essay on mental health during covid 19

• COVID-19 and your mental health

Worries and anxiety about COVID-19 can be overwhelming. Learn ways to cope as COVID-19 spreads.

At the start of the COVID-19 pandemic, life for many people changed very quickly. Worry and concern were natural partners of all that change — getting used to new routines, loneliness and financial pressure, among other issues. Information overload, rumor and misinformation didn't help.

Worldwide surveys done in 2020 and 2021 found higher than typical levels of stress, insomnia, anxiety and depression. By 2022, levels had lowered but were still higher than before 2020.

Though feelings of distress about COVID-19 may come and go, they are still an issue for many people. You aren't alone if you feel distress due to COVID-19. And you're not alone if you've coped with the stress in less than healthy ways, such as substance use.

But healthier self-care choices can help you cope with COVID-19 or any other challenge you may face.

And knowing when to get help can be the most essential self-care action of all.

Recognize what's typical and what's not

Stress and worry are common during a crisis. But something like the COVID-19 pandemic can push people beyond their ability to cope.

In surveys, the most common symptoms reported were trouble sleeping and feeling anxiety or nervous. The number of people noting those symptoms went up and down in surveys given over time. Depression and loneliness were less common than nervousness or sleep problems, but more consistent across surveys given over time. Among adults, use of drugs, alcohol and other intoxicating substances has increased over time as well.

The first step is to notice how often you feel helpless, sad, angry, irritable, hopeless, anxious or afraid. Some people may feel numb.

Keep track of how often you have trouble focusing on daily tasks or doing routine chores. Are there things that you used to enjoy doing that you stopped doing because of how you feel? Note any big changes in appetite, any substance use, body aches and pains, and problems with sleep.

These feelings may come and go over time. But if these feelings don't go away or make it hard to do your daily tasks, it's time to ask for help.

Get help when you need it

If you're feeling suicidal or thinking of hurting yourself, seek help.

• Contact your healthcare professional or a mental health professional.
• Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential.

If you are worried about yourself or someone else, contact your healthcare professional or mental health professional. Some may be able to see you in person or talk over the phone or online.

You also can reach out to a friend or loved one. Someone in your faith community also could help.

And you may be able to get counseling or a mental health appointment through an employer's employee assistance program.

Another option is information and treatment options from groups such as:

• National Alliance on Mental Illness (NAMI).
• Substance Abuse and Mental Health Services Administration (SAMHSA).
• Anxiety and Depression Association of America.

Self-care tips

Some people may use unhealthy ways to cope with anxiety around COVID-19. These unhealthy choices may include things such as misuse of medicines or legal drugs and use of illegal drugs. Unhealthy coping choices also can be things such as sleeping too much or too little, or overeating. It also can include avoiding other people and focusing on only one soothing thing, such as work, television or gaming.

Unhealthy coping methods can worsen mental and physical health. And that is particularly true if you're trying to manage or recover from COVID-19.

Self-care actions can help you restore a healthy balance in your life. They can lessen everyday stress or significant anxiety linked to events such as the COVID-19 pandemic. Self-care actions give your body and mind a chance to heal from the problems long-term stress can cause.

Take care of your body

Healthy self-care tips start with the basics. Give your body what it needs and avoid what it doesn't need. Some tips are:

• Get the right amount of sleep for you. A regular sleep schedule, when you go to bed and get up at similar times each day, can help avoid sleep problems.
• Move your body. Regular physical activity and exercise can help reduce anxiety and improve mood. Any activity you can do regularly is a good choice. That may be a scheduled workout, a walk or even dancing to your favorite music.
• Choose healthy food and drinks. Foods that are high in nutrients, such as protein, vitamins and minerals are healthy choices. Avoid food or drink with added sugar, fat or salt.
• Avoid tobacco, alcohol and drugs. If you smoke tobacco or if you vape, you're already at higher risk of lung disease. Because COVID-19 affects the lungs, your risk increases even more. Using alcohol to manage how you feel can make matters worse and reduce your coping skills. Avoid taking illegal drugs or misusing prescriptions to manage your feelings.

Take care of your mind

Healthy coping actions for your brain start with deciding how much news and social media is right for you. Staying informed, especially during a pandemic, helps you make the best choices but do it carefully.

Set aside a specific amount of time to find information in the news or on social media, stay limited to that time, and choose reliable sources. For example, give yourself up to 20 or 30 minutes a day of news and social media. That amount keeps people informed but not overwhelmed.

For COVID-19, consider reliable health sources. Examples are the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).

Other healthy self-care tips are:

• Relax and recharge. Many people benefit from relaxation exercises such as mindfulness, deep breathing, meditation and yoga. Find an activity that helps you relax and try to do it every day at least for a short time. Fitting time in for hobbies or activities you enjoy can help manage feelings of stress too.
• Stick to your health routine. If you see a healthcare professional for mental health services, keep up with your appointments. And stay up to date with all your wellness tests and screenings.
• Stay in touch and connect with others. Family, friends and your community are part of a healthy mental outlook. Together, you form a healthy support network for concerns or challenges. Social interactions, over time, are linked to a healthier and longer life.

Avoid stigma and discrimination

Stigma can make people feel isolated and even abandoned. They may feel sad, hurt and angry when people in their community avoid them for fear of getting COVID-19. People who have experienced stigma related to COVID-19 include people of Asian descent, health care workers and people with COVID-19.

Treating people differently because of their medical condition, called medical discrimination, isn't new to the COVID-19 pandemic. Stigma has long been a problem for people with various conditions such as Hansen's disease (leprosy), HIV, diabetes and many mental illnesses.

People who experience stigma may be left out or shunned, treated differently, or denied job and school options. They also may be targets of verbal, emotional and physical abuse.

Communication can help end stigma or discrimination. You can address stigma when you:

• Get to know people as more than just an illness. Using respectful language can go a long way toward making people comfortable talking about a health issue.
• Get the facts about COVID-19 or other medical issues from reputable sources such as the CDC and WHO.
• Speak up if you hear or see myths about an illness or people with an illness.

COVID-19 and health

The virus that causes COVID-19 is still a concern for many people. By recognizing when to get help and taking time for your health, life challenges such as COVID-19 can be managed.

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• Mental health during the COVID-19 pandemic. National Institutes of Health. https://covid19.nih.gov/covid-19-topics/mental-health. Accessed March 12, 2024.
• Mental Health and COVID-19: Early evidence of the pandemic's impact: Scientific brief, 2 March 2022. World Health Organization. https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1. Accessed March 12, 2024.
• Mental health and the pandemic: What U.S. surveys have found. Pew Research Center. https://www.pewresearch.org/short-reads/2023/03/02/mental-health-and-the-pandemic-what-u-s-surveys-have-found/. Accessed March 12, 2024.
• Taking care of your emotional health. Centers for Disease Control and Prevention. https://emergency.cdc.gov/coping/selfcare.asp. Accessed March 12, 2024.
• #HealthyAtHome—Mental health. World Health Organization. www.who.int/campaigns/connecting-the-world-to-combat-coronavirus/healthyathome/healthyathome---mental-health. Accessed March 12, 2024.
• Coping with stress. Centers for Disease Control and Prevention. www.cdc.gov/mentalhealth/stress-coping/cope-with-stress/. Accessed March 12, 2024.
• Manage stress. U.S. Department of Health and Human Services. https://health.gov/myhealthfinder/topics/health-conditions/heart-health/manage-stress. Accessed March 20, 2020.
• COVID-19 and substance abuse. National Institute on Drug Abuse. https://nida.nih.gov/research-topics/covid-19-substance-use#health-outcomes. Accessed March 12, 2024.
• COVID-19 resource and information guide. National Alliance on Mental Illness. https://www.nami.org/Support-Education/NAMI-HelpLine/COVID-19-Information-and-Resources/COVID-19-Resource-and-Information-Guide. Accessed March 15, 2024.
• Negative coping and PTSD. U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/gethelp/negative_coping.asp. Accessed March 15, 2024.
• Health effects of cigarette smoking. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm#respiratory. Accessed March 15, 2024.
• People with certain medical conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html. Accessed March 15, 2024.
• Your healthiest self: Emotional wellness toolkit. National Institutes of Health. https://www.nih.gov/health-information/emotional-wellness-toolkit. Accessed March 15, 2024.
• World leprosy day: Bust the myths, learn the facts. Centers for Disease Control and Prevention. https://www.cdc.gov/leprosy/world-leprosy-day/. Accessed March 15, 2024.
• HIV stigma and discrimination. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/basics/hiv-stigma/. Accessed March 15, 2024.
• Diabetes stigma: Learn about it, recognize it, reduce it. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/library/features/diabetes_stigma.html. Accessed March 15, 2024.
• Phelan SM, et al. Patient and health care professional perspectives on stigma in integrated behavioral health: Barriers and recommendations. Annals of Family Medicine. 2023; doi:10.1370/afm.2924.
• Stigma reduction. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/od2a/case-studies/stigma-reduction.html. Accessed March 15, 2024.
• Nyblade L, et al. Stigma in health facilities: Why it matters and how we can change it. BMC Medicine. 2019; doi:10.1186/s12916-019-1256-2.
• Combating bias and stigma related to COVID-19. American Psychological Association. https://www.apa.org/topics/covid-19-bias. Accessed March 15, 2024.
• Yashadhana A, et al. Pandemic-related racial discrimination and its health impact among non-Indigenous racially minoritized peoples in high-income contexts: A systematic review. Health Promotion International. 2021; doi:10.1093/heapro/daab144.
• Sawchuk CN (expert opinion). Mayo Clinic. March 25, 2024.

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COVID-19 and Mental Health

What is covid-19.

COVID-19 is a disease caused by a virus named SARS-CoV-2. COVID-19 most often affects the lungs and respiratory system, but it can also affect other parts of the body. Some people develop post-COVID conditions, also called  Long COVID  . These symptoms can include neurological symptoms such as difficulty thinking or concentrating, sleep problems, and depression or anxiety.

Why is NIMH studying COVID-19 and mental health?

Both SARS-CoV-2 and the COVID-19 pandemic have significantly affected the mental health of adults and children. Many people experienced symptoms of  anxiety ,  depression , and substance use disorder during the pandemic. Data also suggest that people are more likely to develop mental illnesses or disorders in the months following COVID-19 infection. People with Long COVID may experience many symptoms related to brain function and mental health  .

While the COVID-19 pandemic has had widespread mental health impacts, some people are more likely to be affected than others. This includes people from racial and ethnic minority groups, mothers and pregnant people, people with financial and housing insecurity, children, people with disabilities, people with preexisting mental illnesses or substance use problems, and health care workers. 

How is NIMH research addressing this critical topic?

NIMH is supporting research to understand and address the impacts of the pandemic on mental health. This includes research to understand how COVID-19 affects people with existing mental illnesses across their entire lifespan. NIMH also supports research to help meet people’s mental health needs during the pandemic and beyond. This includes research focused on making mental health services more accessible through telehealth, digital tools, and community-based interventions.

NIMH is also working to understand the unique impacts of the pandemic on specific groups of people, including people in underserved communities and children. For example, NIMH supports research investigating how pandemic-related factors, such as school disruptions, may influence children’s brain, cognitive, social, and emotional development.

Where can I learn more about COVID-19 and mental health?

• NIMH video: Mental Illnesses and COVID-19 Risks
• NIMH Director’s Messages about COVID-19
• NIMH events about COVID-19
• NIMH news about COVID-19

Where can I learn more about Long COVID and COVID-19?

• NIH page on Long COVID 
• NIH RECOVER Initiative 
• CDC COVID-19 resources 

How can I find help for mental health concerns?

If you have concerns about your mental health, talk to a primary care provider. They can refer you to a qualified mental health professional, such as a psychologist, psychiatrist, or clinical social worker, who can help you figure out the next steps. Find tips for talking with a health care provider about your mental health.

You can learn more about getting help on the NIMH website. You can also learn about finding support  and locating mental health services  in your area on the Substance Abuse and Mental Health Services Administration (SAMHSA) website.

Last Reviewed:  May 2024

Unless otherwise specified, the information on our website and in our publications is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

• 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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We would like to provide our appreciation and thanks to all the respondents in this study.

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Ida Kupcova, Lubos Danisovic & Stefan Harsanyi

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IK and SH have produced the study design. All authors contributed to the manuscript writing, revising, and editing. LD and MK have done data management and extraction, SH did the data analysis. Drafting and interpretation of the manuscript were made by all authors. All authors read and approved the final manuscript.

