower in frontline staff [ 43 ]. The authors identified confounding factors which may have led to this result, but it is of interest as it is one of the only studies that assessed HCWs outside of the acute general medicine setting. Li et al. [ 32 ], also found that frontline nurses had significantly lower levels of vicarious trauma scores than non-frontline workers and the general population.

Personal protective equipment (PPE)

PPE concerns were the most common theme brought up voluntarily in free-text feedback in a study by Chung & Yeung [ 60 ], and a survey in Pakistan revealed that 80% of participants expected provision of PPE [ 40 ]. H.Cai et al. [ 24 ] also found that PPE was protective when adequate, but a risk factor for stress when inadequate. This finding appears to be bolstered by a qualitative study of frontline nurses in Wuhan, which found that physical health and safety was one of their primary needs. This study also reported PPE as a protective factor [ 46 ].

Heavy workload

Longer working time per week was found to be a risk factor in a study by Mo et al. [ 35 ] This, together with increased work intensity or patient load per hour, were themes in a mixed methods study of 37 staff of a clinic in Beijing [ 26 ] and a qualitative study of nurses in China [ 37 ], also suggesting heavy workload as a risk factor.

Psychosocial factors

Fear of infection.

A fear of infection was a highlighted in a qualitative study by Cao et al., (2020, 31), and brought up as a theme in free-text feedback in a cross sectional survey by Chung & Yeung [ 60 ]. Ahmed et al. [ 59 ] found that 87% of dentists surveyed described a fear of being infected with COVID-19 from either a patient or a co-worker.

Concern about family

This was brought up as one of the main stress factors in a study by H.Cai et al. [ 24 ], particularly amongst staff in the 31–40 year age-group. Knowing that their family was safe was also the greatest stress reliever [ 24 ], whilst fear of infecting family was identified in 79.7% of 222 participants in a study in Pakistan [ 40 ]. It was also a theme highlighted in the qualitative data [ 26 , 37 ].

Sociodemographic factors

Younger age.

One Chinese web-based survey which included the general population and HCWs, showed that younger people had significantly higher anxiety and depression scores, but no difference in sleep quality. Conversely, the same study found that HCWs were significantly more likely to have poor sleep quality, but found no difference in anxiety or depressive symptoms based on occupation. The study did not examine the effect of age group on HCWs [ 29 ].

H. Cai et al. [ 24 ] suggested that age was more complex. They found that all age groups had concerns, but that the focus of their anxieties were different (for example: older staff were more likely to be anxious due to exhaustion from long hours and lack of PPE while younger staff were more likely to worry about their families).

Women were found to be at higher risk for depression, anxiety and insomnia by Lai et al. [ 31 ] This was also found to be an independent risk factor for anxiety in another large nationwide Chinese study [ 47 ]. However, a global survey of dentists found no differences based on gender [ 59 ].

Underlying illness

We found two studies which identified that having an underlying organic illness as an independent risk factor for poor psychological outcomes. A study of dentists in Israel found an increase in psychological distress in those with background illnesses as well as an increased fear of contracting COVID-19 and higher subjective overload [ 36 ]. In medical HCWs in China, organic illness was found to be an independent risk factor for insomnia, anxiety, OCD, somatising symptoms and depression in medical HCWs [ 47 ].

Being an only child

This was independently associated with sleep disturbance in paediatric HCWs in Wuhan [ 42 ]. Being an only child was also found to be significantly associated with stress by Mo et al. [ 35 ].

There was also a significant association between physical symptoms and poor psychological outcomes in a large multicentre study based in India and Singapore. It is unclear if this represented somatization or organic illness and the authors suggest the relationship between physical symptoms and psychological aspects was bi-directional [ 27 ].

Environmental factors

Point in pandemic curve.

One longitudinal study carried out in China in a surgical department, found that anxiety and depression scores during the ‘outbreak’ period were significantly higher when compared to a similar group assessed after the outbreak period [ 58 ]. This was a small sample of 120 and only assessed surgical staff, but this longitudinal data was supported by a qualitative study in China which suggested that anxiety peaks at the start of the outbreak and reduces with time [ 37 ].

Living in a rural area was only assessed by one study which showed that it was an independent risk factor for insomnia and anxiety in medical HCWs [ 47 ]. This may reflect a need to further investigate the effect of rurality on psychological wellbeing during this pandemic.

Protective factors against adverse mental health outcomes

The review identified protective factors against adverse mental health outcomes during COVID-19. Table 4 provides the GRADE evidence profile of the certainty of evidence for this. The protective factors can be grouped into the three thematic areas of: i) occupational, ii) psychosocial and iii) environmental.

W. Cai et al. [ 25 ] found that previous experience in a public health emergency (PHE) was protective against adverse mental health outcomes. Staff that had no previous experience were also more likely to have low rates of resilience, and social support.

A small cohort study of 27 surgeons, who were given pre and post training surveys, suggested that training alleviates psychological stress [ 22 ]. Good hospital guidance was identified to relieve stress in a study by H.Cai et al. [ 24 ], and increasing self-knowledge was a coping strategy deployed by staff. Dissemination of knowledge was also mentioned in a qualitative study by Yin & Zeng [ 46 ]; participants described subjective stress reduction after their seniors explained relevant knowledge to them.

Adequate PPE

As mentioned above, PPE was found to be a protective factor when adequate and a risk factor for poor mental health outcomes when deemed to be inadequate [ 24 , 46 ].

One study assessed self-efficacy in dental staff and found that it was a protective factor [ 36 ]. Self-efficacy was also found to improve sleep quality by Xiao et al. [ 44 ], whilst W.Cai et al. [ 25 ] measured resilience using a validated measure and found it to be a protective factor against adverse MH outcomes.

Being in a committed relationship

This was found to be protective by Shacham et al. [ 36 ] This was not directly assessed in other studies.

Safety of family

This had the biggest impact in reducing stress in a cross-sectional study by H. Cai et al. [ 24 ] This was also not assessed in other studies.

Support and recognition from the health care team, government and community was identified as a protective theme in several studies. Social support, measured using the Social Support Rate Scale (SSRS) was found to indirectly affect sleep by directly reducing anxiety and stress and increasing self-efficacy [ 44 ].

Team support was identified as a protective factor in a qualitative study by Sun et al. [ 37 ] Good hospital guidance was also identified as a stress reliever by H. Cai et al. [ 24 ], who found that HCWs expected recognition from the hospital authorities. This was echoed in a qualitative study of nurses in Wuhan where the desire for community concern was a strong need and tightly linked to the need for PPE and knowledge [ 46 ]:

‘ To be honest, I was very apprehensive before coming to the infectious department as support staff, but on the first day here, the head nurse personally explained relevant knowledge such as disinfection and quarantine, and that helped me calm down a lot . ”

“I hope that our society and government pay more attention to lack of personal protective equipment’ [ 46 ] .

As a communicable disease, and now a global public health emergency (PHE), COVID-19 places a unique challenge on our health and social care workforce that will disrupt not just their usual workplace duties but also their social context [ 62 ]. As we adjust to new ways of living and working, HSCWs are likely to continue to face challenges ahead. Our review confirms that the psychological impact of COVID-19 on health care workers is considerable, with significant levels of anxiety, depression, insomnia and distress. Studies revealed a prevalence of depressive symptoms between 8.9–50.4% and anxiety rates between 14.5–44.6% [ 31 , 39 ]. This is in keeping with other reviews and findings from previous viral outbreaks [ 7 , 8 , 63 ]. The majority of studies published to date come from China, particularly Wuhan - the epicentre of COVID-19. There is minimal evidence published to date on the psychological impact on HCWs in Europe or the US, which have been highly impacted by the pandemic. The studies included in this review were predominantly concerned with hospital settings – we found no studies relating to social care staff or primary care staff. This is a concern, as we have increasing evidence that a large proportion of Western deaths are happening in the community and specifically in care homes [ 64 ].

Our review aimed to identify whether there were any groups particularly vulnerable to poor mental health outcomes during COVID-19. We found some evidence that nurses may be at a higher risk than doctors [ 24 , 26 , 31 ]. This is similar to findings which take into account previous viral outbreaks [ 7 ]. Confounding factors were not robustly addressed however, and there were no studies that compared nurses with the primary care workforce or social care workers. There was some evidence that clinical HCWs may be at higher risk of psychological distress than non-clinical HCWs [ 34 , 47 ], but this was not absolute. Tan et al. [ 39 ] found a higher prevalence of anxiety among non-medical HCWs in Singapore. The prevalence of poor MH outcomes varied between countries. Chew et al. [ 27 ] revealed that in data from India and Singapore, there was an overall lower prevalence of anxiety and depression than similar cross-sectional data from China [ 27 , 31 , 39 , 60 ]. This suggests that different contexts and cultures may reveal different findings. It is possible that being at different points in their respective countries’ outbreak curve may have played a part, as there was evidence that this may be influential [ 58 ]. Tan et al. [ 39 ] postulated that the medical HCWs in Singapore had experienced a SARS outbreak in the past and thus were well prepared for COVID-19 both psychologically and in their infection control measures. What we can deduce is that context and cultural factors are likely to play a role, not just cadre or role of healthcare worker. It also highlights the importance of reviewing the evidence as more data emerges from other countries.

Several risk factors emerged, many in keeping with what has been found in other reviews [ 7 , 8 ]. Those with the strongest evidence were inadequate PPE [ 24 , 40 , 46 , 60 ], fear of infection [ 26 , 59 , 60 ] and heavy workload [ 26 , 35 , 37 ]. Consistent with prior outbreak data [ 7 , 63 ], there was also good evidence that close contact with COVID-19 cases was a predictor of higher levels of anxiety, depression and insomnia [ 30 , 31 , 34 , 42 ], although two studies appeared to show conflicting results [ 32 , 43 ]. Studies suggested that being younger in age [ 24 , 29 , 33 ] or being female [ 31 , 47 , 59 ] may be a risk factor, however this should be treated with caution. An alternative explanation for this study’s findings may be greater risk of frontline exposure amongst women, who are predominantly employed in lower status roles within healthcare globally according to the WHO [ 65 ]. It is important to note that respondents to all studies, when disaggregated by gender, were predominantly female and this may have impacted findings. The consistently higher mortality rate and risk of severe COVID-19 disease amongst men would suggest that the full picture regarding gender and MH during this pandemic is incomplete [ 66 , 67 ]. Although other risk factors were also identified, their certainty of evidence was deemed to be low.