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• Published: 09 July 2021

Public mental health problems during COVID-19 pandemic: a large-scale meta-analysis of the evidence

• Xuerong Liu   ORCID: orcid.org/0000-0002-9236-5773 1 ,
• Mengyin Zhu   ORCID: orcid.org/0000-0001-5561-9570 1 ,
• Rong Zhang   ORCID: orcid.org/0000-0003-4516-4116 2 ,
• Jingxuan Zhang   ORCID: orcid.org/0000-0002-8979-5107 1 ,
• Chenyan Zhang   ORCID: orcid.org/0000-0002-2945-6584 3 ,
• Peiwei Liu   ORCID: orcid.org/0000-0003-2660-1106 4 ,
• Zhengzhi Feng   ORCID: orcid.org/0000-0001-6144-5044 1 &
• Zhiyi Chen   ORCID: orcid.org/0000-0003-1744-4647 1 , 2  

Translational Psychiatry volume  11 , Article number:  384 ( 2021 ) Cite this article

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The coronavirus disease 2019 (COVID-19) pandemic has exposed humans to the highest physical and mental risks. Thus, it is becoming a priority to probe the mental health problems experienced during the pandemic in different populations. We performed a meta-analysis to clarify the prevalence of postpandemic mental health problems. Seventy-one published papers ( n  = 146,139) from China, the United States, Japan, India, and Turkey were eligible to be included in the data pool. These papers reported results for Chinese, Japanese, Italian, American, Turkish, Indian, Spanish, Greek, and Singaporean populations. The results demonstrated a total prevalence of anxiety symptoms of 32.60% (95% confidence interval (CI): 29.10–36.30) during the COVID-19 pandemic. For depression, a prevalence of 27.60% (95% CI: 24.00–31.60) was found. Further, insomnia was found to have a prevalence of 30.30% (95% CI: 24.60–36.60). Of the total study population, 16.70% (95% CI: 8.90–29.20) experienced post-traumatic stress disorder (PTSD) symptoms during the COVID-19 pandemic. Subgroup analysis revealed the highest prevalence of anxiety (63.90%) and depression (55.40%) in confirmed and suspected patients compared with other cohorts. Notably, the prevalence of each symptom in other countries was higher than that in China. Finally, the prevalence of each mental problem differed depending on the measurement tools used. In conclusion, this study revealed the prevalence of mental problems during the COVID-19 pandemic by using a fairly large-scale sample and further clarified that the heterogeneous results for these mental health problems may be due to the nonstandardized use of psychometric tools.

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Introduction.

Since the end of 2019, the coronavirus disease 2019 (COVID-19) outbreak has continued to spread worldwide. Researchers rapidly identified the cause of COVID-19 to be the transmission of serious acute respiratory syndrome by a novel coronavirus (SARS-CoV-2) [ 1 ]. Unfortunately, due to the lack of effective cures and vaccines, the ability of public medical systems to guard against COVID-19 is deteriorating rapidly. Although approved vaccines are now available, their safety is still a concern [ 2 , 3 ]. Further, because of reports regarding the potential to be reinfected with COVID-19, public panic is still spreading even though COVID-19 transmission has been contained substantially [ 4 ]. To date, projections regarding the end of the COVID-19 pandemic around the world are still far from optimistic. There were more than 158.95 million confirmed cases and 3.30 million deaths by May 11, 2021 (supported by Johns Hopkins University), a situation that has led to unprecedented losses and stress.

COVID-19 not only threatens physical health but has also led to mental health sequelae (i.e., loss of family, job loss, social constraints and uncertainty, and fear about the future) [ 5 , 6 , 7 ]. In general, mental health problems, including depression and anxiety, have had major negative impacts on the public during the COVID-19 pandemic [ 8 , 9 ]. Previous studies showed that mental health problems, such as depression, anxiety, insomnia, and post-traumatic stress disorder (PTSD), suddenly increased after the COVID-19 outbreak: 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% of participants reported moderate to severe depressive symptoms; 28.8% of participants reported moderate to severe anxiety symptoms; and 24.5% of participants showed psychological stress [ 10 ]. Moreover, such mental health problems were worse in confirmed patients and healthcare workers. As a typical example, one early study revealed acute anxiety symptoms in 98.84% of confirmed patients and depression symptoms in 79.07% of confirmed cases [ 11 ]. In addition, an early investigation concerning the mental health status of 400 public health workers found that 31% of public health workers had anxiety symptoms, and 24.5% of them had depressive symptoms [ 12 ]. In this vein, it seems that the mental health sequelae of the COVID-19 pandemic warrant more attention. In addition, with the development of the epidemic situation, long-term isolation due to the increasing number of confirmed and suspected patients has caused losses to life and property, which has not only caused considerable psychological stress in the population but has also had physiological effects, such as insomnia and PTSD.

In brief, the COVID-19 pandemic has exposed public health to dramatic risks and resulted in unacceptable mental and physiological stresses. Despite considerable research, two critical concerns regarding mental health problems during the COVID-19 pandemic remain. One concern in previous studies is that the conclusions regarding the prevalence of these mental health problems are highly heterogeneous, irrespective of whether they are derived from original investigations or meta-analyses [ 13 , 14 ]. Another is that early investigations were almost all done during the peak of the COVID-19 pandemic and thus may overestimate the scale of mental health problems. Thus, the main purpose of this study is to provide comprehensive statistical results regarding the impact of COVID-19 on individual mental health through a large-scale meta-analysis of the existing research in this field and to provide an evidence-based reference for the prevention and control of psychological crises during this pandemic. It is noteworthy that this study employs a larger data pool than any of the existing meta-analyses to date. Further, much effort has been made to perform an in-depth investigation of the patterns of mental health problems triggered by the COVID-19 pandemic, including population-, region-, and measurement-specific patterns.

Materials and methods

To improve reproducibility and standardization, all the pipelines and protocols were in line with the Cochrane Handbook and were double-checked by using the PRISMA checklist [ 15 ]. This meta-analysis has been preregistered on OSF for open access ( https://doi.org/10.17605/OSF.IO/A5VMK ).

Search strategy and selection criteria

A systematic search was conducted for studies published from January 1, 2020 to July 1, 2020 (the period from the commencement of the outbreak to its initial control in China) in PubMed, EMBASE, the Cochrane Library, EBSCO, Web of Science, CNKI (Chinese database), WANGFANG DATA, the Chinese Biomedical Literature Service System, and public information release platforms (WeChat Subscription or microblogs). According to the indices of the various databases, keywords, including “2019 novel coronavirus,” “COVID-19,” “novel coronavirus pneumonia,” “NPC,” “2019-nCoV,” “mental health,” “anxiety,” “depression,” “psychological health,” “sleep,” “insomnia,” “Posttraumatic stress disorder,” and “PTSD,” were adopted to retrieve published surveys of psychological status during the COVID-19 epidemic from January 1, 2020 to July 1, 2020. In addition to identifying any target studies that may have been missed, we checked the reference list of each selected paper. The population was divided into three categories according to the probable psychological stress intensity experienced: public health workers, confirmed patients, and the general population (see Fig. 1 , Supplemental information, and Table S1 ).

This flowchart is coincide with the broad-certified 2020 PRISMAstatement. Small sample size was predefined as < 30 participants.

Data extraction and quality assessment

The following data were extracted from each article by two researchers independently: study type; total number of participants; participation rate; region; percentage of physicians, nurses, and other healthcare workers screened in the survey; number of male and female participants; assessment methods used and their cutoffs; and the total number and percentage of participants who screened positive for depression, anxiety, insomnia or PTSD. If any of this information was not reported, the necessary calculations (e.g., transforming the percentage of healthcare workers to the number of healthcare workers) were performed. The accuracy of the extracted or calculated data was confirmed by comparing the collection forms of the two investigators.

In addition, two authors independently evaluated the risk of bias of the included cross-sectional studies using a modified form of the Newcastle-Ottawa scale. Potential disagreements were resolved by a third author. Specifically, the quality assessment criteria were as follows: sample representativeness and size; comparability between respondents and nonrespondents; ascertainment of depression, anxiety, and insomnia; and adequacy of the descriptive statistics. The total quality scores ranged between 0 and 5; studies scoring ≥3 points were regarded as having a low risk of bias, while studies scoring <3 points were regarded as having a high risk of bias (see Table S1 ).

Encoding and statistical analysis

The two investigators (XL and MZ), who performed the literature search, also extracted the data from the included studies independently. Disagreements were resolved with the third investigator (ZC) or by consensus. Then, the following variables were extracted: author, date of publication, age, gender, region, sample size, method, number of positive cases, and positivity rate. All these analytical procedures were performed with the CMA software (V3). In particular, given the heterogeneity within and between studies, random-effects models were used to estimate the average effect and its precision, which would give a more conservative estimate of the 95% confidence intervals (CIs). The I 2 statistic and Cochran’s Q test were conducted to assess statistical heterogeneity.

Prior researchers held that the fixed-effects model is ideally suited to the meta-analysis of a nonheterogeneous data pool ( I 2  < 50%, P value ≥0.1) [ 16 ]. Conversely, the random-effects model should be used when there is heterogeneity between the studies ( I 2  > 50%). According to the factors that may affect the heterogeneity between studies, moderation analysis was further carried out for distinct cohorts (i.e., health workers, confirmed and suspected patients, the general population) and distinct sample sources (China, other countries). A funnel chart was created for visual inspection to determine whether the included studies showed publication bias; Egger’s test and Kendall’s test for the quantitative analysis of publication bias were also used, with p  > 0.05 indicating no publication bias.

In the current study, 896 Chinese and English studies were initially retrieved. According to the inclusion and exclusion criteria, 71 papers were eligible for inclusion in the data pool for the meta-analysis, and the total number of respondents reached 146,139 (see Table 1 and Table S2 ).

Heterogeneity test

The results of the heterogeneity test on the prevalence of mental problems in patients with COVID-19 showed that the heterogeneity across studies was large ( I 2  > 98%, P  < 0.05), which suggested that the random-effects model was needed to analyze the total effect. Importantly, to increase the robustness of the results and reduce the heterogeneity between studies, population, nationality, and subgroup were analyzed as possible moderators.

Prevalence of mental problems

Four symptoms related to stress were selected as the mental problems, and the related symptoms and symptom groups were analyzed according to the definitions given in each study. The prevalence of anxiety was 32.6% (95% CI: 29.1–36.3; N  = 86,035, see Fig. 2 ). In addition, the prevalence of depression was 27.60% (95% CI: 24.0–31.6; N  = 90,156, see Fig. 3 ). Likewise, insomnia prevalence during the COVID-19 pandemic was 30.30% (95% CI: 24.6–36.6; N  = 62,202, see Fig. 4A ). Finally, 16.70% of participants were found to meet the criteria for PTSD during the COVID-19 pandemic in this meta-analysis (95% CI: 8.9–29.2; N  = 17,169, see Fig. 4B ).

The squares colored by orange represent the point estimation foreffect towards corresponding study, with the large square size for high effect size. The orange diamond represent meta-analytic effect size.

The squares colored by orange represent the point estimation for effect towards corresponding study, with the large square size for high effect size. The orange diamond represent meta-analytic effect size.

Moderation analysis

Given the high heterogeneity, we assumed that there were some potential moderators, including the cohort (confirmed patients, healthcare workers, and the general population), region (China and other countries), and measurement tool. The results demonstrated a significantly higher prevalence of mental health problems in confirmed patients than in others (see Table S3 ). Further, the prevalence of mental health problems was found to be lower in China than in other countries. In addition, these findings derived from the moderation analysis revealed the moderating role of the measurement tool, with the results varying significantly across different scales (see Table S3 and Figs. S1–3).

Publication bias assessment

A funnel plot was first used for qualitative analysis of the publication bias. As shown in Figure S4 , a symmetrical distribution was found for the four psychological symptoms. In addition, Begg’s rank test was performed to quantitatively analyze the publication bias. The results showed that there was no publication bias in the studies regarding anxiety (Kendall’s tau = 0.044, p  = 0.614), depression (Kendall’s tau = −0.046, p  = 0.647), insomnia (Kendall’s tau = −0.096, p  = 0.592), or PTSD (Kendall’s tau = −0.145, p  = 0.533).

In this study, a meta-analysis was performed to clarify the mental health situation in the population during the COVID-19 pandemic with respect to anxiety, depression, sleep problems, and PTSD. The results showed that the detection rate of anxiety symptoms in a total of 86,035 cases was 32.6% (95% CI: 29.1–363); the detection rate of depression symptoms in a total of 90,156 cases was 27.6% (95% CI: 24.0–31.6); the detection rate of insomnia symptoms in a total of 62,202 cases was 30.3% (95% CI: 24.6–36.6); and the detection rate of PTSD symptoms was 16.7% in a total of 17,169 cases (95% CI: 8.9–29.2). Furthermore, the moderator analysis showed that mental health problems (i.e., anxiety and depression) had the highest prevalence in COVID-19 patients, and fewer anxiety, depression, and sleep problems were observed in healthcare workers than in the general population. Overall, this study provided solid evidence of the mental health situation during the COVID-19 pandemic and indicated the potential heterogeneity across cohorts, regions, and measurement tools.

Furthermore, regarding anxiety symptoms, health workers accounted for 32.7% (95% CI: 27.9–38.2) of the detection rate; the general population accounted for 29.5% (95% CI: 25.2–34.3). A total of 25.8% (95% CI: 20.4–31.0), and 25.3% (95% CI: 20.4–32.0) of depressive symptoms were found in health workers and the general population, respectively. The highest detection rate of insomnia, which was 37.3% (95% CI: 32.1–42.8%), was found in health workers, and the general population represented 26.1% of cases (95% CI: 18.2–36.1). The detection rate of PTSD was 30.6% (95% CI: 9.1–65.9) in health workers and just 9.3% (95% CI: 4–19.8) in the general population. Moving beyond previous studies, this meta-analysis covered the latest COVID-19-related articles and examined more publications than its predecessors. In contrast to the existing research conclusions, this study found that the mental health problems of healthcare workers are the same as those of the general population, suggesting that the existing research may overestimate the mental health problems of healthcare workers (i.e., one study showed that 50.4% of healthcare workers reported symptoms of depression, 44.6% symptoms of anxiety, and 34.0% insomnia) [ 17 ]. This may be because in the early stage of COVID-19, the pressures experienced by healthcare workers were considerable due to the sudden workload and lack of adequate understanding of the COVID-19 pandemic. However, in later stages, as an understanding of COVID-19 improved, healthcare workers became familiar with the situation and gained a more comprehensive understanding of the disease. This led to higher self-regulation ability under the circumstance of the epidemic even though the stress level of the first-line workers was high. Therefore, a very important conclusion of this study is that the mental health problems of healthcare workers are not as serious as previously thought, and lagging research conclusions may lead to label effects, which in turn worsen the mental health status of healthcare workers. In addition, we found that the detection rate of mental health problems in infected patients is higher in the COVID-19 pandemic than it was during the SARS outbreak [ 18 ]. For example, during SARS, the detection rate of anxiety symptoms was 35.7% (95% CI: 27.6–44.2), and that of depressed mood was 32.6% (95% CI: 24.7–40.9); in contrast, we found anxiety and depression rates of 63.9% (95% CI: 29.6–88.2) and 55.4% (95% CI: 32.8–76.0), respectively, in the COVID-19 context. During the outbreak of SARS in 2003, information dissemination was less developed than at present, and the public understanding of the virus was based on official information, which made the spread of rumors and concomitant psychological distress less likely. This shows that we should pay attention not only to the spread of the virus but also to the spread of false/fake information about the virus.