The majority of cross-sectional studies focussed on measuring adverse MH outcomes which explains the lack of quantitative data on protective factors or coping mechanisms. Of the studies that did assess this, there were protective factors which were associated with adaptive psychological outcomes. Experience of prior infectious disease outbreaks and training were protective against poor mental health outcomes [ 22 , 24 , 25 , 46 ]. Adequate PPE was a protective factor when adequate and a risk factor when inadequate [ 24 , 46 , 60 ]. There was good evidence that resilience (measured by self-efficacy or resilience scales) was protective against poor mental health outcomes [ 25 , 36 , 44 ]. This is of importance when assessing how to positively contribute to reducing the psychological burden on our health and social care staff. There was strong evidence that community support was a protective factor [ 24 , 37 , 44 , 46 ]. Community support was important in a number of studies, referring to social support as well as recognition and support from the healthcare team, government and wider community [ 24 , 37 , 44 , 46 , 68 ]. Other adaptive behaviours emerged from qualitative data, including gratitude and the ability to find purpose and growth from the situation [ 37 ]. These findings are in keeping with a recent study which identified key domains of risk for burnout in healthcare. They highlighted that being part of a supportive team community is a strong protective factor as are clear values and meaningful work [ 69 ]. They advise that organisational-level interventions creating a healthy workplace are the key to preventing burnout [ 69 ]. This is echoed in a recent systematic review and meta-analysis of the effectiveness of interventions designed to reduce symptoms and prevalence of MH disorders and suicidal behaviour among physicians. This review concluded that, whilst individually directed interventions are associated with some reduction in symptoms of common MH disorders, there needs to be increased focus on organisational-level interventions that improve the work environment [ 2 ].

Whilst our findings showed evidence that occupational and environmental factors at the workplace level played a key role for MH outcomes, there was no mention of wider societal structural issues that have been emerging during this pandemic. Of particular importance is the evidence that black and ethnic minority people of all ages in the global north are at greater risk of contracting and dying from COVID-19 [ 70 , 71 , 72 ]. A recent large study in the US found that non-white HCWs were at increased risk of contracting COVID-19 and were disproportionately affected by inadequate PPE and close exposure to COVID-19 patients [ 3 ]. This suggests wider structural factors are at play and need to be investigated.

The paucity of empirical studies investigating the mental health of social care and primary care staff during the COVID-19 pandemic should also be rectified. With the majority of studies taking place in China, where ageing in place rather than residential care is the norm [ 73 ], it is unsurprising that none investigated care homes, where it is estimated around 40–50% of all deaths related to COVID-19 occur in Europe and the US [ 64 ]. Moreover, there is evidence that front-line HCWs who work in nursing homes are among the highest at risk of contracting the virus [ 3 ]. With the majority of studies taking place in urban hospital settings, and particularly in Wuhan – the epicentre of the outbreak – the generalizability of findings to other settings may be limited, particularly as countries pass through different points in the outbreak curve. However, this review does highlight the considerable psychological impact that COVID-19 has played so far on health care workers and, therefore, adds to the recent calls to take notice of this important issue [ 14 ]. Yet the evidence also suggests that, although predictors for psychological distress exist, these are not absolute and context may play an important role on the manifestation of adverse MH outcomes.

Strengths and limitations

This rapid review has synthesized and discussed the current literature on the psychological impact of the COVID-19 pandemic on health and social care workers. A major limitation was that no empirical studies investigating this impact on social care workers could be found – limiting generalisability to the population reviewed. Recent evidence also suggests that having an ongoing connection to a paid job, may be protective against poor MH outcomes during the pandemic [ 74 ]. It would therefore be useful to compare MH outcomes amongst HCWs, or the general population, who were not actively employed during the pandemic. Unfortunately, none of the studies included this data. Furthermore, job retention schemes have varied widely between countries worldwide, thus limiting the generalisability of findings if this data had been available [ 75 ].

However, to our knowledge, this is the first review investigating this population group in the context of COVID-19, without including prior viral outbreaks in its analysis and synthesis. We see this as a strength because this outbreak is different, and worth assessing in its own right. It has affected every country across the globe and disrupted everyday living in a way no other outbreak has in living memory [ 14 ]. A major strength of our review is that it endeavoured towards greater inclusion, during the rapidly changing COVID-19 landscape, by completing two runs of the search strategy spaced 2 weeks apart. Whilst we adhered to high methodological standards by assessing study quality and risk of bias, together with using the GRADE approach to evaluate the certainty evidence and following best practice principles [ 52 , 53 ] to present a narrative and tabulated synthesis, our review remains a rapid one with further clear limitations. The majority of the studies included in this review, for example, were from China and our selection criteria did not include studies from low-income countries or studies in languages other than English - limiting the generalizability of our findings. Being a rapid review, the protocol was not registered on PROSPERO and only one reviewer was responsible for the initial screening of papers and for several of the quality assessments. Finally, as the current review’s searches were carried out early in the pandemic, it will be valuable to consider emerging research from the global arena in the light of this review’s findings.

This rapid review confirms that front line HCWs are at risk of significant psychological distress as a direct result of the COVID-19 pandemic. Published studies suggest that symptoms of anxiety, depression, insomnia, distress and OCD are found within the healthcare workforce. However, most studies draw only from work in secondary care and none draw from the primary care or social care setting. Published studies so far are predominantly from China (18 out of 24 included studies) and most of these have sampled hospital staff in Wuhan - the epicentre. Findings in this review suggest that the study of different contexts and cultures may reveal different findings and we recommend more research in primary care and social care settings and to monitor rapidly emerging evidence from across the world. This should include analysis of wider societal factors including gender, racial and socio-economic disparities that may influence mental health outcomes in HCWs.

Although risk factors did emerge that were in keeping with evidence from other infectious disease outbreaks, our findings were not absolute. This review suggests that nurses may be at higher risk of adverse MH outcomes during this pandemic, but there were no studies comparing them with social care workers or the primary care workforce. Other risk factors that recurred in the data were heavy workload, lack of PPE, close contact with COVID-19, being female and underlying organic illness. Inconsistencies in findings and lack of data on staff outside hospital settings, suggest that targeting a specific group within health and social care staff with psychological interventions may be misplaced – as both presence of psychological distress and risk factors are spread across the healthcare workforce, rather than associated with particular sub-groups.

A recent call to action for mental health science during COVID-19 recommends research be undertaken to identify interventions that can be delivered under pandemic conditions to mitigate deteriorations in psychological well-being and support mental health. This call to action advised that personalised psychological approaches are likely to be a key [ 14 ]. Data from this review suggests that interventions which bolster psychological resilience may be of benefit because this was found to protect against adverse mental health outcomes. Due to the nature of the pandemic which prevents face-to-face interventions, this is likely to be digitally based. A recent systematic review, pre-dating COVID-19, suggested that individualised interventions can have modest effect on reducing adverse mental health outcomes amongst physicians [ 2 ]. However, our findings suggest that occupational and environmental factors in the workplace play a key role as risk factors and protective factors for mental health outcomes during this pandemic. Heavy workload, proximity to COVID-19 and inadequate PPE were risk factors for poor mental health, whereas good knowledge of COVID-19, a supportive work environment and adequate PPE were protective factors. It would appear from our findings that adequate PPE may be protective not just against infection, but also against adverse mental health outcomes. Individually targeted digital interventions are unlikely to address these factors [ 2 ]. We postulate that strengthening psychological resilience in a personalised approach may be effective in protecting our health and social care workers from adverse mental health outcomes but this must not defer responsibility from wider organisations and systems. We suggest that a holistic approach to HCWs psychological wellbeing is needed that includes personalised interventions alongside necessary structural changes to create a healthy, safe and supportive work environment. Further research including social care workers and analysis of wider societal structural factors is recommended.

Availability of data and materials

The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Connor-Davidson Resilience Scale

Centre for Epidemiologic Studies Depression Scale (CES-D)

Coronavirus disease 2019

Depression, Anxiety and Stress Scale

Generalised Anxiety Disorder Questionnaire

The Grades of Recommendation, Assessment, Development and Evaluation Working Group

Generalised self-efficacy scale

Hamilton Anxiety Rating Scale

Hamilton Depression Rating Scale

Healthcare workers

Health and social care workers

Impact of Event Scale

Insomnia Severity Index

Maslach Burnout Inventory (MBI)

Mental health

Public Health Emergency

Patient Health Questionnaire-4

Patient Health Questionnaire

Personal protective equipment

Pittsburgh Sleep Quality Index

Zung Self-Rating Anxiety Scale

The Stanford Acute Stress Reaction questionnaire

Symptom checklist depression scale

The Symptom Checklist-90-R

Zung Self-Rating Depression Scale

Short Form Health Survey (SF-36)

Stress Overload Scale

Social Support Rating Scale

World Health Organisation

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De Kock, J.H., Latham, H.A., Leslie, S.J. et al. A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being. BMC Public Health 21 , 104 (2021). https://doi.org/10.1186/s12889-020-10070-3

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Impact of COVID-19 on mental health and quality of life: Is there any effect? A cross-sectional study of the MENA region

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates

Roles Conceptualization, Formal analysis, Investigation, Methodology, Validation, Writing – review & editing

Affiliation Department of Sport Rehabilitation, Faculty of Physical Education and Sport Sciences, The Hashemite University, Zarqa, Jordan

Roles Formal analysis, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing

Roles Investigation, Writing – review & editing

Affiliations Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates, Department of Health Services Administration, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates

Roles Writing – review & editing

Affiliation Faculty of Agricultural and Food Sciences, Nutrition Department, American University of Beirut, Riad El-Solh, Beirut, Lebanon

Affiliation Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates

Affiliation College of Natural and Health Sciences, Zayed University, Dubai, United Arab Emirates

Roles Investigation, Methodology, Validation, Writing – review & editing

Affiliations Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates, Institute for Health and Sport, Victoria University, Melbourne, Victoria, Australia

Roles Investigation, Methodology, Writing – review & editing

Affiliations Department of Clinical Nutrition and Dietetics, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates, Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates, Nutrition and Dietetics Program, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

Affiliation Port Fouad Hospital, Egyptian Ministry of Health, Port Said, Egypt

Affiliation Community-Based Initiatives and Health for Older People, World Health Organization, Regional Office for Eastern Mediterranean Region, Cairo, Egypt

Roles Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliations Department of Clinical Nutrition and Dietetics, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates, Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates, Department of Nutrition and Food Technology, Faculty of Agriculture, Jordan University of Science and Technology, Irbid, Jordan

[ ... ],

Affiliations Department of Clinical Nutrition and Dietetics, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates, Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates, Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom

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Ayesha S. Al Dhaheri,
Mo’ath F. Bataineh,
Maysm N. Mohamad,
Abir Ajab,
Amina Al Marzouqi,
Amjad H. Jarrar,
Carla Habib-Mourad,
Dima O. Abu Jamous,
Habiba I. Ali,

Published: March 25, 2021
https://doi.org/10.1371/journal.pone.0249107
Reader Comments

The COVID-19 pandemic is a major health crisis that has changed the life of millions globally. The purpose of this study was to assess the effect of the pandemic on mental health and quality of life among the general population in the Middle East and North Africa (MENA) region. A total of 6142 adults from eighteen countries within the MENA region completed an online questionnaire between May and June 2020. Psychological impact was assessed using the Impact of Event Scale-Revised (IES-R) and the social and family support impact was assessed with questions from the Perceived Support Scale (PSS). The IES-R mean score was 29.3 (SD = 14.8), corresponding to mild stressful impact with 30.9% reporting severe psychological impact. Most participants (45%–62%) felt horrified, apprehensive, or helpless due to COVID-19. Furthermore, over 40% reported increased stress from work and financial matters. Higher IES-R scores were found among females, participants aged 26–35 years, those with lower educational level, and participants residing in the North Africa region ( p <0.005). About 42% reported receiving increased support from family members, 40.5% were paying more attention to their mental health, and over 40% reported spending more time resting since the pandemic started. The COVID-19 pandemic was associated with mild psychological impact while it also encouraged some positive impact on family support and mental health awareness among adults in the MENA region. Clinical interventions targeted towards vulnerable groups such as females and younger adults are needed.

Citation: Al Dhaheri AS, Bataineh MF, Mohamad MN, Ajab A, Al Marzouqi A, Jarrar AH, et al. (2021) Impact of COVID-19 on mental health and quality of life: Is there any effect? A cross-sectional study of the MENA region. PLoS ONE 16(3): e0249107. https://doi.org/10.1371/journal.pone.0249107

Editor: Bidhubhusan Mahapatra, Population Council, INDIA

Received: December 28, 2020; Accepted: March 12, 2021; Published: March 25, 2021

Copyright: © 2021 Al Dhaheri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The novel coronavirus, later designated as COVID-19, is an infectious disease that can spread among humans. It emerged initially in the city of Wuhan in China in late December 2019, when cases of pneumonia of unknown etiology were reported [ 1 ]. Following its emergence, it manifested as an outbreak that led to serious public health concerns by the World Health Organization (WHO), and by mid-March 2020, the WHO declared a global pandemic due to the substantial global-wide spread of the disease affecting many countries [ 2 ]. By 14 February 2021, over 108 million cases were confirmed worldwide, of which 5.99 million cases were reported in the Eastern Mediterranean region [ 3 ].

In response to this global health crisis, quarantine and lock down measures were implemented by international and government health organizations to contain the rapid spread of the virus. Further measures included suspension of flights, avoidance of large gatherings, mandatory use of face mask in many countries, social distancing, teleworking, home-schooling of children and health orders to stay at home [ 4 ]. While the WHO and worldwide health authorities are actively working on containing the outbreak, such a period of health crisis has significant repercussions on human health and welling, accompanied by psychological distress and related symptoms such as stress, panic and anxiety in the general population [ 5 ]. Moreover, psychological impact is considered to be more profound in comparison to the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003, due to the extensive social media exposure and increased global connectivity [ 6 , 7 ]. SARS-related psychological problems have been reported to be prevalent mainly among healthcare workers and SARS survivors [ 8 , 9 ]. In 2012, the Middle East respiratory syndrome coronavirus (MERS-CoV) was first identified in Saudi Arabia [ 10 ]. The spread of MERS-CoV across the Middle East was linked to the transmission of the pathogen from Dromedary camels to humans [ 11 ]. The MERS-CoV outbreak was associated with tremendous public anxiety in the affected countries, and it resulted in thousands of mortality cases, fear, anxiety, and psychosocial stress among the population, in addition to economic losses [ 12 , 13 ]. Consequently, it is crucial to understand the extent of impact for such pandemics on mental health and other aspects of life [ 14 , 15 ].

Historically, quarantine has been a successful measure adopted worldwide in infectious diseases outbreaks; however, it represents an unfavorable experience for the population. Movement restriction, separation from family or friends, limited freedom and fear of an uncertain future are all factors that may exacerbate negative psychological impact [ 16 ]. Large scale outbreaks as previously seen in the SARS epidemic have been associated with higher prevalence of psychological symptoms, emotional disturbance, depression, stress, post-traumatic stress symptoms and irritability [ 8 ]. Similarly, healthcare workers taking care of patients during the MERS-CoV outbreak in Saudi Arabia, reported feeling afraid and nervous, mainly about their safety as well as about colleagues and family, and the availability of infection control guidelines [ 17 ]. Literature shows that multiple stressors including longer duration of quarantine, fear of infection, distress, loneliness, boredom, confinement, inadequate information and financial loss, play a role in aggravating poor mental health [ 18 ].

The Middle East and North Africa (MENA) region in general, is a very sensitive area economically, politically, culturally and religiously. There are many challenges to contain the spread of COVID-19 in the region including political conflicts, humanitarian crises, suboptimal transparency, and frequent social and religious mass gatherings [ 19 ]. Additionally, the ongoing outbreak and the social isolation could have a huge impact on the mental health of individuals in the MENA region. Limited data is available on how people within the MENA region are coping with the COVID-19 pandemic and the extent of its ramifications on their mental health and well-being. Thus, this study aims to examine the impact of the COVID-19 outbreak on the mental health and quality of life among residents of the MENA region. The authors hypothesized that changes in family and social support, lifestyle changes, and increases in negative indicators were associated with higher IES-R total scores.

1. Study design and participants

A cross-sectional, web-based survey was conducted in the MENA region between 11 May 2020 and 15 June 2020. The sample was drawn from eighteen countries within the MENA region; including Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Republic of Yemen, Saudi Arabia, Sudan, Syria, Tunisia, and United Arab Emirates. Consenting adults aging 18 years and older were recruited electronically using convenience and snowball sampling methods in order to guarantee a large-scale distribution and recruitment of participants. There was no restriction on the total number of participants, however a minimum target of 100 participants from each country was desired. A total of 6142 participants (32.7% males) completed the survey and their data were included in the analysis.

The psychological impact of COVID-19 among adults was measured on the Impact of Event Scale-Revised (IES-R) and the social and family support impact was assessed using questions from the Perceived Support Scale (PSS) [ 20 – 22 ]. The questionnaires were prepared using Google Document Forms in the English, Arabic and French languages and it was automatically hosted via a unique URL. The electronic survey was pilot tested for clarity in a sample of 26 people from three countries in the MENA region. A few adjustments to wording were made preceding the pilot test to ensure the questionnaire’s clarity and applicability. A uniform resource locator (URL) was retrieved for the survey and was distributed formally (using e-mail invitations) and informally (using social media platforms, e.g., LinkedIn ™ , Facebook ™ , and WhatsApp ™ ). In addition, researchers involved in this project distributed the survey to their contacts and work colleagues.

An information sheet and a consent form were available on the first page of the questionnaire in all three languages. Participants were free to withdraw at any time without giving explanations and no personal identification was requested to retain information confidentiality. Participants were given no incentives for participating in the questionnaire. The system of Google Forms only provides responses for questionnaires with 100% completion rate. The responses were download as an Excel file and securely stored using a password protected “Cloud” database. The present study followed the ethical code for web-based research [ 23 , 24 ] and conforms to the principles embodied in the Declaration of Helsinki [ 25 ]. The study protocol was approved by the Social Sciences Research Ethics Committee at United Arab Emirates University (ERS_2020_6115).

2. Survey questionnaire

Information on the socio-demographic characteristics of the respondents was collected including age, gender, country of residence, education level, employment status, marital status, and work or study setting.

2.1 Impact of Event Scale-Revised Scoring (IES-R).

The Impact of Event Scale-Revised (IES-R) was used to assess the psychological impact of COVID-19 among adults residing in the MENA region [ 20 , 26 ]. The IES-R is a self-administered questionnaire containing 22 items and it has been previously translated and validated in the English, Arabic and French languages [ 27 – 30 ]. The IES-R has also been used to measure symptomatology experienced during the COVID-19 pandemic in Saudi Arabia, Egypt, Italy, and China [ 15 , 22 , 31 – 33 ]. The response for each question was scored based on a five-point Likert scale ranging from 0 (not at all) to 4 (extremely) and generated a total score (ranging from 0 to 88). The total IES-R score was considered normal (from 0 to 23); indicative of mild (from 24 to 32); moderate (from 33 to 36); or severe (≥ 37) psychological impact [ 15 ]. Three subscale scores were also calculated measuring intrusion (8 items), avoidance (8 items), and hyperarousal (6 items) [ 21 ].

2.2 Indicators of negative mental health impact.

Six modified and validated questions were asked regarding negative mental health impacts resulting from the COVID-19 pandemic [ 21 ]. Three questions inquired whether participants felt horrified, apprehensive, or helpless due to the pandemic. The other three questions assessed changes in stress from work, financial stress, and stress from home during the pandemic. The response options to these questions were much increased, increased, same as before, decreased, and much decreased.

2.3 Impact on social and family support.

This section included modified and validated questions from the Perceived Support Scale (PSS) assessing the impact of the COVID-19 pandemic on the support received from family or friends [ 15 , 21 ]. It included five items including support from friends, support from family members, sharing feelings with a family member, sharing feelings with others when blue, and caring for family members’ feelings. The response options were much increased, increased, same as before, decreased, and much decreased.

2.4 Mental health-related lifestyle changes.

Participants were also asked to rate whether they were paying less or more attention to mental health related lifestyle changes during the COVID-19 pandemic using modified and validated questions [ 21 ]. This section included four items; attention to mental health, devoting enough time to rest, to relaxation, and to exercise. The response options were much increased, increased, same as before, decreased, and much decreased.