The second core finding of this study is that the detection rates of anxiety, depression, insomnia, and PTSD in other countries are higher than those in China. Existing study demonstrated the higher anxiety and depression symptoms in overseas Chinese lived in Italy than do of overseas Chinese lived in mainland China [ 19 ]. This may be because China was the first country to have an outbreak of the diseases and has taken a series of effective measures. Civil society organizations took responsibility for isolating residents in every community and helped solve practical life difficulties. At the individual level, home isolation, social distancing, and the wearing of personal protective equipment such as face masks were implemented to prevent community transmission nationwide. Due to the development of advanced technology, residents have had easy access to reliable information and medical guidance, which can reduce misinformation and the impact of rumors. The public was well educated on the seriousness of COVID-19 complied cooperatively with the national approach of hand washing, mask wearing, social distancing, and universal temperature monitoring. All citizens were keenly aware of their roles in preventing the virus from spreading. To strike a balance between epidemic control and normal social and economic operations, industrial activities have gradually resumed in phases and batches since February 8, 2020 [ 20 ]. The supply of daily necessities was kept stable in every stage of the outbreak to ensure the smooth operation of society. The WHO-China Joint Mission report said that China has rolled out perhaps the most ambitious, agile, and aggressive disease containment efforts in history [ 21 ]. By striking contrast, the number of confirmed cases outside China is quickly climbing following an exponential growth trend. The total number of COVID-19 cases outside China has reached 333,706,43, including 999,603 deaths as of September 29, 2020. Furthermore, we also conjecture that the reason why fewer pandemic impacts were seen in mainland China is that the well-established psychological rescue system strongly guards against the potential panic arising from the COVID-19 pandemic. Specifically, Chinese governmental intervention agencies provide professional psychological intervention services for patients with confirmed diseases or mental disorders, front-line medical staff, and other key groups in special places such as designated hospitals and isolated hospitals. In addition, public psychological rescue organizations offer free 24/7 on-call professional psychological advice to the public. Ultimately, massive open online courses were released to enrich the Chinese public’s understanding of the COVID-19 pandemic, which has significantly strengthened belief in the ability to control this disaster [ 22 ]. In addition, the comparative analysis of the results obtained with different measurement tools showed heterogeneity and poor consistency across the tools. Therefore, it is suggested that reliable measurement tools should be established in future research to avoid deviation in research results caused by measurement tools.

This study adjusted the prevalence of mental health problems reported in previous studies by analyzing more recent studies and thus provided a more accurate picture of the mental health status of the population. Previous studies have provided very timely and important evidence to prove that the COVID-19 pandemic is a threat to individual mental health. However, most of the surveys were performed in the early and peak periods and may overestimate the prevalence of these problems. Moreover, for the sake of timeliness in sharing research findings, low-quality articles were published in some journals. Therefore, this study also adopts the method of quality control evaluation to exclude articles with lower quality and obtain more accurate and unbiased conclusions. In general, the detection rate of mental health problems found in this study was lower than that in previous studies. There may be two reasons for this. First, stricter quality control was adopted in this study, making the analysis results more accurate and unbiased. Second, more new studies were included in this study; that is, the investigation time extended from the initial stage to the peak of the pandemic and then to the later stage of COVID-19 pandemic in the present study. Therefore, the results of this study may reflect that, with better control and understanding of the epidemic situation, people’s mental health status has improved, which is a good sign.

This study has several limitations. First, the sample sizes were not matched well, with the number of healthcare workers being smaller than the number of people from the general population. Second, the international sample was insufficient, and the research on Chinese people significantly exceeded than that on people from other countries. Third, the impact of specific epidemic status was not taken into account. In future studies, covariates can be added to the meta-analysis to control the epidemic situation of samples in different regions.

In conclusion, our systematic review and meta-analysis provide a timely and comprehensive synthesis of existing evidence, confirming the presence of mental health problems in patients (including suspected patients) as well as insomnia and PTSD in medical staff. The findings help to quantify staff support in the context of a pandemic when stratified and customized interventions are needed to enhance resilience and reduce vulnerability. With the continuous emergence of new evidence, we can further update the meta-analysis and perform follow-ups to analyze the factors related to the epidemic situation to facilitate national-level planning, improve the hierarchical intervention of the mental health security system, and address similar public health events in the future.

Data and code availability

Study protocols and hypotheses were preregistered on the Open Science Framework (OSF) ( https://osf.io/a5vmk/ ). Raw data, protocols, and analysis scripts are available openly at the OSF ( https://osf.io/a5vmk/ ).

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Acknowledgements

Special appreciations to Dr. Yancheng Tang (Peking University, Beijing, China; School of Business and Management, Shanghai International Studies University, Shanghai, China) for his comments on scientific contexts. Many thanks to Xi Luo and Ke Xu (Army Medical University, Chongqing, China) for their contributions to English writing. This study was supported by the People’s Liberation Army of China (PLA) Key Researches Foundation (CWS20J007).

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Department of Medical Psychology, Army Medical University, Chongqing, China

Xuerong Liu, Mengyin Zhu, Jingxuan Zhang, Zhengzhi Feng & Zhiyi Chen

School of Psychology, Southwest University, Chongqing, China

Rong Zhang & Zhiyi Chen

Cognitive Psychology Unit, The Institute of Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Leiden, Netherlands

Chenyan Zhang

Department of Psychology, University of Florida, Gainesville, FL, USA

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XL and ZC: conceptualization, methodology, software, writing—original draft and visualization; MZ, JZ, and RZ: writing—review and editing, methodology, or validation; PL and CZ: writing—revision; RZ and XL: replication analysis and validation; ZC: formal analysis and validation; ZC and ZF: conceptualization, supervision, project administration, and funding acquisition.

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Liu, X., Zhu, M., Zhang, R. et al. Public mental health problems during COVID-19 pandemic: a large-scale meta-analysis of the evidence. Transl Psychiatry 11 , 384 (2021). https://doi.org/10.1038/s41398-021-01501-9

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• http://orcid.org/0000-0003-1512-4471 Emily Long 1 ,
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• 1 MRC/CSO Social and Public Health Sciences Unit , University of Glasgow , Glasgow , UK
• 2 MRC/CSO Social and Public Health Sciences Unit, Institute of Health & Wellbeing , University of Glasgow , Glasgow , UK
• Correspondence to Dr Emily Long, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G3 7HR, UK; emily.long{at}glasgow.ac.uk

This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the nature of the public health response. We then introduce four distinct domains of social relationships: social networks, social support, social interaction and intimacy, highlighting the mechanisms through which the pandemic and associated public health response drastically altered social interactions in each domain. Throughout the essay, the lens of health inequalities, and perspective of relationships as interconnecting elements in a broader system, is used to explore the varying impact of these disruptions. The essay concludes by providing recommendations for longer term recovery ensuring that the social relational cost of COVID-19 is adequately considered in efforts to rebuild.

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Introduction

Infectious disease pandemics, including SARS and COVID-19, demand intrapersonal behaviour change and present highly complex challenges for public health. 1 A pandemic of an airborne infection, spread easily through social contact, assails human relationships by drastically altering the ways through which humans interact. In this essay, we draw on theories of social relationships to examine specific ways in which relational mechanisms key to health and well-being were disrupted by the COVID-19 pandemic. Relational mechanisms refer to the processes between people that lead to change in health outcomes.

At the time of writing, the future surrounding COVID-19 was uncertain. Vaccine programmes were being rolled out in countries that could afford them, but new and more contagious variants of the virus were also being discovered. The recovery journey looked long, with continued disruption to social relationships. The social cost of COVID-19 was only just beginning to emerge, but the mental health impact was already considerable, 2 3 and the inequality of the health burden stark. 4 Knowledge of the epidemiology of COVID-19 accrued rapidly, but evidence of the most effective policy responses remained uncertain.

The initial response to COVID-19 in the UK was reactive and aimed at reducing mortality, with little time to consider the social implications, including for interpersonal and community relationships. The terminology of ‘social distancing’ quickly became entrenched both in public and policy discourse. This equation of physical distance with social distance was regrettable, since only physical proximity causes viral transmission, whereas many forms of social proximity (eg, conversations while walking outdoors) are minimal risk, and are crucial to maintaining relationships supportive of health and well-being.

The aim of this essay is to explore four key relational mechanisms that were impacted by the pandemic and associated restrictions: social networks, social support, social interaction and intimacy. We use relational theories and emerging research on the effects of the COVID-19 pandemic response to make three key recommendations: one regarding public health responses; and two regarding social recovery. Our understanding of these mechanisms stems from a ‘systems’ perspective which casts social relationships as interdependent elements within a connected whole. 5

Social networks

Social networks characterise the individuals and social connections that compose a system (such as a workplace, community or society). Social relationships range from spouses and partners, to coworkers, friends and acquaintances. They vary across many dimensions, including, for example, frequency of contact and emotional closeness. Social networks can be understood both in terms of the individuals and relationships that compose the network, as well as the overall network structure (eg, how many of your friends know each other).

Social networks show a tendency towards homophily, or a phenomenon of associating with individuals who are similar to self. 6 This is particularly true for ‘core’ network ties (eg, close friends), while more distant, sometimes called ‘weak’ ties tend to show more diversity. During the height of COVID-19 restrictions, face-to-face interactions were often reduced to core network members, such as partners, family members or, potentially, live-in roommates; some ‘weak’ ties were lost, and interactions became more limited to those closest. Given that peripheral, weaker social ties provide a diversity of resources, opinions and support, 7 COVID-19 likely resulted in networks that were smaller and more homogenous.

Such changes were not inevitable nor necessarily enduring, since social networks are also adaptive and responsive to change, in that a disruption to usual ways of interacting can be replaced by new ways of engaging (eg, Zoom). Yet, important inequalities exist, wherein networks and individual relationships within networks are not equally able to adapt to such changes. For example, individuals with a large number of newly established relationships (eg, university students) may have struggled to transfer these relationships online, resulting in lost contacts and a heightened risk of social isolation. This is consistent with research suggesting that young adults were the most likely to report a worsening of relationships during COVID-19, whereas older adults were the least likely to report a change. 8

Lastly, social connections give rise to emergent properties of social systems, 9 where a community-level phenomenon develops that cannot be attributed to any one member or portion of the network. For example, local area-based networks emerged due to geographic restrictions (eg, stay-at-home orders), resulting in increases in neighbourly support and local volunteering. 10 In fact, research suggests that relationships with neighbours displayed the largest net gain in ratings of relationship quality compared with a range of relationship types (eg, partner, colleague, friend). 8 Much of this was built from spontaneous individual interactions within local communities, which together contributed to the ‘community spirit’ that many experienced. 11 COVID-19 restrictions thus impacted the personal social networks and the structure of the larger networks within the society.

Social support

Social support, referring to the psychological and material resources provided through social interaction, is a critical mechanism through which social relationships benefit health. In fact, social support has been shown to be one of the most important resilience factors in the aftermath of stressful events. 12 In the context of COVID-19, the usual ways in which individuals interact and obtain social support have been severely disrupted.

One such disruption has been to opportunities for spontaneous social interactions. For example, conversations with colleagues in a break room offer an opportunity for socialising beyond one’s core social network, and these peripheral conversations can provide a form of social support. 13 14 A chance conversation may lead to advice helpful to coping with situations or seeking formal help. Thus, the absence of these spontaneous interactions may mean the reduction of indirect support-seeking opportunities. While direct support-seeking behaviour is more effective at eliciting support, it also requires significantly more effort and may be perceived as forceful and burdensome. 15 The shift to homeworking and closure of community venues reduced the number of opportunities for these spontaneous interactions to occur, and has, second, focused them locally. Consequently, individuals whose core networks are located elsewhere, or who live in communities where spontaneous interaction is less likely, have less opportunity to benefit from spontaneous in-person supportive interactions.

However, alongside this disruption, new opportunities to interact and obtain social support have arisen. The surge in community social support during the initial lockdown mirrored that often seen in response to adverse events (eg, natural disasters 16 ). COVID-19 restrictions that confined individuals to their local area also compelled them to focus their in-person efforts locally. Commentators on the initial lockdown in the UK remarked on extraordinary acts of generosity between individuals who belonged to the same community but were unknown to each other. However, research on adverse events also tells us that such community support is not necessarily maintained in the longer term. 16

Meanwhile, online forms of social support are not bound by geography, thus enabling interactions and social support to be received from a wider network of people. Formal online social support spaces (eg, support groups) existed well before COVID-19, but have vastly increased since. While online interactions can increase perceived social support, it is unclear whether remote communication technologies provide an effective substitute from in-person interaction during periods of social distancing. 17 18 It makes intuitive sense that the usefulness of online social support will vary by the type of support offered, degree of social interaction and ‘online communication skills’ of those taking part. Youth workers, for instance, have struggled to keep vulnerable youth engaged in online youth clubs, 19 despite others finding a positive association between amount of digital technology used by individuals during lockdown and perceived social support. 20 Other research has found that more frequent face-to-face contact and phone/video contact both related to lower levels of depression during the time period of March to August 2020, but the negative effect of a lack of contact was greater for those with higher levels of usual sociability. 21 Relatedly, important inequalities in social support exist, such that individuals who occupy more socially disadvantaged positions in society (eg, low socioeconomic status, older people) tend to have less access to social support, 22 potentially exacerbated by COVID-19.

Social and interactional norms

Interactional norms are key relational mechanisms which build trust, belonging and identity within and across groups in a system. Individuals in groups and societies apply meaning by ‘approving, arranging and redefining’ symbols of interaction. 23 A handshake, for instance, is a powerful symbol of trust and equality. Depending on context, not shaking hands may symbolise a failure to extend friendship, or a failure to reach agreement. The norms governing these symbols represent shared values and identity; and mutual understanding of these symbols enables individuals to achieve orderly interactions, establish supportive relationship accountability and connect socially. 24 25

Physical distancing measures to contain the spread of COVID-19 radically altered these norms of interaction, particularly those used to convey trust, affinity, empathy and respect (eg, hugging, physical comforting). 26 As epidemic waves rose and fell, the work to negotiate these norms required intense cognitive effort; previously taken-for-granted interactions were re-examined, factoring in current restriction levels, own and (assumed) others’ vulnerability and tolerance of risk. This created awkwardness, and uncertainty, for example, around how to bring closure to an in-person interaction or convey warmth. The instability in scripted ways of interacting created particular strain for individuals who already struggled to encode and decode interactions with others (eg, those who are deaf or have autism spectrum disorder); difficulties often intensified by mask wearing. 27

Large social gatherings—for example, weddings, school assemblies, sporting events—also present key opportunities for affirming and assimilating interactional norms, building cohesion and shared identity and facilitating cooperation across social groups. 28 Online ‘equivalents’ do not easily support ‘social-bonding’ activities such as singing and dancing, and rarely enable chance/spontaneous one-on-one conversations with peripheral/weaker network ties (see the Social networks section) which can help strengthen bonds across a larger network. The loss of large gatherings to celebrate rites of passage (eg, bar mitzvah, weddings) has additional relational costs since these events are performed by and for communities to reinforce belonging, and to assist in transitioning to new phases of life. 29 The loss of interaction with diverse others via community and large group gatherings also reduces intergroup contact, which may then tend towards more prejudiced outgroup attitudes. While online interaction can go some way to mimicking these interaction norms, there are key differences. A sense of anonymity, and lack of in-person emotional cues, tends to support norms of polarisation and aggression in expressing differences of opinion online. And while online platforms have potential to provide intergroup contact, the tendency of much social media to form homogeneous ‘echo chambers’ can serve to further reduce intergroup contact. 30 31

Intimacy relates to the feeling of emotional connection and closeness with other human beings. Emotional connection, through romantic, friendship or familial relationships, fulfils a basic human need 32 and strongly benefits health, including reduced stress levels, improved mental health, lowered blood pressure and reduced risk of heart disease. 32 33 Intimacy can be fostered through familiarity, feeling understood and feeling accepted by close others. 34

Intimacy via companionship and closeness is fundamental to mental well-being. Positively, the COVID-19 pandemic has offered opportunities for individuals to (re)connect and (re)strengthen close relationships within their household via quality time together, following closure of many usual external social activities. Research suggests that the first full UK lockdown period led to a net gain in the quality of steady relationships at a population level, 35 but amplified existing inequalities in relationship quality. 35 36 For some in single-person households, the absence of a companion became more conspicuous, leading to feelings of loneliness and lower mental well-being. 37 38 Additional pandemic-related relational strain 39 40 resulted, for some, in the initiation or intensification of domestic abuse. 41 42

Physical touch is another key aspect of intimacy, a fundamental human need crucial in maintaining and developing intimacy within close relationships. 34 Restrictions on social interactions severely restricted the number and range of people with whom physical affection was possible. The reduction in opportunity to give and receive affectionate physical touch was not experienced equally. Many of those living alone found themselves completely without physical contact for extended periods. The deprivation of physical touch is evidenced to take a heavy emotional toll. 43 Even in future, once physical expressions of affection can resume, new levels of anxiety over germs may introduce hesitancy into previously fluent blending of physical and verbal intimate social connections. 44

The pandemic also led to shifts in practices and norms around sexual relationship building and maintenance, as individuals adapted and sought alternative ways of enacting sexual intimacy. This too is important, given that intimate sexual activity has known benefits for health. 45 46 Given that social restrictions hinged on reducing household mixing, possibilities for partnered sexual activity were primarily guided by living arrangements. While those in cohabiting relationships could potentially continue as before, those who were single or in non-cohabiting relationships generally had restricted opportunities to maintain their sexual relationships. Pornography consumption and digital partners were reported to increase since lockdown. 47 However, online interactions are qualitatively different from in-person interactions and do not provide the same opportunities for physical intimacy.

Recommendations and conclusions

In the sections above we have outlined the ways in which COVID-19 has impacted social relationships, showing how relational mechanisms key to health have been undermined. While some of the damage might well self-repair after the pandemic, there are opportunities inherent in deliberative efforts to build back in ways that facilitate greater resilience in social and community relationships. We conclude by making three recommendations: one regarding public health responses to the pandemic; and two regarding social recovery.

Recommendation 1: explicitly count the relational cost of public health policies to control the pandemic

Effective handling of a pandemic recognises that social, economic and health concerns are intricately interwoven. It is clear that future research and policy attention must focus on the social consequences. As described above, policies which restrict physical mixing across households carry heavy and unequal relational costs. These include for individuals (eg, loss of intimate touch), dyads (eg, loss of warmth, comfort), networks (eg, restricted access to support) and communities (eg, loss of cohesion and identity). Such costs—and their unequal impact—should not be ignored in short-term efforts to control an epidemic. Some public health responses—restrictions on international holiday travel and highly efficient test and trace systems—have relatively small relational costs and should be prioritised. At a national level, an earlier move to proportionate restrictions, and investment in effective test and trace systems, may help prevent escalation of spread to the point where a national lockdown or tight restrictions became an inevitability. Where policies with relational costs are unavoidable, close attention should be paid to the unequal relational impact for those whose personal circumstances differ from normative assumptions of two adult families. This includes consideration of whether expectations are fair (eg, for those who live alone), whether restrictions on social events are equitable across age group, religious/ethnic groupings and social class, and also to ensure that the language promoted by such policies (eg, households; families) is not exclusionary. 48 49 Forethought to unequal impacts on social relationships should thus be integral to the work of epidemic preparedness teams.

Recommendation 2: intelligently balance online and offline ways of relating

A key ingredient for well-being is ‘getting together’ in a physical sense. This is fundamental to a human need for intimate touch, physical comfort, reinforcing interactional norms and providing practical support. Emerging evidence suggests that online ways of relating cannot simply replace physical interactions. But online interaction has many benefits and for some it offers connections that did not exist previously. In particular, online platforms provide new forms of support for those unable to access offline services because of mobility issues (eg, older people) or because they are geographically isolated from their support community (eg, lesbian, gay, bisexual, transgender and queer (LGBTQ) youth). Ultimately, multiple forms of online and offline social interactions are required to meet the needs of varying groups of people (eg, LGBTQ, older people). Future research and practice should aim to establish ways of using offline and online support in complementary and even synergistic ways, rather than veering between them as social restrictions expand and contract. Intelligent balancing of online and offline ways of relating also pertains to future policies on home and flexible working. A decision to switch to wholesale or obligatory homeworking should consider the risk to relational ‘group properties’ of the workplace community and their impact on employees’ well-being, focusing in particular on unequal impacts (eg, new vs established employees). Intelligent blending of online and in-person working is required to achieve flexibility while also nurturing supportive networks at work. Intelligent balance also implies strategies to build digital literacy and minimise digital exclusion, as well as coproducing solutions with intended beneficiaries.

Recommendation 3: build stronger and sustainable localised communities

In balancing offline and online ways of interacting, there is opportunity to capitalise on the potential for more localised, coherent communities due to scaled-down travel, homeworking and local focus that will ideally continue after restrictions end. There are potential economic benefits after the pandemic, such as increased trade as home workers use local resources (eg, coffee shops), but also relational benefits from stronger relationships around the orbit of the home and neighbourhood. Experience from previous crises shows that community volunteer efforts generated early on will wane over time in the absence of deliberate work to maintain them. Adequately funded partnerships between local government, third sector and community groups are required to sustain community assets that began as a direct response to the pandemic. Such partnerships could work to secure green spaces and indoor (non-commercial) meeting spaces that promote community interaction. Green spaces in particular provide a triple benefit in encouraging physical activity and mental health, as well as facilitating social bonding. 50 In building local communities, small community networks—that allow for diversity and break down ingroup/outgroup views—may be more helpful than the concept of ‘support bubbles’, which are exclusionary and less sustainable in the longer term. Rigorously designed intervention and evaluation—taking a systems approach—will be crucial in ensuring scale-up and sustainability.

The dramatic change to social interaction necessitated by efforts to control the spread of COVID-19 created stark challenges but also opportunities. Our essay highlights opportunities for learning, both to ensure the equity and humanity of physical restrictions, and to sustain the salutogenic effects of social relationships going forward. The starting point for capitalising on this learning is recognition of the disruption to relational mechanisms as a key part of the socioeconomic and health impact of the pandemic. In recovery planning, a general rule is that what is good for decreasing health inequalities (such as expanding social protection and public services and pursuing green inclusive growth strategies) 4 will also benefit relationships and safeguard relational mechanisms for future generations. Putting this into action will require political will.

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Twitter @karenmaxSPHSU, @Mark_McCann, @Rwilsonlowe, @KMitchinGlasgow

Contributors EL and KM led on the manuscript conceptualisation, review and editing. SP, KM, CB, RBP, RL, MM, JR, KS and RW-L contributed to drafting and revising the article. All authors assisted in revising the final draft.

Funding The research reported in this publication was supported by the Medical Research Council (MC_UU_00022/1, MC_UU_00022/3) and the Chief Scientist Office (SPHSU11, SPHSU14). EL is also supported by MRC Skills Development Fellowship Award (MR/S015078/1). KS and MM are also supported by a Medical Research Council Strategic Award (MC_PC_13027).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Published: 15 June 2022

COVID-19 and mental health in Australia – a scoping review

• Yixuan Zhao 1 ,
• Liana S. Leach 1 ,
• Erin Walsh 1 ,
• Philip J. Batterham 1 ,
• Alison L. Calear 1 ,
• Christine Phillips 2 ,
• Anna Olsen 2 ,
• Tinh Doan 1 ,
• Christine LaBond 1 &
• Cathy Banwell 1  

BMC Public Health volume  22 , Article number:  1200 ( 2022 ) Cite this article

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The COVID-19 outbreak has spread to almost every country around the world and caused more than 3 million deaths. The pandemic has triggered enormous disruption in people’s daily lives with profound impacts globally. This has also been the case in Australia, despite the country’s comparative low mortality and physical morbidity due to the virus. This scoping review aims to provide a broad summary of the research activity focused on mental health during the first 10 months of the pandemic in Australia.

A search of the Australian literature was conducted between August-November 2020 to capture published scientific papers, online reports and pre-prints, as well as gaps in research activities. The search identified 228 unique records in total. Twelve general population and 30 subpopulation group studies were included in the review.

Conclusions

Few studies were able to confidently report changes in mental health driven by the COVID-19 context (at the population or sub-group level) due to a lack of pre-COVID comparative data and non-representative sampling. Never-the-less, in aggregate, the findings show an increase in poor mental health over the early period of 2020. Results suggest that young people, those with pre-existing mental health conditions, and the financially disadvantaged, experienced greater declines in mental health. The need for rapid research appears to have left some groups under-researched (e.g. Culturally and Linguistically Diverse populations and Indigenous peoples were not studied), and some research methods under-employed (e.g. there was a lack of qualitative and mixed-methods studies). There is a need for further reviews as the follow-up results of longitudinal studies emerge and understandings of the impact of the pandemic are refined.

Peer Review reports

The outbreak of COVID-19, an infectious disease causing severe acute respiratory syndrome, led the Director-General of the World Health Organisation (WHO) to declare a public health emergency of international concern on the 30 th January 2020 [ 72 ]. By April 2021, the disease had spread to almost every country around the world, and caused more than 3 million deaths [ 74 ]. The pandemic has triggered enormous disruption in people’s daily lives and has undoubtedly had a widespread and profound global impact.

Australia has managed to date to achieve low total numbers of local infection, partly because of its geographic isolation (i.e. all borders are surrounded by sea) and also because of early interventions to contain the virus. Following the first confirmed case on the 25 th January 2020 [ 34 ], the Federal Government quickly introduced border controls, quarantine measures and urged the public to take precautions in response to the virus. By March 2020, a series of stringent containment measures were put in place by the state and territory governments to stop the spread of the virus and protect people’s lives. These included requirements to stay at home (except for specific reasons), business closures, restrictions on social gatherings and interstate travel, as well as a ban on all international travel. Residents in the state of Victoria experienced particularly stringent restrictions (e.g. a nightly curfew, a 5 km-limit for all activities, and mandatory mask-wearing [ 6 ]) during a second wave of COVID from June-October, 2020. To date, these restrictions have proven to be successful at reducing the transmission of the virus in Australia [ 16 ,  13 ]. However, they have come at a considerable economic and health cost to individuals, businesses, communities and the nation. Government data shows that during June-July, 2020, the Australian Gross Domestic Product fell by a record 7% and the unemployment rate hit 7.5%—the highest it had been in over 20 years. Reassuringly, after July, the Australian economy started to improve in all states except Victoria [ 3 ].