3. Statistical analysis

Normality of data was tested with the use of Kolmogorov-Smirnov test of normality. Descriptive statistics for the sociodemographic characteristics were reported as numbers and percentages. The IES-R total and subscale scores were presented as Median and Interquartile Range (IQR). A Chi-square (χ 2 ) test was used to determine the association between IES-R categories (normal, mild, moderate, and severe) with categorical variables. A non-parametric Kruskal-Wallis H test was used to determine differences in IES-R, intrusion, avoidance, and hyperarousal scores between different regions. Followed by post-hoc pairwise comparisons with Bonferroni adjustment. A generalized linear model based on negative binomial distribution was used to assess the confounding effects of sociodemographic factors, negative mental health impact factors, social and family support indicators, and lifestyle factors on continuous IES-R total score. Variables included in the final model were selected using univariant general linear analysis and only factors with a cut-off value of p <0.2 were selected. A p -value <0.05 was considered to be statistically significant. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 26.0 (IBM, Chicago, IL, USA). The minimum sample size (n = 3246) was calculated using G*power software, version 3.1.9.4 (HHU, Germany) to detect a small effect size (0.10), with a power of 0.99, and alpha 0.05.

1. Demographic characteristics

The percentage of participants that completed the survey in the Arabic, English and French languages was 86.4%, 10.2% and 3.3% respectively. The sociodemographic characteristics of the study population are presented in Table 1 . The female to male ratio was almost 2:1, with 32.7% males. The majority of surveyed individuals were aged 36–45 years (27.3%), were married (60.8%), had a bachelor’s degree (49.3%), worked full-time (44.5%), were working or studying from home (52.6%), and were residing in the Gulf region (48.7%).

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https://doi.org/10.1371/journal.pone.0249107.t001

2. Impact of Event Scale-Revised Scoring (IES-R)

The overall mean IES-R score was 29.3 ± 14.8 (range 0–84), reflecting a mild stressful impact of the COVID-19 pandemic on the surveyed participants. The overall mean scores for the intrusion, avoidance and hyperarousal scales in participants were 9.5 ± 6.1, 11.8 ± 5.8, and 7.9 ± 5.0, respectively. A Kruskal-Wallis H analysis revealed an expected significant difference in total IES-R scores between the different regions, ( X 2 (2) = 102.937, p <0.001), with a mean rank IES-R score of 2897.95 for Gulf region, 3036.45 for Levant region, and 3471.21 for North Africa region ( Table 2 ). Furthermore, there was a significant difference in intrusion scores between the different regions, ( X 2 (2) = 106.650, p <0.001), with a mean rank intrusion score of 2913.00 for Gulf region, 2996.70 for Levant region, and 3486.87 for North Africa region. A significant difference in avoidance scores between regions were observed, ( X 2 (2) = 38.410, p <0.001), with a mean rank avoidance score of 2984.50 for Gulf region, 3010.56 for Levant region, and 3322.88 for North Africa region. Moreover, there was a significant difference in hyperarousal scores between the different regions, ( X 2 (2) = 109.964, p <0.001), with a mean rank hyperarousal score of 2853.84 for Gulf region, 3142.34 for Levant region, and 3437.78 for North Africa region.

https://doi.org/10.1371/journal.pone.0249107.t002

3. Sociodemographic and Impact Event Scale-Revised (IES-R)

The association of IES-R scores with sociodemographic factors is presented in Table 3 . A Chi-square analysis revealed significant association between IES-R categories with gender ( X 2 = 36.440; p <0.001), age ( X 2 = 54.585; p <0.001), education level ( X 2 = 32.663; p <0.001), employment status ( X 2 = 65.989; p = 0.017), and region of residence ( X 2 = 102.244; p <0.001). As expected, the multivariate regression analysis revealed that females (Estimated rate ratio: 9.1%; p = 0.003), participants aged 26–35 years (Estimated rate ratio: 12.2%; p = 0.022), school or college diploma graduates (Estimated rate ratio: 9.4%; p = 0.034), and residence of North Africa region (Estimated rate ratio: 11.8%; p <0.001) were more likely to have higher IES-R scores. However, marital status, employment status and working from home were not significantly associated with changes in total IES-R score.

https://doi.org/10.1371/journal.pone.0249107.t003

4. Indicators of negative mental health impact

Table 4 presented the association between IES-R scores and negative mental health indicators. About 40% of the participants reported increased stress from work during the outbreak, 45.3% felt an increased level of stress from financial matters, and 60.3% of participants had increased stress from home during the pandemic. Furthermore, 61.0% of the participants felt horrified, 61.5% felt apprehensive, and 45.2% felt helpless due to the pandemic. A Chi-square analysis revealed significant association between IES-R categories with increased stress from work ( X 2 = 387.901; p <0.001), increased stress from financial matters ( X 2 = 5197.234; p <0.001), increased stress from home ( X 2 = 354.400; p <0.001), feeling horrified ( X 2 = 678.749; p <0.001), feeling apprehensive ( X 2 = 529.160; p <0.001), and feeling helpless ( X 2 = 496.914; p <0.001). The multivariate regression analysis detected that increased stress from work (Estimated rate ratio: 16.6%; p <0.001), increased financial stress (Estimated rate ratio: 6.3%; p = 0.027), increased stress from home (Estimated rate ratio: 10.9%; p <0.001), feeling horrified (Estimated rate ratio: 23.4%; p <0.001), feeling apprehensive (Estimated rate ratio: 9.3%; p = 0.008), and feeling helpless (Estimated rate ratio: 14.1%; p <0.001) were significantly associated with higher IES-R scores.

https://doi.org/10.1371/journal.pone.0249107.t004

5. Impact on social and family support

Table 5 showed the association between IES-R score and family and social support. The results showed that 42.1% of the participants reported receiving increased support from family members, 24.3% received increases support from friends, and 48.1% stated increased shared feelings with their family members during the pandemic. In addition, the majority of participants (67.4%) cared more about their family members’ feelings following the onset of the pandemic.

https://doi.org/10.1371/journal.pone.0249107.t005

A Chi-square analysis revealed significant association between IES-R categories with getting support from friends ( X 2 = 265.459; p <0.001), getting support from family members ( X 2 = 215.531; p <0.001), sharing feelings with family members ( X 2 = 340.216; p <0.001), sharing feelings with others ( X 2 = 450.398; p <0.001), and caring for family members’ feelings ( X 2 = 194.155; p <0.001). The multivariate regression analysis revealed that increased support from friends (Estimated rate ratio: 8.3%; p <0.001), and increased sharing feelings with others (Estimated rate ratio: 7.9%; p <0.001) were significantly associated with higher IES-R scores.

6. Mental health-related lifestyle changes

Table 6 displayed the association of IES-R scores with lifestyle indicators during the pandemic. About 41% of participants reported paying more attention to their mental health since the pandemic started. Additionally, over 40% of the participants reported spending more time to rest and relax. However, 41.8% of the participants reported spending less time exercising during the outbreak. A Chi-square analysis revealed significant association between IES-R categories with paying attention to mental health ( X 2 = 312.943; p <0.001), spending time to rest ( X 2 = 221.645; p <0.001), spending time to relax ( X 2 = 252.510; p <0.001), and spending time to exercise ( X 2 = 94.757; p <0.001). As expected, the multivariate regression analysis showed that decreased attention to mental health and decreased time spent to relax were significantly associated with higher IES-R scores ( p = 0.001).

https://doi.org/10.1371/journal.pone.0249107.t006

This study aimed to investigate the impact of the COVID-19 outbreak on mental health and quality of life among residents of the MENA region. The survey was conducted after two months of lockdown measures implemented in the MENA region. Moreover, the pandemic is not over yet and it is rapidly expanding in many countries of the Middle East. Although many studies have examined the physiological effect of COVID-19, however, to our knowledge, this is the first large-scale study published investigating mental health and quality of life across eighteen countries in the MENA region.

Findings of this study suggested that participants from North Africa region were more likely to have higher stress scores compared to those residing in the Gulf and Levant regions. This study was conducted between May and mid of June 2020. During which, all countries included in the survey have already declared the state of emergency due to COVID-19 [ 34 ]. The number of confirmed cases by mid of June varied widely between MENA countries and ranged between 127 thousand cases in Saudi Arabia and 177 cases in Syrian Arab Republic [ 35 ]. Moreover, the number of deaths also varied in the same period and ranged between 972 in Saudi Arabia and 6 cases in Syrian Arab Republic [ 35 ]. Although, variation in the number of confirmed cases and deaths were observed between countries and sub-regions of the MENA, the greatest number of confirmed cases and deaths were reported in the Gulf region. All countries included in the study implemented strict measures between March 2020 and June 2020 or even longer [ 34 ]. This study might not reflect the diverse impact on the entire population from the MENA region considering the different stages of the pandemic in different countries.

The results of this study showed that about 40% of the participants in the MENA region had an IES-R score indicating moderate to severe disturbance due to the pandemic. Similarly, a study among Lebanese citizens has shown a rise of Post-traumatic Stress Disorder (PTSD) symptomatology during the fourth week of the COVID-19 quarantine [ 36 ]. Additionally, an online survey conducted in Saudi Arabia reported mild to moderate rates of anxiety among the general population and a significantly higher level of anxiety among married respondents [ 37 ]. In the current study females and participants aged 26–35 years were more likely to have higher stress scores. Likewise, a study in Saudi Arabia assessed the psychological impact of COVID-19 using the IES-R, and the Depression, Anxiety, and Stress Scale (DASS-21), and found that health care workers, students and females had higher levels of stress, anxiety and depression symptoms [ 32 ]. Our results also agree with recent studies from China and Italy which revealed that females are more vulnerable to stress compared to males, and that younger age groups had a higher tendency to be stimulated by the surrounding stressors [ 5 , 38 ].

The biological, social and cognitive processes underlying gender differences in the susceptibility to psychological disorders have not yet been fully understood. However, some evidence indicates that fluctuations in ovarian hormone levels may be responsible for altered sensitivity to emotional stimuli among women [ 39 ]. Additionally, studies suggest that greater brainstem activation to threat stimuli may contribute to the greater prevalence of PTSD among women, and greater hippocampal activation in men may enhance their capacity for contextualizing fear-related stimuli [ 40 , 41 ]. Telehealth services such as telephone counseling helplines, are useful to provide support to the vulnerable groups and is an appropriate tool for the delivery of mental health services [ 42 ]. Additionally, implementing community-based strategies to support psychologically vulnerable individuals during the COVID-19 pandemic is essential [ 18 ]. Likewise, awareness about self-relaxation and self-care measures for participants and their families can be encouraged to lessen social isolation [ 43 ].