Despite the successful management of the pandemic to date and the ongoing economic recovery, there are indications that Australians’ mental health declined in the early months of the pandemic and that this reduction has been somewhat sustained. Data from the Australian Bureau of Statistics (ABS) shows that in January 2021 22% of Australians reported that their mental health was ‘worse’ or ‘much worse’ than in March 2020; comparatively only 0.1% of people in Australia have been infected with COVID-19. Similarly, 21% reported that their mental health was ‘fair’ or ‘poor’ in January 2021—higher than the 14.4% who reported this in July 2020 [ 2 , 4 ]. Although this self-report data is not based on validated mental health measures, it demonstrates the importance of investigating the widespread and potentially enduring impact of the pandemic on mental health in Australia. Mental health experts have stated that increases in mental health problems are likely due to risk factors attributable to the virus itself (e.g. fear of contracting the virus, concerns about the lack of treatment options and/or being in a high-risk group for mortality, and uncertainty about when the virus will be controlled) as well as risk factors attributable to the lockdowns aimed at combating the virus (e.g. interrupted daily routines, unemployment and underemployment, loss of income, reduced social support, financial distress, and loneliness) [ 38 ]. The latter are well-established risk factors for poor mental health generally, let alone within the complex context of a global pandemic [ 50 , 32 ].

The Australian context is unusual in terms of the focus on individuals’ and communities’ mental health in 2020. In part, because the prevalence of COVID-19 has been relatively low in Australia compared to other countries, discussion regarding the more distal mental health impacts of COVID has been prominent alongside concerns about the proximal physical impacts. Justifiably, the research community (and the media) in Australia has paid tremendous attention to the potential mental health impacts of the outbreak. An influx of studies have been conducted in the past year (mainly from March to September 2020) to understand people’s experiences and gauge any increase in mental health problems during the pandemic. While many of these studies are still ongoing, numerous results have been published reporting on the prevalence and severity of mental health problems during this time (mostly common experiences such as psychological distress, depression and anxiety), and the vulnerability of different groups. For context, it is also important to note that the COVID pandemic closely followed the Black Summer bushfires. From September 2019 to February 2020, large swathes of Australia were burnt, accompanied by destruction of life, property, the natural environment and wildlife [ 11 ] (although most COVID-focused studies have not considered the population’s possible lingering emotional responses to the bushfires).

Despite the influx of research activity in Australia investigating mental health during 2020, comprehensive summaries of what has been done and what has been found are scarce (for an international review and meta-analyses see Prati & Mancini [ 56 ]). Given it has been over a year since the outbreak began, the current scoping review provides a timely summary of the Australian research conducted in 2020 during the early phase of the COVID-19 outbreak. The review also aimed to identify gaps in research activities, knowledge and understanding of how the pandemic is affecting Australian’s mental health.

Study design

In this review, the use of the term ‘mental health’ goes beyond the presence/absence of diagnosed mental illness and instead focuses on the most common psychological symptoms experienced in the community, such as distress, anxiety, and depression. Because this review aimed to be inclusive, and also considering much research regarding the pandemic is ongoing (with some research reports and online pre-prints not yet available in peer-reviewed scientific journals), we deemed a descriptive broader scoping review more appropriate than a traditional systematic review [ 44 , 64 ]. This review follows the PRISMA-ScR checklist, an extension of the PRISMA statement for conducting scoping reviews [ 66 , 51 ].

Eligibility criteria

While this scoping review was necessarily broad, clear well-defined eligibility criteria and research questions were still required. Following the JBI recommendations [ 51 ] we define our  population  as Australians, our  context  as Australia during the first 10 months of the COVID-19 pandemic, and our  concept  as mental health prevalence (or outcomes) and risk factors during this window of time.

Publications (reports, non-reviewed pre-prints of papers and peer-reviewed articles) were eligible to be included if they were focused on mental health during the COVID-19 pandemic, reported original research findings/results (i.e. media releases, editorials, opinion pieces, commentaries, protocol papers or general text summaries within reports (with no detailed findings) were excluded), were conducted within the Australian population, and were written in English.

Literature search and data extraction

Searches of the literature were conducted between August-November 2020 to capture research with a focus on COVID-19 and mental health in Australia. The search included three elements:

Four databases (PsycINFO, PubMed, Scopus and Web of Science) were searched using key words to capture published peer-reviewed articles focused on COVID-19 and mental health in Australia. These keywords were COVID AND ("mental health" OR "psychological dis*" OR "mental dis*" OR depress* OR anxiety OR wellbeing OR well-being OR "well being" OR worr* OR fear OR lonel* OR "alcohol use" OR "substance use” OR stress OR confus* OR anger OR optimism OR pessimism OR "mental ill*" OR mood OR panic) AND Australia *. The search was generally within the title and abstract field (in some databases, keywords and author information were also included). The document type was limited to “article” where possible so that other types of publications such as reviews, study protocols, editorials, commentaries, viewpoints, letters to editors, and dissertations, were excluded.

The online search engine Google was searched using the phrase “COVID mental health research survey Australia” to capture research findings not yet published in scientific journals. The results were limited to records within one year, verbatim, and pages published in or originating from Australia. Reports, online papers and pre-prints that included mental health/wellbeing measures or interview questions (and sufficient information about study methods) were identified and recorded. In addition, we checked the reference lists of identified publications and reached out to our existing research networks to identify relevant pre-prints or recently accepted publications.

All the records in the databases for the Research Tracker and Facilitator for Assessment of COVID-19 Experiences and Mental Health project [ 14 ] were checked for any additional studies not already identified. This project aims to track research being undertaken on COVID-19 and mental health by Australian researchers.

General description of studies included

The search and selection process is outlined in Fig.  1 . As the manual search of reference lists did not yield any more records beyond the records identified through other search methods, this was not specified in Fig.  1 . The records identified through the database searches were reviewed by two researchers (YZ and LL) independently. Any disagreements regarding the eligibility of articles were resolved via broader discussion with the project team. Overall, 42 articles were identified as eligible for inclusion in the scoping review. Two reviewers (YZ and EW) independently assessed the full-texts of the 42 articles and extracted and recorded relevant data (including sample characteristics, whether the study included pre-COVID comparisons, mental health outcomes and measures, study key findings, and any main risk or protective factors identified). All discrepancies regarding data extraction were resolved through discussion.

Search and selection process for the review

The characteristics of the 42 included studies are outlined in Tables 1 and 2 (see Additional file 1 ).

Study time-frame and geographical coverage

The majority of the eligible studies were conducted between the end of March and early June 2020, covering the time period when the whole country was under stringent stay-at-home measures, with strict restrictions placed on social gatherings. Seven studies included data collected after this period, when the restrictions were beginning to relax across Australia (except for Victoria) [ 9 , 10 , 30 , 36 , 39 , 40 , 57 ]. All but one [ 39 ] of these seven studies included data from every state including Victoria after the second wave’s containment measures. However, Griffiths et al. [ 30 ] was the only study that made direct comparisons between Victoria and the rest of Australia.

Study populations

Out of the 42 research studies, 12 were conducted among the general Australian adult population, while the remaining 30 focused on a specific group within the population (e.g. parents of young children, health workers, people with an existing health or mental health condition, or young people). The characteristics and key findings for the general population studies are summarized in Table 1 and for specific group studies in Table 2 . Three studies [ 10 , 52 , 68 ] drew a subsample of data from surveys conducted among the general population. However, because the aims and findings of these studies focused on specific subpopulation groups, they were included as research conducted among specific groups.

Pre-COVID comparisons

Of the total 42 studies, nine studies were longitudinal or repeated cross-sectional and had data collection points covering the time period before and during the COVID-19 outbreak (with comparative data collection methods and mental health measures employed) [ 7 , 8 ,  15 , 22 ,  39 ,  43 ,  63 , 65 , 67 ]. These studies were more robustly able to compare participants’ mental health during the COVID-19 pandemic to a pre-COVD level. In other words, the evidence provided in these studies was higher quality than other studies with no baseline pre-COVID comparison. Ten further studies compared the results of their studies to norms or results of similar studies conducted before the pandemic. Four studies asked the participants to self-report on whether, and to what extent, their mental health had changed since the onset of the pandemic (these studies are susceptible to recall misjudgements). Several studies used more than one mental health measure and the pre-COVID comparison for each measure sometimes varied. Twenty studies did not report any pre-COVID comparison data, making it difficult to draw confident conclusions about changes in mental health due to COVID.

Research on the general population in Australia

Study sampling and data sources.

In the 12 general population studies (Table 1 ), the participants were usually required to be aged over 18 and currently living in Australia. Four of the 12 studies were based on representative samples of Australian population – 1 & 2. ANUpoll study (Life in Australia™) Footnote 1 [ 7 , 8 ]; 3. Taking the Pulse of the Nation Survey Footnote 2 [ 9 ]; 4. The Australian National COVID-19 Mental Health, Behaviour and Risk Communication (COVID-MHBRC) Survey [ 18 ]. Six studies recruited participants online via social media (e.g. through Facebook advertisements) – 1 & 2. Fisher et al. [ 27 ] and Owen et al. [ 48 ] drew data from the Living with COVID-19 restrictions in Australia survey Footnote 3 ; 3. Rossell et al. [ 58 ] used data from the COVID-19 and you: Mental health in Australia now survey (COLLATE) Footnote 4 ; 4. Gurvich et al. [ 31 ] used data drawn from the COVID-19 and Mental Health Survey Footnote 5 ; 5. Newby et al. [ 45 ] used data from the Mental Health and Coronavirus Study conducted by UNSW and the Black Dog Institute (approval number 3330); 6. Survey data used by Stanton, To & Khalesi et al. [ 62 ] (approval number 22332). The sample representativeness when recruiting participants via online platforms varies greatly in published research [ 53 ]. It is generally accepted that studies based on random and/or representative samples are higher quality with more generalisable findings. However, online methodologies are considered feasible and efficient for broadly summarising population experiences and for correlational research, as they provide timely access to a significant number of individuals [ 40 ]. The two remaining studies in Table 1 [ 21 , 25 ] were based on analyses of online content. Given the ubiquity of internet use, analysing online content offers researchers an avenue to understand public sentiments and opinions [ 21 , 25 ].

During-COVID/Pre-COVID study comparisons

Most of the surveys investigating the COVID-19 outbreak and mental health have collected, or intend to collect, follow-up data to understand changes in the public’s experiences and mental health symptomology as the pandemic evolves, but currently available publications mostly report baseline data. In other words, the majority of studies are cross-sectional and the longitudinal results are not yet available. Out of the 12 studies included in Table 1 , four report changes in participants’ mental health over time during the pandemic. These studies correlate changes in mental health symptomology with varying case rates of COVID-19, as well as changes in social and economic policies and other life circumstances in the first few months of the pandemic [ 7 , 9 , 21 , 25 ].

In terms of pre-COVID comparisons, we identified no studies tracking mental health from pre-COVID and into the COVID period using the same sample/cohort over time. However, six of the 12 studies made comparisons between current COVID results and results from a pre-COVID sample in Australia. Biddle et al. [ 7 ] and [ 8 ] compared their current results with previous waves of the same survey, although the same cohort of respondents was not tracked individually. Four studies compared their results with findings from various representative studies conducted prior to COVID [ 9 , 18 , 27 , 58 ]. These comparisons provided some information about whether, and how, people’s mental health changed during COVID, but the comparisons are less rigorous than if pre-COVID data were available from longitudinal cohort studies tracking temporal changes in individuals.

Mental health outcome measures

Studies generally focused on psychological distress, depression and anxiety. These mental health problems were primarily examined using validated psychometric scales – demonstrating good quality, robust measurement. The most common measures included the Kessler 6 (K6) scale (used by Biddle et al., [ 7 , 8 ] as an indicator for general psychological distress; Patient Health Questionnaire-9 (PHQ-9) (used by Dawel et al. [ 18 ]; Fisher et al. [ 27 ]; Owen et al. [ 48 ]) to assess depression symptoms, suicidality and eating patterns; Generalized Anxiety Disorder-7 (GAD-7) (used by Dawel et al. [ 18 ]; Fisher et al. [ 27 ] to measure anxiety and irritability; and the 21-item Depression Anxiety Stress Scales (DASS-21) (used by Gurvich et al. [ 31 ]; Newby et al. [ 45 ]; Rossell et al. [ 58 ]; Stanton et al. 62 ]) to measure dimensions of depression and anxiety symptoms. Gurvich et al. [ 31 ] also reported on suicidal thoughts using the relevant items in Beck Depression Inventory (BDI). Among the two studies analysing online content, Du et al. [ 21 ] selected the terms “fear”, “panic”, “worry” to represent fear-related emotions as they showed high consistency with each other, while Ewing & Vu [ 25 ] harvested public sentiments through researchers’ interpretations of the tweet data from Twitter.

Overall study findings

The results of the four nationally representative studies (Biddle, et al. [ 7 , 8 ], Botha et al. [ 9 ], Dawel et al. [ 18 ] all showed an increase in mental health problems compared to pre-pandemic published statistics. Three of the remaining general population studies also found an elevation in mental health problems when comparing their results with pre-pandemic norms [ 27 , 45 , 58 ]. Du et al. [ 21 ] tracked the internet searches for fear-related emotions, protective behaviours, health-related knowledge, and panic buying by Australian throughout March, and Ewing &Vu [ 25 ] analysed 3-weeks of tweets by Australian in April. They both found a decline in positive emotions, which matched the deterioration of the COVID-19 situation over time. The three studies by Gurvich et al. [ 31 ], Owen et al. [ 48 ] and Stanton et al. [ 62 ] had no pre-COVID comparisons, and provided no evidence about whether mental health deteriorated during the pandemic. Instead, these studies identified a series of risk and protective factors for mental health during COVID-19. Despite the reports of pessimism in the population, some optimistic feelings were also identified – Biddle et al. [  8 ] found a significant increase in social cohesion and trust to fellow Australians in the population and Fisher et al. [ 27 ] found that on average Australians were optimistic about the future.

Several studies identified demographic and socio-economic characteristics associated with mental health during COVID-19. For example, Newby et al. [ 45 ], Biddle et al. [ 7 ] and Dawel et al. [ 18 ] all found that younger people reported poorer mental health during the pandemic relative to older groups. Those who experienced job loss, reductions in work hours, and financial hardship during COVID were also more likely to record mental health problems (e.g. [ 7 ,  9 ]). Another important factor was pre-existing mental health conditions. Participants with a prior mental health diagnosis were more likely to report worse mental health during COVID-19 [ 18 , 45 , 58 , 62 ].

Studies also showed that people who were worried about contracting COVID-19 were more likely to report poorer mental health [ 27 , 45 , 48 ]. Surprisingly, Dawel et al. [ 18 ] found that direct COVID-19 exposure was not associated with mental health problems. Instead, impairments in work and social functioning and financial distress due to COVID-19 were more strongly associated with poorer mental health. Dawel et al.’s study [ 18 ] also considered the experience of bushfire exposure during the 2019–2020 fires. The results showed that exposure to the fire was not associated with mental health symptomology, but exposure to the bushfire smoke was associated with decreased wellbeing.

Research on specific subpopulation groups

The 30 studies with a focus on specific subpopulations included 25 quantitative studies (with the majority based on survey data and five based on administrative data), four qualitative studies and one mix-method study. Two of the four qualitative studies (Digby et al., 2021; [ 19 , 24 ]) reported the qualitative findings of mixed-methods research, with the quantitative findings reported elsewhere.

Study samples and populations of interest

Of these 30 studies, 20 studies collected data from participants across the nation (although one comprised largely of people living in Victoria (88.2%)) [ 57 ]. Only Sollis et al. [ 61 ] and Broadway et al. [ 10 ] were based on survey data analysed from nationally representative samples, and Johnston et al. [  36 ] pre-stratified their data/sample to approximate a nationally representative sample. The remaining ten studies focused on specific states or cities. One focused on South Australian [ 67 ]; one on Queensland [ 39 ]; two studies were conducted in Western Australia [ 22 , 41 ]; and two studies in Sydney or New South Wales [ 43 , 60 ]. Four studies were conducted in Melbourne or Victoria [ 15 ]; Digby et al. 2020; [ 20 , 33 ].

People with a particular vulnerability were a major focus of these studies. They included patients presenting to and/or staying in hospital due to poor health or mental health in the study period [ 15 , 22 , 60 ]; people with a pre-existing physical or mental health disorder [ 52 , 68 ]; and people accessing mental health services [ 63 , 65 , 67 ]. Leske et al. [ 39 ] studied suicide rates and motives during the pandemic. Hospital staff, whose physical and mental health may have been more vulnerable during the pandemic, were the population of interest in three studies (Digby et al., 2021, [ 19 , 20 , 33 ]. Other potential participant vulnerabilities included being an adolescent or young adult [ 40 , 41 , 43 ], in self-isolation/quarantine [ 35 ], living alone [ 46 ] and having higher dysmorphic concern [ 55 ].

Families with young children were considered vulnerable and therefore a population of interest in nine studies. Six studies drew data from the COVID-19 Pandemic Adjustment Survey which was conducted among parents of children under the age of 18 (see Table 2 ). Two studies drew data from other nationwide surveys [ 36 , 10 ]. Additionally, Chivers et al. [ 17 ] conducted a qualitative research on new and expecting parents.

Pre-COVID/ during-COVID study comparisons

As indicated in Table 2 , 15 of the 30 studies reported on changes in mental health and other wellbeing indicators before and during the COVID-19 outbreak. Most studies investigating specific populations were cross-sectional and compared current results with the results or statistics from pre-COVID studies that used similar samples (or comparable admissions/administrative data). Other studies asked participants to self-report on the differences in their mental health before and during the pandemic. Four studies reporting administrative data from health services [ 15 , 22 , 63 , 65 ] selected data collected during the corresponding period of 2019 as their pre-COVID comparisons (to avoid the period immediately before the pandemic when Australia experienced the severe bushfire crisis). One longitudinal study tracking the same cohort of participants [ 43 ] adopted a cut-off date to compare mental health before and after the implementation of the COVID-19 restrictions. Separate from the pre-COVID comparisons, four studies [ 15 , 22 , 30 , 63 ] compared mental health across multiple time points during the pandemic, linking changes in participants’ mental health to changes in case rates for COVID-19 in Australia.

Mental health measures

Similar to studies focused on the whole general population, most of the subpopulation studies measured participants’ mental health and wellbeing using validated scales such as the K6, K10, PHQ-9, GAD-7 and the DASS-21. A series of other mental health measures were also adopted (see Table 2 ). Apart from the validated mental health measures, behaviours related to mental health, including eating and exercise behaviours [ 52 ], and appearance-focused behaviours [ 55 ], were also adopted as mental health indicators. Several studies examined public or administrative records, including emergency department presentations [ 15 , 22 ], suicide registers [ 39 ] and website visits and call centre traffic for mental health services [ 65 , 63 ]. A small number of studies did not use validated measures and instead asked participants to self-report on their mental health, lowering the quality of mental health measurement in these studies (e.g. [ 10 , 35 , 36 , 41 , 43 ]). None of the sub-group studies assessed the widespread and likely traumatic impact of the 2019–20 bushfires (a significant individual and community-level pre-pandemic vulnerability).

Five studies qualitatively assessed participants’ descriptions of their experiences and feelings during the COVID-19 pandemic [ 17 ], Digby et al., 2021; [ 19 , 24 , 46 , 60 ] to gain a deeper understanding into participants’ psychological wellbeing in relation to their specific contexts. Of the five studies, Chivers et al. [ 17 ] analysed posts related to COVID-19 in an online parenting forum to understand perinatal distress. Shaban et al. [ 60 ] conducted bedside interviews of COVID-19 patients to explore their lived experiences and perceptions. The other three studies added open-ended questions asking about participants’ concerns related to COVID-19 in their surveys.

In general, the studies investigating specific subpopulation groups showed similar patterns to the findings of the studies on the general population – mental health and wellbeing deteriorated with the emergence of the COVID-19 pandemic and associated restrictions. This trend is consistent across the different populations of interest. However, it is also apparent that important population groups, such as Indigenous and CALD (Culturally and Linguistically Diverse) groups were not researched, limiting our knowledge for these groups. Psychological distress was reported widely among hospital staff in the two studies that measured hospital workers’ mental health [ 20 , 33 ]. Three studies focusing on adolescents and university students consistently showed higher psychological distress and lower subjective wellbeing since the COVID-19 outbreak [ 40 , 41 , 43 ]. Studies focusing on parents with young children identified a range of mental health challenges and risks during the COVID-19 period, and the three studies that included a pre-COVID comparison indicated that psychological distress increased [ 10 ,  70 , 71 ]. The themes identified from the qualitative studies differed as they were specific to the experiences of each subpopulation group. However, participants in these studies acknowledged the impact and the challenges brought by the COVID-19 pandemic and expressed worry and concerns (refer to Table 2 for details).

The two studies [ 30 , 63 ] reporting on participants’ mental health several times across the pandemic showed similar results to Biddle et al.’s [ 7 ] study of the general population. Griffiths et al. [ 30 ] focused on working adults and Staples et al. [ 63 ] focused on consecutive users of digital mental health services during the pandemic. Corresponding with Biddle et al. [ 7 ], both studies found that declines in mental health appeared to be more significant during March to April, and then improved in later months (returning normal levels) (except for the Victorian participants in Griffiths et al. [ 30 ]).

In contrast to the consistent findings from survey data showing increases in common mental health problems (i.e. psychological distress, depression and anxiety), two studies analysed data on emergency department (ED) presentations during the pandemic and showed varying results. Cheek et al. [ 15 ] found that mental health presentations potentially increased,while Dragovic et al. [ 22 ] found that the total number of mental health presentations decreased and that the trend varied depending on the reasons for the presentation. A decrease in ED presentations is not surprising given that face-to-face access to many health services declined during the pandemic (as people restricted their mobility) [ 5 ] – and thus, actual service use during this time does not likely reflect the need for services in the community. Importantly, according to data from AIHW [ 5 ], mental health related services, particularly services delivered online or via phone showed heightened service usage since the restrictions were introduced. The contrast between the two studies is likely because they were based on data from two different states with different COVID-19 responses, and Cheek et al. [ 15 ] only included paediatric patients.

In terms of suicidal intention, plans or behaviours, data from Queensland showed no change in suspected suicides [ 39 ] and in Western Australia, the presentations to emergency departments due to suicide or self-harm decreased significantly during this period [ 22 ]. On a national level, those who accessed digital mental health services during the pandemic also showed no changes regarding suicidal thoughts or plans [ 63 ].

Several potentially positive experiences related to the COVID-19 situation were identified from existing studies. Many individuals and families practicing isolation/social distancing reported some “silver linings”, such as strengthening relationships with their families, enjoying spending time at home, and developing new hobbies [ 24 , 35 ]. Patients with COVID-19 who were in isolation also reported some positive factors [ 60 ]. For example, although patients reported that they were disconnected from the outside world, lost track of time, and had limited mobility, some saw this as a reflection of the professionalism and quality of care provided. This enhanced their confidence and helped to ameliorate their initial concerns about being infected. Positive experiences were also identified as potential indicators of resilience and helped to mitigate the negative effect of the pandemic and restrictions on mental health [ 20 , 35 , 42 , 24 ]. For example, Oliva & Johnston’s study [  24 ], showed the mental health benefits of having a dog during the lockdown, likely because it encouraged exercise and provided an opportunity to socialize with other people.

Several studies made comparisons between specific population groups and the general population, or other population groups. These studies provide insights into which population groups might be at greater risk of experiencing mental health problems, and what factors were protective during the pandemic. Specifically, Broadway et al. [ 10 ] showed the protective effect of having two earners in the family in times of uncertainty. Phillipou et al. [ 52 ] found that individuals previously diagnosed with eating disorders experienced more mental health problems compared to the general population while people with high and low dysmorphic concern displayed different psychological and behaviour responses to the shutdown of the beauty industry in the COVID-19 lockdown [ 55 ].

In summary, we found that Australians in general experienced poorer mental health during the early stages of the pandemic in 2020 compared to pre-COVID. However, the absence of robust longitudinal cohort studies with pre-pandemic baseline data with makes this difficult to conclude definitively. Despite variation in the prevalence of and responses to COVID in individual countries, internationally research similarly indicates there has been a consistent deterioration in mental health and wellbeing levels around the world (see Findlay et al. [ 26 ] (Canada), Fitzpatrick et al. [ 28 ] (US), Pierce, Hope & Ford et al. [ 54 ] (UK). For example, the results of a meta-analysis [ 56 ] of longitudinal studies and natural experiments regarding the psychological impact of COVID-19 pandemic lockdowns internationally, aligns with our findings, showing an increase in psychological symptoms such as depression and anxiety, but no changes in suicidal risk. However, it is worth mentioning that all studies above were conducted in relatively high-income countries. Low-to-middle income countries have experienced even greater impacts during the pandemic, because of their inadequate and underprepared health systems and the uncertainty of their economies. Therefore the mental health impacts of COVID-19 are possibly more serious in the low-to-middle income countries and worthy of specific attention [ 1 , 12 ].

Apart from this general trend, some other key issues regarding the impact of the COVID-19 pandemic on mental health were also evident from the research findings. First, a series of demographic and socio-economic characteristics were identified as risk factors for adverse mental health outcomes. Most clearly, mental health and wellbeing levels seemed to deteriorate in younger age groups – while adolescents and young adults are at greater risk of poor mental health at any time (i.e. outside of pandemic conditions) the deterioration in their mental health during COVID appeared greater than for older age groups [ 7 ]. One explanation is that age is associated with other mental health risk factors that were heightened during the pandemic – such as employment and financial status. In April 2020, the underemployment rate in Australia was 13.8% while the youth underemployment rate hit 23.6% [ 3 ]. Along with employment and financial insecurity, young people are also more likely to have precarious housing and be more reliant on social and peer support which diminished during the pandemic [ 69 ]. As a consequence, it appears there has been a disproportional impact on younger adult’s mental health, despite their relative physical robustness [ 73 ]. Another important risk factor identified was pre-existing mental health problems. Earlier in 2020, Galletly [ 29 ] stated that the pandemic would be a difficult time for people with chronic mental illness. This is echoed by research showing that participants with a prior mental health diagnosis had poorer mental health during the pandemic – however the lack of studies reporting pre-COVID comparative data makes it difficult to determine the extent to which mental health decline for this group comparative to those with no pre-existing mental health problems.

The current review found that people reported some positive mental health and wellbeing experiences that emerged during the early stages of the pandemic. Potentially positive experiences reported by the participants in the reviewed studies included strengthening relationship with family and increased confidence in healthcare system [ 24 , 60 ]. Identifying the positive aspects of peoples’ experience during this challenging time is as important as identifying risk factors in terms of grasping a holistic understanding of what approaches and strategies are most useful to mitigate the negative impact of the pandemic on mental health.