The findings of this study indicated that during the pandemic, over one-third of the participants experienced increased stress related to work and financial matters, and over half of the participants had increased stress related to home matters. Similar trends were reported in a study among Egyptian adults, where 34.1% of participants reported an increase of stress from work, 55.7% had increased financial stress, and 62.7% had increased stress related to home matters [ 33 ]. Moreover, during the COVID-19 pandemic families were more likely to experience a lack of support from external sources (such as from schools or childcare settings), and financial strain, especially lower-income individuals and those who lost their jobs as a result of the pandemic [ 44 ]. Furthermore, families were affected by prolonged school closure, requiring online education support and uncertainty about examinations and enrolment arrangements [ 45 ]. With limited resources and barriers to providing assistance through welfare initiatives, governments and health care professionals must unite their efforts to protect high risk vulnerable people with additional support such as online peer group support sessions, psychoeducation, home-based relaxation techniques and stress management skills with online guidance [ 46 ].

Additionally, the study found that high school and college educated participants were more likely to have experienced an increased level of stress compared to those with higher education. Conflicting findings about the possible relationship between the level of education and stressful impact were reported in the literature. Some studies suggests that those with a higher level of education might practice better coping strategies and therefore report less stress score [ 47 , 48 ]. Others proposed that highly educated people might be more stressed due to higher self-awareness and discernment of the pandemic severity [ 49 , 50 ].

More than half of the participants in this study felt shock apprehension due to the pandemic, however they did not feel helpless as they reported paying more attention to their mental health and spending more time relaxing and resting during the pandemic. Additionally, the majority of participants reported getting increased support from family members as well as caring more about the feelings of family members during the pandemic. Such positive impacts on mental health may have helped the participants to cope with other negative impacts of the COVID-19 pandemic. The increased family support observed in this study was in line with previous studies from Egypt and China which demonstrated that family and friends were much valued in a time of crisis [ 22 , 31 , 33 ]. Researchers suggested that during quarantine, family members had the ability to spend more time together and were also more concerned about their health and family, while less so about leisure activities and friends [ 51 ]. On the other hand, the World Health Organization Europe member states have reported a 60% increase in emergency calls from women subjected to violence by their intimate partner during the pandemic [ 52 ]. Domestic violence reports in France have increased by 30% and domestic violence calls in Argentina have increased by 25% [ 53 ]. Similarly, in New York City the Police Department responded to a 10% increase in domestic violence reports during March 2020 compared to March 2019 [ 54 ]. Reasons could include job losses, rising alcohol based harm and drug use, stress and fear [ 52 ].

Unfortunately, about 42% of participants reported spending less time exercising during the outbreak. Recent evidence suggests that levels of physical activity were also negatively affected during quarantine [ 55 – 57 ]. It might be due to the widespread closure of sport facilities and parks, as well as complete lockdowns. Achieving minimum physical activity levels and reducing sedentary behavior during quarantine is a challenge and a necessity for everyone. A study investigating the influence of home confinement during the COVID-19 pandemic outbreak on lifestyle and mental wellbeing among Arab adults revealed that the mental wellbeing score was significantly higher among participants with medium to high physical activity levels [ 58 ]. Several studies have indicated the positive impact of physical activity as an effective therapy in support of mental and physical health [ 59 , 60 ]. Moreover, physical activity and exercise were recommended as a therapy to fight against the mental and physical consequences of quarantine during the SARS and COVID-19 outbreaks [ 61 , 62 ]. Home-based physical activity interventions are feasible, safe, and an effective way to increase physical activity among the general population [ 63 ]. Therefore, awareness about different types of home exercises and their benefits on mental health is essential [ 61 , 64 ].

Limitations of this study include the use of self-reported questionnaire which might cause some respondent bias or misreporting of data; and the cross-sectional study design which provides only a snapshot of psychological responses at a particular point in time. Another potential limitation of this study was the use of snowballing sampling strategy, which is a non-probability sampling technique without adjusting for the population size of different countries. Also using an online survey limited the reach to non-social media users which led to less generalizable results. Moreover, information on the stressful impact due to political or economic status prior to the pandemic were not determined in the study. However, due to the time-sensitivity of the outbreak and with a strict quarantine measures in place, using an online survey allowed data collection from eighteen countries in the MENA region. It also guaranteed the anonymity of the participants, therefore reducing the social desirability bias. Another strength of this research project was conducting the survey in multiple languages, which allowed for wider distribution in the MENA region countries.

The current study identified females, younger age groups (26–35 years), people with school or college education and those residing in the North Africa region as high-risk groups to suffer from psychological distress. Additionally, recent studies also revealed that health care workers, students, people with history of medical problems, as well as those infected with COVID-19 and their family members are prone to psychological disorders [ 5 , 32 , 38 , 50 , 65 ]. Therefore, clinical interventions targeted towards vulnerable groups are needed to improve their mental health during the ongoing pandemic.

This large-scale study across 18 countries, is the first study to our knowledge, investigating mental health and quality of life in the MENA region due to the COVID-19 pandemic. The findings of this study indicate that the COVID-19 pandemic was associated with mild psychological impact among adults in the MENA region. However, it also encouraged some positive impacts on family support and mental health awareness. There is a need to increase the awareness among the various media platforms about psychological challenges during pandemics and highlight the importance of seeking help and engaging in physical activity for the management of mental health disorders. Furthermore, an increase in awareness among the health care professionals in identifying and targeting the high-risk groups of the population who are at risk in developing mental health problems is vitally important.

Governments and policymakers must offer moral and financial support for low-income families and those who lost their jobs. Also, regulating working hours is needed to reduce the burden on individuals during the current pandemic. Future large-scale comparable studies among other age groups such as adolescents and children will help public health authorities shape their reactions and interventions in the future in response to similar crises.

Supporting information

S1 file. statistical analysis plan..

https://doi.org/10.1371/journal.pone.0249107.s001

S2 File. Data set.

https://doi.org/10.1371/journal.pone.0249107.s002

Acknowledgments

To Tathqeef Health Treatment Undertakings Services for their support with the dissemination of the survey through their network.

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Published: 05 September 2022

The effect of COVID-19 on employees' mental health

Didem Rodoplu Şahin ORCID: orcid.org/0000-0002-1779-8472 1 ,
Mustafa Aslan ORCID: orcid.org/0000-0001-8049-3615 2 ,
Harun Demirkaya ORCID: orcid.org/0000-0003-0260-7538 1 &
Hülya Ateşoğlu ORCID: orcid.org/0000-0003-2116-3821 2

Scientific Reports volume 12 , Article number: 15067 ( 2022 ) Cite this article

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Human behaviour

Long lockdowns, food shortages, and the inability to receive basic primary healthcare have aggravated the effects of pandemics. However, most studies have focused on the health problems of the infected people or the measures employed to keep the disease under control. This cross-sectional study focused primarily on the mental health issues of employees. By employing a convenient sampling method, we reached 237 respondents (135 with coronavirus history) to assess the impact of the pandemic on employees. Multivariate causal relationships were assessed with Structural Equation Modeling (SEM). The predictors included internal entrapment (INT) and difficulty identifying feelings (DIF), which are significant predictors of depression (DEPR). DIF was found to be a significant predictor of INT and EXT feelings, while FEAR was found to be a significant predictor of INT, DIF, and DEPR. Quality of life (QoL) was found to be a significant predictor of DIF and DDF, DEPR, EXT and INT, and FEAR. The results also showed that DIF mainly manifested its effect on depression through INT. The DEPR level of employees working only from home was higher than that of other employees. The depression levels of women, young employees, and those whose QoL was adversely affected by the coronavirus were higher than the rest.

Impact of COVID-19 emergency on the psychological well-being of susceptible individuals

The mediating role of job satisfaction in the stressor–strain relationship among Chinese government employees

Acute psychological effects of Coronavirus Disease 2019 outbreak among healthcare workers in China: a cross-sectional study

Introduction.

The COVID-19 pandemic, which emerged in December 2019, caused a public health crisis worldwide. On July 28, 2022, the number of confirmed cases was over 571 million, and the death toll was over 6.3 million worldwide 1 ; these figures continue to rise steadily every day. The situation was not different in Turkiye, with over 15 million confirmed cases and around one hundred thousand deaths due to the coronavirus between March 2020 and May 2022 2 . This situation has created a sense of threat and concern that has spread at an alarming rate over the world 3 . Due to COVID-19, millions of people were locked down for weeks, lost their jobs, and, most importantly, their loved ones. In short, COVID-19 has had an impact on all aspects of our lives, from financial to social interactions, family to business relations, and physical to mental health, especially healthcare workers who have been fighting coronavirus at the frontline 4 , 5 , and older adults 6 .

Many COVID-19 patients show signs of post-traumatic stress disorder (PTSD). Employees suffering from PTSD are more likely to suffer from other mental health concerns and lose their ability to focus on cognitive activities. The three main clusters of PTSD symptoms (avoidance, intrusion, and hyperarousal) were proved to be substantially predicted by high levels of alexithymia, dissociation, anxiety, and sadness in persons who had recovered from COVID-19 7 . People who suffer from PTSD harbor frequent intense, distressing thoughts and feelings related to their traumatic experience. They may be stricken with grief, fear, or rage or feel isolated or disconnected from others 8 . They are also more likely to have alexithymic characteristics 9 , which means they can think, act, communicate, and perceive emotions but fail to correlate them with the related feelings, i.e., disconnection of the body and mind. In the absence of communication between the mind and the body, a state of body-mind dissociation ensues, which might be a sign of a protective mechanism or an alexithymic disorder 10 .

Moreover, the pandemic increased the risk of PTSD. According to Total Brain and the National Alliance of Healthcare Purchaser Coalitions 11 , the risk of PTSD has climbed month over month and, as of June 2022, is 51% greater than in the pre-pandemic era. According to the measure, nearly one-fifth of employees were at risk of having PTSD.

Alexithymia is a Greek word that means " absence of words for emotions " 12 . People suffering from this disorder have problems establishing a correlation between their feelings and thoughts and expressing them 12 . People with alexithymia typically struggle to recognize and express their emotions, display emotional functions, and establish interpersonal relationships 13 . Alexithymia has three dimensions: (1) difficulty in identifying feelings and distinguishing them from bodily sensations (DIF); (2) difficulty in describing feelings and putting them into words (DDF); (3) externally oriented thinking (EOT) 14 . The dimensions associated with identifying (DIF) and describing (DDF) feelings are positively related to depression and anxiety 15 , 16 , 17 , 18 .

Entrapment, on the other hand, is the desire to leave an unpleasant or challenging circumstance or uncertainty while also feeling compelled to avoid the unpleasantness of unease. When an individual is subjected to prolonged stress or has his or her conduct restricted by internal or external circumstances, he or she is said to be entrapped. Feeling entrapped in all aspects of life can have a negative impact on one's self-development and interpersonal relationships, either directly or indirectly 19 . Furthermore, when a person feels impotent to modify his or her circumstances, he or she is more likely to develop mental health issues. The experience of entrapment can be caused by a variety of factors, which the research categorizes as internal and external aspects 20 , 21 . During COVID- 19, people all around the world have had more than their fair share of suffering from feelings of entrapment 22 .