Shortcomings in the research response

The current scoping review demonstrates that many Australian mental health researchers, like researchers internationally, responded rapidly to the pandemic. While this swift response captures a highly valuable snapshot of the impacts of this worldwide disaster, there are shortcomings in terms of design and the reliability and validity of findings. One key gap highlighted in this review is the lack of longitudinal studies with comparative pre-COVID data from the same cohort. Consequently, conclusions about how mental health changed over the course of the pandemic (from pre-pandemic levels), how people adapted during COVID, and whether trajectories varied for different groups are currently limited. A number of important national Australian studies (longitudinal and repeated cross-sectional) are yet to release data collected towards the end of 2020 (e.g. the Longitudinal Study of Australian Children wave 9C1; the ABS Intergenerational Health and Mental Health Study) – we expect these and other studies still to be published will go some way to addressing this knowledge gap. A further shortcoming is that the impact of the 2019–2020 Australian bushfires has rarely been considered.

The small number of qualitative and mixed method studies indicates another gap in the available research. There is value in adding qualitative research components to the mix that can elucidate contextual factors and lived experience particularly for specific and vulnerable groups which may assist in better provision of services to them. As COVID-19 is a novel virus leading to unprecedented challenges and experiences, qualitative research may contribute to a deeper understanding of the complexities (and emerging issues) of mental health and wellbeing pathways during the pandemic, and its potentially lasting impact on mental health once the pandemic has subsided.

These possibilities suggest that we need to fund good quality longitudinal research, as well as turn to rigorous and multi-faceted research. There is a need to gather baseline and follow-up data (including the use of administrative data, longitudinal, mixed-methods studies, and in-depth qualitative research). On a practical note, while the practicalities and mechanics of research are not the focus of the current review, it is important to note that the pandemic has revealed some of the barriers to conducting high quality mental health research that is responsive and has longevity. The time sensitivity of the pandemic, and its rapidly evolving nature highlighted delays related to need to for prompt ethics clearances across multiple institutions in Australia (under-resourced ethics committees were inundated with requests that needed to be expedited). The formal requirements of funding bodies are not well suited to rapidly evolving pandemics either, with funding for COVID-19 mental health research announced in November 2020 after the most restrictive lockdowns had ended. While Australia is a success story compared to similar wealthy western nations, the mental health impacts of COVID-19 (and the current gaps in this body of research) suggests that efforts to address current research practices and resource constraints may improve the country’s responsiveness to comprehensively study future challenges.

Research still to come….

The studies included in this review were conducted generally between April–May 2020. However, the COVID experience in Australia and worldwide is rapidly evolving: it has been contained in some Australian locations while additional outbreaks have occurred elsewhere. It is anticipated that Australian research results from studies conducted in the second half of 2020 and early 2021 will be different from those reported in the current review as efforts to contain the virus have been also evolving across the states and territories. The vaccine program rollout, currently being implemented, may have a significant impact. Research on the long-term mental health effects of disasters suggest that people’s responses evolve considerably [ 59 ]. However, the health nature of this pandemic may differentiate it from natural disasters, and comparative literature is not currently available.

While most existing studies show that COVID-19 containment measures have impacted negatively on the mental health of the general population and on specific vulnerable groups, it is anticipated that the population’s mental health outlook will improve as the vaccination program takes hold and lockdown measures are no longer needed [ 30 ]. However, the discontinuation of the national Job-keeper program (a federally funded program paid to businesses to keep their employees) and the Coronavirus Supplement payment for Job-seekers (an unemployment payment) [ 23 ] by end of March 2021 may trigger job and income losses, leading to declines in mental health for some. Financial insecurity is an important risk factor for poorer mental health—the Taking the Pulse of the Nation survey showed mental distress (depression or anxiety) was closely aligned with financial stress throughout 2021 [ 10 ]. Concerns remain for those with pre-existing mental health conditions, for those who may experience financial hardship over a long period, and for those who experience future lockdowns. For example, it appears that the mental health of residents in Victoria varied from the rest of Australia [ 30 ] as they were subjected to a second lengthy and severe lockdown period when the virus re-emerged that delayed re-entry to employment, schooling and services.

The COVID-19 pandemic may have a delayed impact on mental health in subpopulation groups in myriad interactive and cumulative ways. One example is the mental health of those who were pregnant during the early phases of the pandemic, who in 2021 will have infants and be in the postnatal phase and may have added vulnerability to postnatal depression and anxiety. In addition, as we note above, some vulnerable population groups are under-represented in the existing studies with implications for the management of the pandemic. For example, media reports at the time suggested that some CALD and socially and economically disadvantaged groups may have had different COVID-19 experiences and may have missed out on mainstream messaging; consequently, there may be discrimination that impacts the mental health for different ethnic groups for some time to come. The mental health status of healthcare workers, who have been on the frontline of this crisis, also requires further attention from the research community. The existing studies on the mental health of healthcare workers identified in this review were only conducted among hospital staff in several health services in Melbourne – not nearly enough to cover the experience of this population group in Australia. Fear of transmitting the virus to family, community perception of frontline workers as potential disease carriers, extreme workloads, limited availability of protective equipment and moral dilemmas have all added extra burdens to the mental health of the healthcare workers (Digby et al., 2021) [ 19 ]. A systematic review and meta-analysis of studies conducted in other countries has found high prevalence of mood and sleep disturbances among this specific group [ 49 ]. These future possibilities and identified research gaps demonstrate the need for ongoing research to better understand what happened to mental health both during the pandemic phase and in the aftermath.

Limitations

As noted, there are a number of limitations to this scoping review that need to be briefly acknowledged. The first relates to the rapidly changing and emergence of new published results. This review only provides a snapshot of the research available during the period when the existing literature was searched and it is possible that some information published online has been missed. Further updated reviews need to be conducted to continue to synthesize research findings. Second, while the current review did not perform a quality rating of the studies included in the review, discussion of study quality is included throughout and Tables 1 and 2 list detailed information about the characteristics of each study—including document type, sample size and representativeness, as well as whether pre-COVID comparisons were made. This information provides a reference for making judgements about the strengths and weaknesses (quality) of each study. We do conclude that studies published in peer-reviewed journals, based on a nationally representative sample of Australian population, with a pre-COVID comparison sample from the Australian population are the highest quality. We also make the point that prospective longitudinal studies including baseline (pre-COVID) data from the same sample or cohort are the most robust, but are rare. Third, an analysis of publication bias was not undertaken given that the body of literature is still so new – an analysis of publication bias that extends to considering those vulnerable groups that may have been missed (or difficult to access during COVID-19) would be worthwhile once a more substantial body of literature exists.

The review does not provide detailed data on prevalence rates and statistical associations for each study as many of them did not provide this information. Therefore, we instead aimed to scope the breadth of research conducted and provide a narrative overview (in the text and the Tables) of the findings. Future reviews will provide a comparative summary of the prevalence rates and associations (such as meta-analyses), once this information is obtained. Although the range of differences between studies (e.g. measures used, timing of survey within 2020) that we have observed is likely to make it challenging to combine the data to obtain comparative estimates.

The current scoping review provides a detailed record of the studies published online and in the academic literature investigating mental health during the COVID-19 pandemic in Australia. Our findings suggest that despite the comparatively low prevalence of the disease in the population, mental health problems (i.e. psychological distress, anxiety, depression, poor wellbeing) increased during the early part of the COVID pandemic in 2020. This finding points to the need to focus on mental health problems once the physical health impacts are reduced in countries where the pandemic has been widespread. However, limitations associated with many of the studies in the review, preclude reaching a more definite finding. Young people, those with fewer socio-economic resources and those with pre-existing mental health conditions showed the strongest associations with poor mental health during this time. The review highlights the importance of considering particular vulnerable groups, including health and hospital workers, those in quarantine or isolation, adolescents, parents of children, and people with a pre-existing mental health condition or who were accessing services. Heightened impact on these vulnerable groups suggests that policy attention needs to be given to their economic and psycho-social health to reduce the pandemic’s potentially long-lasting regressive effect. There is a need for further reviews as the follow-up results of longitudinal studies emerge and estimates and understandings of the impact of the pandemic are refined. There is also an important opportunity to consider the limitations of the research available and identify what resources are needed to ensure future timely responses to major disruptions to our way of life to understand the mental health impacts.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

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This scoping review was supported by funding from the Australian National Mental Health Commission. The findings and views reported are those of the authors and should not be attributed to the National Mental Health Commission.

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Table 1 Research conducted among general Australian adult population [ 37 , 47 ]. Table 2 Research conducted among specific subgroups in the population.

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Zhao, Y., Leach, L.S., Walsh, E. et al. COVID-19 and mental health in Australia – a scoping review. BMC Public Health 22 , 1200 (2022). https://doi.org/10.1186/s12889-022-13527-9

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Protecting the Nation's Mental Health

• Data show that the United States—especially its youth—is in mental health crisis.
• A public health approach that helps to improve environments where we live, work, learn, and play can positively impact mental health.
• Focusing on health equity can help ensure all groups of people have fair access to health and can live to their fullest potential.

Recent data show that the United States is in mental health crisis, experienced by people of all ages. This trend was observed prior to the COVID-19 pandemic, but has been worsened by pandemic-related factors.

• One in five American adults experienced symptoms of anxiety and depression in 2023. 1
• Even before the onset of the pandemic, there were noted increases in depression among Americans ages 12 and older. 2
• From 2020 through 2023, nearly 1 in 10 Americans reported experiencing depression. 3
• 5.8 million emergency department visits occurred in 2021 with mental, behavioral, and neurodevelopmental disorders as the primary diagnosis. 4

In addition, deaths from drugs, alcohol, and suicide more than doubled between 2000 and 2017 and continue to rise. 5 These deaths, often associated with mental distress, continue to impact families and communities socially, emotionally, and economically long after they occur.

Young people in the United States are particularly affected by the mental health crisis:

• Two in five high school students reported struggling with persistent feelings of sadness or hopelessness in 2023. 6
• In the 10 years leading up to the COVID-19 pandemic, students' persistent feelings of sadness and hopelessness increased by about 40% among high school students. 7
• Youth and young adults (ages 10-24) account for 15% of all suicides, an increase of 52% since 2000. It is the second leading cause of death for this age group. 8

Get help now‎‎

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org .

See available help and support resources here.

What government is doing

The mental health crisis impacts families, communities, workplaces, and the economy. The highest levels of national leadership are working to address this issue in several ways:

• The White House has committed to a national strategy for addressing mental illness and substance use disorders.
• Many of the US Surgeon General's current priorities revolve around mental health—including firearm violence, social connection, youth mental health, social media, health misinformation, workplace wellbeing, and health care worker burnout.
• Those living with mental health conditions, including serious mental conditions that significantly interfere with the ability to carry out life's activities.
• CDC plays a role in improving mental health through a public health approach, influencing conditions where people live, work, learn, and play (called the " social determinants of health ").

Improving mental health through public health

No one approach can solve the mental health crisis alone. CDC uses its expertise in public health data, science, and systems to improve mental health outcomes in the US.

• Public health uses a primary prevention approach to promote positive mental health by focusing on the drivers of well-being and mental distress. This approach aims to prevent mental health conditions before they develop or worsen.
• We identify, understand, and intervene on upstream protective factors, i.e., environmental and societal factors, to prevent mental distress and promote well-being for individuals and communities.
• We work with partners at the federal, state, and community level to improve mental health. These partners can include health care providers, public health workers, community organizations, faith-based communities, employers, local government leaders, and others.

CDC's Mental Health Strategy builds on the Mental Health Framework created in partnership between CDC, the Association of State and Territorial Health Officials (ASTHO), Mental Health America (MHA), and the Center for Law and Social Policy (CLASP) in October 2023. The intent of the partner-developed Mental Health Framework is to help public health practitioners understand and communicate with multisector partners about their role in mental health promotion.

CDC Mental Health Strategy for Individual, Family, Community, Society

Guiding Principle: CDC works with communities and partners to promote mental well-being to ensure everyone has an equitable chance to thrive.

Mental Health Framework Strategies (ASTHO, MHA, CLASP, CDC)

• Promote Well-being
• Improve Access to Supports and Opportunities
• Collect and use data
• Promote mental well-being and prevent mental distress
• Educate and inform about mental health and public health
• Strengthen mental health systems and support providers
• Engage and empower partners and communities to improve mental health
• Improve population surveillance of mental well-being and mental distress
• Use data to inform recommendations
• Support caregivers and communities, especially related to early childhood and adolescence
• Promote quality social connections
• Increase awareness and decrease stigma
• Develop and share tools, trainings, guidance, and resources for evaluation
• Increase access to and awareness and availability of services and supports
• Strengthen health workforce capacity and resilience
• Strengthen partnerships and create new opportunities
• Build state, territorial, local, and tribal capacity
• Strengthen supportive environments where we live, work, learn, and play

CDC recognizes that mental health is closely linked to physical health and social determinants and impacts health-related outcomes throughout life.

Health equity

CDC's public health strategy to improve mental health is guided by principles of health equity . Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. 9 When people have limited access to resources they need to be healthy, such as access to health care, they are more likely to struggle with health issues.

CDC works with partners to promote policies and focus resources on improving the lives of populations disproportionately impacted by the mental health crisis. This includes a focus on addressing differences in social determinants of health to accelerate progress towards achieving health equity.