During the COVID-19 pandemic, many people died, and many went through traumatic experiences. Despite the fact that the number of confirmed cases is limited to barely 3.5% of the world's population, the coronavirus outbreak has caused increased fear and trauma due to widespread media coverage. Prolonged lockdowns, both qualitative and quantitative job insecurities and unemployment due to downsizing or bankruptcies 22 , shortage of food, inability to receive basic healthcare, fear of death, or causing the death of a loved one were primary factors are worsening the trauma. The outbreak, which rendered many people unable to think, act, or react 24 , 25 , has become this generation's worst frustrating experience. People were unable to avoid this predicament despite their best efforts 20 , 21 . They felt helpless 26 , 27 and defeated 28 , no matter the measures were taken against the disease.

Although symptoms and the effects of coronavirus on health have been excessively covered by media 29 , many people, including healthcare workers, experienced vaccine hesitation due to a lack of confidence in the vaccines 30 , 31 . Moreover, misinformation spread through social media 31 , and being exposed to them due to the overuse of electronic devices during the lockdowns left people anxious, fearful, and ultimately hopeless 32 . Furthermore, the lockdown and other measures to keep the disease under control restricted people's engagement in physical and social activities, making them vulnerable to a higher risk of physical and physiological problems 33 .

Despite the pandemic's highly unfavorable impact on public health, most of the research on the COVID-19 pandemic has been mainly on infected people's health issues or the impact of lockdowns or other measures used to keep the disease under control. Although every adult is either an employee or has at least one employee in their household, there has been almost no research comparing the mental health of infected and uninfected employees and examining the impact of the pandemic as a whole (not only the steps taken to prevent the spread of coronavirus but also the fear experienced by individuals).

Hence, this study aims to investigate the effect of COVID-19 on employees' mental health by assessing the effect of coronavirus-caused fear on identifying and describing feelings dimensions of alexithymia and of entrapment on depression level of employees. Although workers of some sectors, especially the health care sector, are exposed to COVID-19 more than any other sector, this study does not focus on a specific sector, gender, or age group.

Study design

The questionary consists of five parts. The questions in the first part were about the demographics of the participants, such as age, gender, and workplace during the pandemic (e.g., from home, both from home & workplace, and only from the workplace).

The second part incorporated a questionnaire including the following questions: "Have you lost any relatives or close friends due to coronavirus?", "How did the COVID-19 pandemic affect the quality of your life?", and "What would you fear most if you had been infected with coronavirus?" In the third part, we used three different scales: (1) the Turkish version of the Toronto Alexithymia Scale (TAS-20) 34 to measure identifying and describing feelings , (2) the 21-item Beck Depression Inventory-II 35 , and (3) the entrapment scale developed by Gilbert and Allan 36 . The scores of the Beck Depression Inventory-II were interpreted as suggested by Smarr and Keefer 37 .

Because the current scales have not been measuring the fear of infecting and causing the death of other people, especially relatives and loved ones, the authors have to create their own scale. The scale had a total of five items, and the respondents were asked to rate the five items from 1 to 5 (From the lowest to the highest, the level of fear is ranked from 1 to 5). The exact same questions were asked to both groups but with different tenses (e.g., "I am afraid of dying" to uninfected, and "I was afraid of dying" to the employee with coronavirus history).

The five items were related with:

Afraid of being infected with the coronavirus.

Afraid of infecting one's own family members or loved ones.

Afraid of infecting people other than one's own family members and loved ones.

Afraid of losing someone because of transmitting the disease to him or her.

Afraid of dying.

The aim of asking the question, "How did the COVID-19 pandemic affect the quality of your life?" was to assess the participant's perception of the quality of life (QoL) during the pandemic. The options given to the question were (1) no effect; (2) minimal adverse effect; (3) moderate adverse effect; (4) very high adverse effect.

Participants marked (0) if they had not lost any relatives or close friends, (1) for one relative or close friends, and (2) for more than one relative and close friends.

Data collection

This cross-sectional study was conducted in the Istanbul province of the Republic of Turkiye between September 26 and October 15, 2021. We reached the participants through social media and sent the questionary links (a total of two links; one for those with coronavirus history and one for those having no history) to those who volunteered to participate in the study. To promote participation, the researchers undertook to donate to Darülşşafaka Society-a well-known NGO in Turkiye founded in 1863 to provide equality of opportunity in education to needy, talented children who had lost their fathers—and stated this undertaking in the introduction part of the questionary. Participants then shared the questionary in their networks.

Being an employee (18 years old or over) was required to take part in the study. 237 of the 243 collected surveys were included in the analysis. Six surveys were omitted because two of the participants were underage, and four were housewives and thus were not eligible to participate in the study. The participants' average age was 40.17. Table 1 shows the demographics of the participants.

This study is approved by the Kocaeli University Social and Human Sciences Ethics Committee (protocol number: E-10017888–108.99–62,960).

Data analysis

Confirmatory Composite Analysis, Convergence and Discriminant Validities, and Reliability Tests were performed. Partial Least Square Structures Equation Modelling (PLS-SEM) with SmartPLS version 3.2.9 is used for data analysis. The coefficient of determination (R-square) and the Q-square value (the prediction relevance) was used to assess the model's acceptability. SPSS version 26 was also used as deemed necessary. The Pearson correlation coefficient and significance levels used to interpret results of correlation analysis. Figure 1 depicts path analyses using the path model.

Path model. FEAR: Fear; LOC: Work Location; DEC: Decease of a Relative or Acquaintance; QoL: Quality of Life; DDF: Difficulty Describing Feelings; DIF: Difficulty Identifying Feelings; EXT: External Entrapment; INT: Internal Entrapment; DEPR: Depression Level.

Criteria for the validity and reliability are as follow:

For Convergence Validity:

The average Variance Extracted (AVE) value must be equal to or greater than 0.50 38 , 39 .

Composite Reliability (CR) value must be equal to or greater than 0.70 and the square root of the AVE value 38 , 39 .

Cronbach Alpha value must be equal to or greater than 0.70 38 , 39 .

For Discriminant Validity:

Heterotrait-Monotrait Ratio (HTMT) Values have to be 0.90 for the theoretical concepts close to each other and 0.85 for those that are distinct 40 .

Variance Inflation Factor (VIF) value must be below 5 41 .

For model acceptability:

The coefficients of determination (R 2 ), which implies the model's goodness-of-fit for the dependent variable, must be greater than 0.10 39 , 42 .

The Q 2 value (the prediction relevance) has to be greater than zero 43 .

Furthermore, factor loadings have to be equal to or greater than 0.70. and the items with factor loadings below 0.40 have to be excluded from the analysis. Items with factor loadings between 0.40 and 0.70 will be kept in the model if CR and Cronbach Alpha values of the construct are over the threshold 39 .

Background of the study

A close friend of one of the article's authors called in and asked for assistance about quitting his job. Following a discussion on how he felt, he appeared to be perplexed and had difficulty articulating and expressing his emotions. Afterwards, the author interviewed approximately 20 persons with coronavirus history, and observed similar symptoms with majority of them. Especially those experienced the coronavirus severely had difficulty with describing and expressing their feelings. Most of them described the situation they are in as "I feel like I'm being suffocated." Based on their observations, the authors designed this study to investigate the possible effect of coronavirus on alexithymia, entrapment, and depression.

Ethical approval

This study is approved by the Kocaeli University Social and Human Sciences Ethics Committee (protocol number: E-10017888-108.99-62,960).

Human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consents were obtained from all individuals participated in the study.

Results and discussion

After performing Confirmatory Composite Analysis (CCA), the factor loading of item number 11 of the TAS-20 was found to be less than 0.40 and removed from the model. The final run's Cronbach's Alpha, CR, and AVE values (Table 2 ) confirmed that the scales collectively satisfied the internal consistency reliability and convergent validity conditions.

The highest HTMT value was measured as 0.751 < 0.900 between INT and EXT, and VIF as 2.817 < 5.000 between INT and DEPR. Therefore, we concluded that the scales satisfied the discriminant validity condition, and no collinearity was observed between variables.

The coefficients of determination (R 2 ), which imply the model's goodness-of-fit, and Q 2 value (the prediction relevance), were measured and reported in Table 3 .

The results reported in Table 3 show that the Q 2 and R 2 values meet the criteria. Hence, it was concluded that the measurement model was acceptable.

Following the verification of the validity, reliability of the scales, and the measurement model's acceptance, The Partial Least Squares Structural Equation Modeling (PLS-SEM) and path analysis were used to test the structural equation model. In the analyses, using the bootstrapping method, 5,000 sub-samples were taken. The path coefficients (β values) and statistical significance ( p values) of the effects were calculated and reported in Table 4 (only significant effects included in the table, full table provided as supplementary resource). The total effects were also calculated and reported in Table 5 .

As per the results reported in Tables 4 and 5 , Depression (DEPR) was increased mainly by Internal Entrapment (INT), Difficulty Identifying Feelings (DIF), and Quality of Life (QoL), but Difficulty Describing Feelings (DDF) reduced it. INT was mainly affected by DIF, QoL, and FEAR. FEAR was mainly affected by QoL, DIF by QoL, FEAR, and Decease of a Relative or Acquaintance (DEC), respectively, and External Entrapment (EXT) by DIF. Moreover, Quality of Life (QoL) was affected by work location (LOC).

When an individual's perceived quality of life is being affected adversely, it causes an increase in the difficulty of identifying feelings, fear, external and internal entrapment feelings, and ultimately depression. The perceived level of quality of life is affected by work location. The perceived quality of life of the individual working from home is better than those working only from a workplace.

The work location also affects the external entrapment (Table 4 ), which makes us think that the measures taken to prevent the spread of the pandemic cause employees working only from the workplace to feel trapped in a situation they cannot escape. Interestingly enough, the work location did not have a significant effect on employees' fear. Upon not being able to observe any effect of work location on fear, we took a step forward and performed a correlation analysis. Still, we could not determine any correlation (r = − 0.043; p = 0.516). Normally working at the workplace, which requires being among crowds (especially during the rush hour commutes) every day, should have caused employees to develop a certain level of fear of contracting coronavirus and transmitting it to other people, whether they be family members or others. However, the results of our study showed the other way around, i.e., the fear of coronavirus has no relation to the workplace.

The average fear is measured as 4.0153 out of 5 point scale. As per descriptive statistics given in Table 6 , the highest fear employees experienced was causing someone else's death because of transmitting the disease to him or her (M = 4.4153), and the lowest was dying (M = 2.7089).

The mean differences of the following items were statistically significant compared to those with coronavirus history:

Afraid of infecting his/her family members or loved ones (ΔM = 0.30; p = 0.044)

Afraid of causing the death of someone else because of transmitting the disease to him or her (ΔM = 0.51; p = 0.001).

In both items, the average was higher for employees with coronavirus history. Nevertheless, the mean difference of the overall fear was not statistically significant (p = 0.112). The mean differences among work-location groups were not statistically significant either.

Although the work location did not have a statistically significant effect on fear, it had a significant effect on difficulty identifying feelings (β = 0.138; p < 0.01) and on external entrapment feeling (β = -0.137; p < 0.05). Working only from home increases the feeling of external entrapment, which should be quite a normal feeling since working from home may cause employees to develop a sense of isolation and entrapment 44 . The expectation, however, was quite the opposite since during the pandemic, home is generally considered a safe haven, while going out may be perceived as a threat.

Working only from home increases difficulty in identifying feelings. As can be found in the literature, working from home causes employees to develop negative feelings and agoraphobics 44 . The problem with the female employees working only from home reminds the problem described by Freidan[ 45 :11] in her book, The Feminine Mystique :

“American women have luxuries that women in other times and lands never dreamed of; part of the strange newness of the problem is that it cannot be understood in terms of the age-old material problems of man: poverty, sickness, hunger, cold. The women who suffer this problem have a hunger that food cannot fill.”

Female employees working only from home had everything they needed, as American women had, but the problem was feeling trapped in the house. For male workers, it is not exactly the same but similar; as Ahrentzen[ 44 :282] quotes from a homeworker, " It's difficult to detach from things at home. I must get physically away. [Man, Adults Only]. "

Another factor that increases the difficulty of identifying feelings is the loss of someone. Alexithymia is linked to a defensive mechanism that seeks to limit difficult, intense, and negative emotions and avoid terrifying or intolerable feelings 46 . When an employee loses his/her relative or close friend, this defense mechanism may enter the equation to protect the individual from the loss's painful, negative, or powerful feelings. In other words, the death of a loved one may trigger the defense mechanism, which may cause the person to have difficulty identifying feelings.

This study also showed that fear causes difficulty identifying and describing feelings. The isolation and feeling of loneliness experienced in the midst of the pandemic may lead us to recall the basic anxiety, for the conditions we experience during the pandemic resemble, if not identical to, those experienced during the basic anxiety. The basic anxiety is defined by Horney[ 47 :41] as " the feeling a child has of being isolated and helpless in a potentially hostile world. " This basic anxiety may also increase the use of this defense mechanism and fear. Fear, in return, may cause increased difficulty identifying feelings. Furthermore, on top of this pandemic situation that makes people feel entrapped 20 , the fear of infecting their families and others may cause the employees to develop anxiety, worry, helplessness, and uncertainty 48 . This fear may cause an increase in internal and external entrapment feelings, which is another finding of this study.

We also found that difficulty identifying and describing feelings, two dimensions of alexithymia that are closely associated with depression and anxiety 15 , 16 , 17 , 18 , also affect internal and external entrapment feelings. Furthermore, we believe this study also contributes to understanding the effect of alexithymia on depression. One possible mechanism is that difficulty identifying feelings increases internal entrapment, which in return causes an increase in depression. Although the literature is full of studies showing the relation of alexithymia with anxiety and depression, no study that links it to the feeling of entrapment exists. Therefore, the explanation that we have come up with maybe erroneous or have inadequacies. Being unable to identify feelings may cause employees to feel trapped inside because they could be capable of finding a solution or a way out if they were able to identify what they feel. That is why the difficulty identifying feelings has the highest effect (β = 0.582; p < 0.01) on inner entrapment feelings. This feeling of internal entrapment causes depression since it was found to be a significant predictor of depression (β = 0.614; p < 0.01). In their study carried out on 145 undergraduate students, Motan and Gençöz 49 came up with similar findings, concluding that internal entrapment is a significant predictor of depression and anxiety. The reducing effect of difficulty describing feelings on depression, on the other hand, is a subject that needs to be clarified.

As per the results given in Table 7 , no statistically significant differences were found between employees with and without coronavirus history. Furthermore, the mean depression score of employees with coronavirus history (M = 10.2444) is lower than the others (M = 11.5392), while this difference is not statistically significant (p = 0.326).

The mean depression score of employees working only from home (M = 14.0000) is higher than those working from both home and workplace (M = 9.3409) and only from the workplace (M = 10.6538) and this difference is statistically significant (F(2,234) = 3.421; p = 0.034). The depression score of employees working only from home shows that those employees suffer from mild depression symptoms.

The mean depression score of employees below the age of 21 (M = 26.5000) statistically (F(8,228) = 3.388; p = 0.01) differs from employees between the age of 31–35 (M = 8.9643), 41–45 (M = 7.8077), 46–50 (M = 8.8974), and 56-and above (M = 6.6190). Furthermore, personnel under the age of 21 exhibit moderate depression (M = 26.5000) symptoms, while those between the ages of 21 and 25 exhibit mild depression (M = 14.7778) symptoms.

The mean depression score of females (M = 12.6250) is higher than that of males (M = 8.3465), and this difference is statistically significant (p = 0.01). The mean depression score differences of employees whose quality of life was affected at moderate or very high levels were statistically significant (F(3,233 = 7.529; p = 0.000). Moreover, the depression score of employees whose quality of life was affected at a very high level (M = 17.0000) reveals that those employees are showing mild depression symptoms. The depression score of employees whose quality of life was affected at a moderate level (M = 13.2353) is at the edge of mild depression.

Multi-group analysis (MGA)

MGA was also performed to determine if the path model has statistically significant differences across demographic groups. The multi-group analysis allows researchers to reveal any significant differences in group-specific parameter estimates between pre-defined data groups (e.g., outer weights, outer loadings, and path coefficients). As suggested by Henseler et al. 50 , group comparisons using structural equation modeling (SEM) without establishing the invariance of composite models can be misleading 50 . Therefore, before conducting MGA, Measurement Invariance of Composite Models (MICOM) was assessed with its procedure in three distinct steps. The MGA may be performed on variables that have two groups. In our study, it may be performed only for gender and COVID-History variables.

The MICOM process was performed with SmartPLS 3.2 statistical software with 5,000 permutations, a two-tailed test type at 0.05 significance level, 1,000 maximum iterations, and a 10 –7 stop criterion. When running MICOM in SmartPLS, Step 1 of the procedure suggested by Hanseler et al. 50 is automatically confirmed 52 , 53 , 54 . Step 2 and Step 3 of MICOM were performed by a permutation test.

As per the results, full measurement invariance was found to exist in overall composites for both variables. The MGA is performed for both variables, and its results are reported in Table 8 .

According to Table 8 , the effect of the quality of life on depression, external entrapment, and difficulty identifying feelings was higher for employees with COVID-19 history. Fear had a more significant impact on internal and external entrapments in those not infected with the coronavirus. On the other hand, the effect of difficulty describing feelings on depression was higher for employees with a coronavirus history. These results suggest that the employees who have been infected with coronavirus feel less fear than those uninfected since they have experienced the coronavirus. This experience may have reduced the fear and entrapment caused by fear. However, the difficulty describing employees' feelings with coronavirus history was higher than in others. This finding is also supported by the findings of Ayaz and Dincer 55 .

Limitations

The findings of this study should be interpreted in light of its limitations. Because all of the data in this study came from the same source, it is susceptible to common method variance error. The Harman single-factor test 56 was performed to determine the magnitude of this error. The test result was 0.34973 (which is less than 0.50), which makes us conclude that the inaccuracy is acceptable. Another disadvantage of the study is that the interpretations and inferences may not be as precise or exact as intended because no comparable study has been detected in the literature.

This study also explored the history of infected and uninfected people, not the severity of their clinical course. Therefore, the results need to be interpreted accordingly.

Another limitation of this study has not differentiated participants based on their work area. Since not all workers were exposed to the same stress levels, the results may not be generalized for all sectors and should be interpreted cautiously.

This study is not longitudinal, but a cross-sectional study and the authors do not have pre-pandemic data of the participants. Therefore, the inferences related to alexithymia and its impact on the appearance of affective symptoms during the pandemic could result from previous personality traits or underlying mental disorders. Hence, the results should be interpreted accordingly.

Other drawbacks include using a convenience sampling strategy, relying only on self-reported measuring instruments, and carrying out the measurement only once. It may raise concerns about the findings' generalizability, selection bias, and causality inference difficulties.

Another drawback stems from the study's design. The data was acquired from the participants at a single point in time, and the researchers did not follow up with them over time. As a result, the findings should be carefully interpreted and validated through longitudinal research.

Implications for Practice

The dramatic spread of COVID-19 has disrupted lives, communities, and businesses alike. In their efforts to adapt themselves to the new challenges posed by the pandemic and mitigate the COVID- 19 impact, businesses were forced to find ways to help their employees stay in the work process as much as possible. Designing the workflow for employees in a way to enable them to work from home was one of the approaches by which many businesses responded to the coronavirus crisis. However, as revealed by this study, this approach or solution harbors an unforeseen and unrecognized consequence; it may cause employees to develop mental health problems.

As the study suggests, young employees and women who work solely at home are the two groups that suffer from mental health problems more than others. Proper conditions created in a workplace deeply motivate and engage employees and impact their mood, drive, and mental health. On the other hand, the home lacks such favorable features facilitating professional working and thus brings its own set of challenges that can negatively impact the mood when used as a workplace. Furthermore, working from home may cause the line between work and private life to get blurred. Expectations of other family members while working at home may leave female employees frustrated or feelings of unease, particularly at times when they fail to respond with the required reflex. Interruption of work with a ring at the door (to receive cargo, essential daily needs of the home such as drinking water etc.), technical problems (internet connection, computer problems that need the support of an IT person), personal calls, dropping by visitors/relatives sometimes extending their visit overnight and other unanticipated home situations also put a strain on the minds of employees and contribute to the undesirable atmosphere home offers for working.

As with the case of young employees (especially those under 21), the possibility of living with parents, and thus most probably, being unable to live in a home with physical conditions addressing to personal preferences and comfort, may cause distress while working from home. The presence of younger siblings who disrupt the working atmosphere with their nuisance or wishes, non-availability of a proper working space not accommodating the comfort office furniture provides, etc., may make young employees one of the groups suffering from mental issues more than others. Meanwhile, some young employees may also feel frustrated from being unable to express their inconvenient conditions at home to their employers. Being overwhelmed with the fear of the pandemic and thus feeling the urge to work at home, they may continue to work at home and feel its psychological pressure against all odds.

When these home-related inconveniences are kept in mind, businesses need to address all these mostly unrecognized issues to provide a favorable working atmosphere for their employees working only from home. Supporting the employees, whether by financial means or others deemed necessary, to improve their physical conditions at home will relieve them and make them feel less depressed, ultimately making them experience fewer mental issues.

Meanwhile, if possible, offering hybrid working conditions (working both from home and the workplace) or reducing the workload (including work hours) of those working only from home should be considered and assessed.

As well to young employees and female employees, employees with coronavirus history also seem to have higher mental health problems. The mental issues of the employees in these categories should be addressed by special care or particular policies.

On the other hand, working with psychologists or encouraging employees to visit psychologists, especially during the COVID-19 pandemic, maybe another solution for organizations. Finally, for those who experience mental health problems during the pandemic, organizations should be more flexible with their employees and amend their policies and key performance indicators accordingly.

The aim of this study was to investigate the effects of fear on identifying and describing feelings dimensions of alexithymia and dimensions of entrapment on the depression level of employees during the COVID-19 pandemic. The results show that internal entrapment and difficulty identifying feelings are the significant predictors of depression, whereas the difficulty identifying feelings is the significant predictor of internal and external entrapment feelings. Fear was the significant predictor of internal entrapment, difficulty identifying feelings, and depression. On the other hand, quality of life is a significant predictor of difficulties identifying and describing feelings, depression, external and internal entrapment, and fear.

The results also show that difficulty identifying feelings manifests its effect on depression mainly through internal entrapment.

This study also revealed that the depression level of the employees working only from home is higher than other employees. Moreover, the depression level of women, young employees, and those whose life quality was adversely affected by the coronavirus is higher than the rest.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Rodoplu Şahin, D., Aslan, M., Demirkaya, H. et al. The effect of COVID-19 on employees' mental health. Sci Rep 12 , 15067 (2022). https://doi.org/10.1038/s41598-022-18692-w

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Implications of cash transfer programs for mental health promotion among families facing significant stressors: using ecological systems theory to explain successes of conditional and unconditional programs.

1. Introduction

2. implications of cash transfer programs for mental health, 2.1. conditional cash transfer programs, 2.2. unconditional cash transfer programs, 3. applying ecological systems theory to child development and family well-being: implications for cash transfer programs, 3.1. individual level, 3.2. microsystem, 3.3. exosystem and macrosystem, 4. a need to address stigma and consider structural factors, 5. overview and summary, 6. a call for transnational research to explore connections between cash transfer programs and mental health outcomes among families, 6.1. research agenda, 6.1.1. line of inquiry, 6.1.2. multi-country study, 6.2. policy agenda, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Lesser, T.L.; Matalon, M.; Clauss-Ehlers, C.S. Implications of Cash Transfer Programs for Mental Health Promotion among Families Facing Significant Stressors: Using Ecological Systems Theory to Explain Successes of Conditional and Unconditional Programs. Behav. Sci. 2024 , 14 , 770. https://doi.org/10.3390/bs14090770

Lesser TL, Matalon M, Clauss-Ehlers CS. Implications of Cash Transfer Programs for Mental Health Promotion among Families Facing Significant Stressors: Using Ecological Systems Theory to Explain Successes of Conditional and Unconditional Programs. Behavioral Sciences . 2024; 14(9):770. https://doi.org/10.3390/bs14090770

Lesser, Tali L., Maya Matalon, and Caroline S. Clauss-Ehlers. 2024. "Implications of Cash Transfer Programs for Mental Health Promotion among Families Facing Significant Stressors: Using Ecological Systems Theory to Explain Successes of Conditional and Unconditional Programs" Behavioral Sciences 14, no. 9: 770. https://doi.org/10.3390/bs14090770

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COMMENTS

How COVID-19 shaped mental health: from infection to pandemic effects
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 4-6.For most common mental disorders (including major depressive disorder, anxiety disorders and alcohol use disorder), environmental stressors play a major etiological role.
How COVID-19 shaped mental health: from infection to pandemic effects
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 ...
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The COVID-19 pandemic represents an unprecedented threat to mental health in high, middle, and low-income countries. In addition to flattening the curve of viral transmission, priority needs to be given to the prevention of mental disorders (e.g. major depressive disorder, PTSD, as well as suicide).
COVID-19 and mental health consequences: moving forward
The COVID-19 pandemic highlighted stark disparities in mental health along degrees of social determinants of health (income, employment, and housing) that affect access to care. The study findings can guide responses to future pandemics with regard to the crucial need to consider mental health-related responses in addition to medical ones.
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The COVID-19 pandemic has profoundly influenced the world. In wave after wave, many countries suffered from the pandemic, which caused social instability, hindered global growth, and harmed mental health. Although research has been published on various mental health issues during the pandemic, some profound effects on mental health are ...
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COVID‐19 can also result in increased stress, anxiety, and depression among elderly people already dealing with mental health issues. Family members may witness any of the following changes to the behavior of older relatives ; Irritating and shouting behavior. Change in their sleeping and eating habits.
PDF Mental Health and COVID-19: Early evidence of the pandemic's impact
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The COVID-19 pandemic has had a severe impact on the mental health and wellbeing of people around the world while also raising concerns of increased suicidal behaviour. In addition access to mental health services has been severely impeded. However, no comprehensive summary of the current data on these impacts has until now been made widely ...
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The Lancet Psychiatry. Download PDF. While the effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the nervous system remain unclear, there is no doubt that the COVID-19 pandemic is bad for mental health. To alleviate the impact of both the virus and the measures taken to control its spread, we need high quality ...
Lifestyle and mental health disruptions during COVID-19
A mental health crisis has emerged during the COVID-19 pandemic. The US Centers for Disease Control and Prevention (CDC) estimates that as of June 2020 nearly one-third of US adults were suffering from anxiety or depression ().The rates are almost two times higher for young adults, a population that has already seen a significant increase in the prevalence of mental health disorders over the ...
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Prior research showed significant mental health degradation associated with the COVID-19 pandemic 6,7,18,19, however, no research investigated the causal relation between COVID-19 mitigation ...
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View PDF; Download full issue; Search ScienceDirect. Current Research in Behavioral Sciences. Volume 2, November 2021, 100037. Impact of COVID-19 on mental health: A quantitative analysis of anxiety and depression based on regular life and internet use. ... The dataset related to this research paper is available via the GitHub repository https: ...
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The mental health impact of the COVID-19 pandemic on ...
The impact of the COVID-19 pandemic on mental health in people with pre-existing mental health disorders is unclear. In three psychiatry case-control cohorts, we compared the perceived mental health impact and coping and changes in depressive symptoms, anxiety, worry, and loneliness before and during the COVID-19 pandemic between people with and without lifetime depressive, anxiety, or ...
A rapid review of the impact of COVID-19 on the mental health of
Health and social care workers (HSCWs) continue to play a vital role in our response to the COVID-19 pandemic. It is known that HSCWs exhibit high rates of pre-existing mental health (MH) disorders [1,2,3] which can negatively impact on the quality of patient care [].Studies from previous infectious outbreaks [5, 6] suggest that this group may be at risk of experiencing worsening MH during an ...
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The COVID-19 pandemic is a major health crisis that has changed the life of millions globally. The purpose of this study was to assess the effect of the pandemic on mental health and quality of life among the general population in the Middle East and North Africa (MENA) region. A total of 6142 adults from eighteen countries within the MENA region completed an online questionnaire between May ...
The impact of the COVID-19 pandemic on adolescent mental health: a
Table 5 shows the main results for phase (i.e. the impact of exposure to the COVID-19 pandemic) from models predicting the 1-year follow-up primary and secondary mental health outcomes while controlling for centred baseline mental health scores and the full set of individual and school-level covariates in the study. The full models, including ...
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In short, COVID-19 has had an impact on all aspects of our lives, from financial to social interactions, family to business relations, and physical to mental health, especially healthcare workers ...
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Bereavement, isolation, loss of income and fear triggering. mental health conditions or exacerbating existing ones. Pre-existing MNS disorders increase the risk of death, severe illness or long-term complications. COVID-19 itself is associated with neurological and mental. complications. Increased demand for MNS services, with community-.
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Introduction. The COVID-19 pandemic, which emerged out of Wuhan China at the end of 2019 (Spiteri et al., Citation 2020) had a profound impact on the world, triggering the largest global economic crisis in more than a century (Wade, Citation 2023).It saw health services throughout the world being overwhelmed, resulting in an estimated 18 million deaths by the end of 2021 (OECD, Citation 2023 ...
Implications of Cash Transfer Programs for Mental Health Promotion
The purpose of this paper is to apply Bronfenbrenner's ecological systems theory to explore the literature on how Conditional Cash Transfer (CCT) and Unconditional Cash Transfer (UCT) programs might support positive mental health outcomes. The paper begins with transnational considerations of stress, such as poverty and COVID-19, and their impact on mental health. Bronfenbrenner's theory ...
Full article: A reflexive autoethnography of supervisory psychosocial
Mental health as the basis. Mental health serves as the foundation for achieving comprehensive well-being. The World Health Organization (WHO, Citation 2020) defines mental health as a condition of well-being where a person recognises their own capabilities, manages everyday life stresses, functions effectively and constructively in work (studies), and contributes positively to their community.

The coronavirus ( COVID ‐19) pandemic's impact on mental health

Abdullah Sarwer

Erik B. Soto

Zia‐ur‐Rehman Mashwani

1. INTRODUCTION

2. CHILDREN AND TEENS AT RISK

3. ELDERS AND PEOPLE WITH DISABILITIES AT RISK

4. HEALTH WORKERS AT RISK

5. STIGMATIZATION

6. TAKE HOME MESSAGE

CONFLICT OF INTEREST

AUTHOR CONTRIBUTIONS

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Effects of the COVID-19 pandemic on mental health, anxiety, and depression

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A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being

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Data synthesis and analysis

Patient and public involvement

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Study characteristics

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Psychological toll on healthcare workers

Risk factors associated with adverse mental health outcomes

Occupational factors

Healthcare groups

Frontline staff/direct contact with COVID-19

Personal protective equipment (PPE)

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Psychosocial factors

Concern about family

Sociodemographic factors

Underlying illness

Being an only child

Environmental factors

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Adequate PPE

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