Disproportionately affected populations include: 10

• Racial and ethnic minority groups, e.g., Black , Hispanic and Latino , American Indian/Alaska Native (AI/AN), Asian American, Native Hawaiian, and Pacific Islander ( AA and NHPI )
• Lesbian, Gay, Bisexual, and Transgender, Queer, and Intersex (LGBTQI+)
• People experiencing homelessness
• People who are justice-involved
• People who live in rural areas
• Household Pulse Survey. (2020–2024). Anxiety and Depression . [Data set]. CDC National Center for Health Statistics and U.S. Census Bureau. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm
• Goodwin, R. D., Dierker, L. C., Wu, M., Galea, S., Hoven, C. W., & Weinberger, A. H. (2022). Trends in U.S. Depression Prevalence From 2015 to 2020: The Widening Treatment Gap. American journal of preventive medicine , 63(5), 726–733. https://doi.org/10.1016/j.amepre.2022.05.014
• Substance Abuse and Mental Health Services Administration. (2024). 2023 Companion infographic report: Results from the 2021, 2022, and 2023 National Surveys on Drug Use and Health (SAMHSA Publication No. PEP24-07-020). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/report/2021-2022-2023-nsduh-infographic
• Cairns C, Kang K. (2021). National Hospital Ambulatory Medical Care Survey: 2021 emergency department summary tables. CDC National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/nhamcs/web_tables/2021-nhamcs-ed-web-tables-508.pdf
• Joint Economic Committee. (2019). Long-Term Trends in Deaths of Despair (Social Capital Project Report No. 4-19). United States Congress. https://www.jec.senate.gov/public/index.cfm/republicans/2019/9/long-term-trends-in-deaths-of-despair
• Centers for Disease Control and Prevention. (2024). Youth Risk Behavior Survey Data Summary & Trends Report: 2013–2023 . Retrieved from https://www.cdc.gov/yrbs/dstr/ .
• National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of Adolescent and School Health. (2020). Youth Risk Behavior Survey Data Summary & Trends Report 2009-2019. CDC. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBSDataSummaryTrendsReport2019-508.pdf
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• CDC. (2024). What is Health Equity? Retrieved August 1, 2024 from https://www.cdc.gov/health-equity/what-is/?CDC_AAref_Val=https://www.cdc.gov/healthequity/whatis/index.html
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Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations ☆

Shweta singh, deblina roy, krittika sinha, sheeba parveen, ginni sharma, gunjan joshi.

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Corresponding author.

Received 2020 May 30; Revised 2020 Aug 22; Accepted 2020 Aug 23; Issue date 2020 Nov.

Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

COVID-19 pandemic and lockdown has brought about a sense of fear and anxiety around the globe. This phenomenon has led to short term as well as long term psychosocial and mental health implications for children and adolescents. The quality and magnitude of impact on minors is determined by many vulnerability factors like developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection or fear of infection.

This paper is aimed at narratively reviewing various articles related to mental-health aspects of children and adolescents impacted by COVID-19 pandemic and enforcement of nationwide or regional lockdowns to prevent further spread of infection.

Methodology

We conducted a review and collected articles and advisories on mental health aspects of children and adolescents during the COVID-19 pandemic. We selected articles and thematically organized them. We put up their major findings under the thematic areas of impact on young children, school and college going students, children and adolescents with mental health challenges, economically underprivileged children, impact due to quarantine and separation from parents and the advisories of international organizations. We have also provided recommendations to the above.

There is a pressing need for planning longitudinal and developmental studies, and implementing evidence based elaborative plan of action to cater to the psycho social and mental health needs of the vulnerable children and adolescents during pandemic as well as post pandemic. There is a need to ameliorate children and adolescents’ access to mental health support services geared towards providing measures for developing healthy coping mechanisms during the current crisis. For this innovative child and adolescent mental health policies policies with direct and digital collaborative networks of psychiatrists, psychologists, paediatricians, and community volunteers are deemed necessary.

Keywords: COVID-19, Lockdown, Mental health, Children, Adolescents

1. Introduction

There are more than 2.2 billion children in the world who constitute approximately 28% of the world's population. Those aged between 10 to 19 years make up 16 % of the world's population ( UNICEF, 2019 ). COVID-19 has impacted the lives of people around the world including children and adolescents in an unprecedented manner. Throughout the world, an essential modus of prevention from COVID- 19 infection has been isolation and social distancing strategies to protect from the risk of infection ( Shen et al., 2020 ). On these grounds, since January, 2020, various countries started implementing regional and national containment measures or lockdowns. In this backdrop one of the principal measures taken during lockdown has been closure of schools, educational institutes and activity areas. These inexorable circumstances which are beyond normal experience, lead to stress, anxiety and a feeling of helplessness in all.

It has been indicated that compared to adults, this pandemic may continue to have increased long term adverse consequences on children and adolescents ( Shen et al., 2020 ). The nature and extent of impact on this age group depend on many vulnerability factors such as the developmental age, current educational status, having special needs, pre-existing mental health condition, being economically under privileged and child/ parent being quarantined due to infection or fear of infection. The following sections discuss about findings of studies on mental-health aspects of children and adolescents impacted by COVID-19 pandemic and lockdowns being implemented at national or regional levels to prevent further spread of infection.

2. Material and methods

We searched the electronic data bases of MEDLINE through PubMed, Cochrane Library, Science-direct and Google Scholar databases, from January,2020 till June,2020. We carried out the search with the following methods like, MeSH or free text terms and Boolean operators were employed for PubMed; COVID-19 and Children [All Fields] OR (Children and COVID-19 effects [Terms] OR & Psychological effects of COVID-19 on children &Quot;[All Fields] OR (&Quot; COVID effects on children &Quot;[All Fields] AND &quot; &Quot;[All Fields]) OR effects on Children of COVID-19 &quot; Psychological effects of COVID, Children &quot;[All Fields]) OR (&quot;COVID-19 and children &quot;[MeSH Terms] OR &quot; Psychological effects of COVID-19, Children &quot;[All Fields]. This search strategy and terms were modified for other databases as appropriate. The searches were done by five independent reviewers. A manual search was also conducted of the references of the related articles to gather information about the relevant studies. Initial PubMed search with the term with “ COVID-19 in children” showed only 12 results. Among these, only four articles were related to “Psychological effects of COVID in children”. Therefore in order to make the review more comprehensive and informative, we also included studies that reported the effect on older children and impact of COVID1-19 on their lives. This was done keeping in mind the varied terminologies used to describe the phenomenon of ‘Children and COVID-19”. After using the above strategy, our search showed 112 results. Only articles in English language peer reviewed journals were included. Grey literature such as conference proceedings were not included due to possibility of insufficient information. We included case studies and review articles and Advisories by the WHO (World Health Organization), APA (American Psychiatric Association) and NHS (National Health Services) and Government of India Ministry of Health. Based on these inclusion criteria we included 22 articles. Three independent authors participated in study selection and all authors reached a consensus on the studies to be included. Being a narrative review, we did not attempt computation of effect sizes or do a risk of bias assessment for included papers.

The studies included were categorized under eight headings divided in various thematic sections and discussed with studies and reports found. The data is qualitatively analysed and reported in the paper. A summary of the papers included in this narrative review is presented in Table 1 .

Articles on mental health and psycho-social aspects of COVID among children and adolescents.

2.1. Impact on young children

Stress starts showing its adverse effect on a child even before he or she is born. During stress, parents particularly pregnant mothers are in a psychologically vulnerable state to experience anxiety and depression which is biologically linked to the wellbeing of the foetus ( Biaggi et al., 2016 ; Kinsella and Monk, 2009 ). In young children and adolescents the pandemic and lockdown have a greater impact on emotional and social development compared to that in the grown-ups. In one of the preliminary studies during the on-going pandemic, it was found younger children (3-6years old) were more likely to manifest symptoms of clinginess and the fear of family members being infected than older children (6-18 years old). Whereas, the older children were more likely to experience inattention and were persistently inquiring regarding COVID-19. Although, severe psychological conditions of increased irritability, inattention and clinging behaviour were revealed by all children irrespective of their age groups ( Viner et al., 2020a ). Based on the questionnaires completed by the parents, findings reveal that children felt uncertain, fearful and isolated during current times. It was also shown that children experienced disturbed sleep, nightmares, poor appetite, agitation, inattention and separation related anxiety ( Jiao et al., 2020 ).

2.2. Impact on school and college going students

Globally, the pre-lockdown learning of children and adolescents predominantly involved one-to-one interaction with their mentors and peer groups. Unfortunately, the nationwide closures of schools and colleges have negatively impacted over 91% of the world's student population ( Lee, 2020 ). The home confinement of children and adolescents is associated with uncertainty and anxiety which is attributable to disruption in their education, physical activities and opportunities for socialization ( Jiao et al., 2020 ). Absence of structured setting of the school for a long duration result in disruption in routine, boredom and lack of innovative ideas for engaging in various academic and extracurricular activities. Some children have expressed lower levels of affect for not being able to play outdoors, not meeting friends and not engaging in the in-person school activities ( Lee, 2020 ; Liu et al., 2020 ; Zhai and Du, 2020 ). These children have become more clingy, attention seeking and more dependent on their parents due to the long term shift in their routine. It is presumed that children might resist going to school after the lockdown gets over and may face difficulty in establishing rapport with their mentors after the schools reopen. Consequently, the constraint of movement imposed on them can have a long term negative effect on their overall psychological wellbeing ( Lee, 2020 ).

A study found that older adolescents and youth are anxious regarding cancellation of examinations, exchange programs and academic events ( Lee, 2020 ). Current studies related to COVID-19 demonstrate that school shut downs in isolation  prevent about 2-4% additional deaths which is quite less if compared to usage of other measures of social distancing. Moreover, they suggest to the policy makers that other less disrupting social distancing strategies should be followed by schools if social distancing is recommended for a long duration ( Lee, 2020 ; Sahu, 2020 ; Viner et al., 2020a ). However, in current circumstances, it is controversial whether complete closure of school and colleges is warranted for a prolonged period.

It has been reported that panic buying in times of distress indicate an instinctual survival behaviour ( Arafat et al., 2020 ). In present pandemic era there has been a rise in the hoarding behaviour among the teenagers ( Oosterhoff et al., 2020a ). It is also found that among youth social distancing is viewed primarily as a social responsibility and it is followed more sincerely if motivated by prosocial reasons to prevent others from getting sick (Oosterhoff et al., 2020a). Further, due to prolonged confinement at home children's increased use of internet and social media predisposes them to use internet compulsively, access objectionable content and also increases their vulnerability for getting bullied or abused ( Cooper, 2020 ; UNICEF, 2020b ). Worst of all, during lockdown when schools, when legal and preventative services do not functioning fully, children are rarely in a position to report violence, abuse and harm if they themselves have abusive homes.

2.3. Impact on children and adolescents having special needs

There are about 1 in every 6 children within the age group of 2-8 years who have some or the other neurodevelopmental, behavioural or emotional difficulty ( CDC, 2019 ). These children with special needs [autism, attention deficit hyperactivity disorder, cerebral palsy, learning disability, developmental delays and other behavioural and emotional difficulties] encounter challenges during the current pandemic and lockdown ( CDC, 2019 ). They have intolerance for uncertainty and there is an aggravation in the symptoms due to the enforced restrictions and unfriendly environment which does not correspond with their regular routine. Also, they face difficulties in following instructions, understanding the complexity of the pandemic situation and doing their own work independently. With the closure of special schools and day care centres these children lack access to resource material, peer group interactions and opportunities of learning and developing important social and behavioural skills in due time may lead to regression to the past behavior as they lose anchor in life, as a result of this their symptoms could relapse ( Lee, 2020 ). These conditions also trigger outburst of temper tantrums, and conflict between parents and adolescents. Although prior to the pandemic, these children had been facing difficulties even while attending special schools, but in due course they had learnt to develop a schedule to adhere to for most of the time of the day ( APA, 2020 ; Cortese et al., 2020 ; UNICEF, 2020a ). To cater to these challenges, it is difficult for parents to handle the challenged children and adolescents on their own, as they lack professional expertise and they mostly relied on schools and therapists to help them out ( Dalton et al., 2020 ).

Since every disorder is different, every child has different needs to be met. The children with autism find it very difficult to adapt to the changing environment. They become agitated and exasperated when anything is rearranged or shifted from its existing setup. They might show an increase in their behavioral problems and acts of self-harm. It is a huge challenge for parents to handle autistic children due to lockdown. The suspension of speech therapy and occupational therapy sessions could have a negative impact on their skill development and the achievement of the next milestone, as it is difficult for them to learn through online sessions ( UNICEF, 2020a ). The children with Attention Deficit Hyperactivity Disorder (ADHD), struggle to make meaning of what is going around them from the cues they get from their caregivers. It is difficult for them to remain confined to a place and not to touch things, which might infect them.  Due to being confined to one place the chances of their hyperactivity increases along with heightened impulses and it becomes difficult for the caregivers to engage these children in meaningful activities ( Cortese et al., 2020 ).

Obsessive compulsive disorder (OCD) among the children and adolescents is estimated to be of 0.25%–4% among children and adolescents ( CDC, 2019 ). Children with OCD are suspected to be one of the most affected ones by this pandemic.  Due to obsessions and compulsions related to contamination, hoarding, and somatic preoccupation, they are expected to experience heightened distress. Cleanliness is one key protective measure against the spread of COVID-19. According to United Nations’ policy guidelines to fight the infection one has to be careful about washing their hands six times a day, and whenever they touch anything ( APA, 2020 ; United Nations, 2020 ). The lockdown, which has made the healthy population distressed about possessing enough food and prevention related resources like masks and sanitizers, has made it worse for people with hoarding disorder ( APA, 2020 ; Mukherjee et al., 2020 )

2.4. Impact of lockdown on underprivileged children

Social inequality has been associated with the risk of developing mental health challenges. The pandemic and lockdown world has experienced global economic turn-down which has directly worsened the pre-existing social inequality. In developing countries, with the imposed lockdown, the underprivileged children face acute deprivation of nutrition and overall protection. The prolonged period of stress could have a long term negative impact on their development. For instance, in India, which has the largest child population in the world with 472 million children, the lockdown has significantly impacted 40 million children from poor families. These include children working on farms, fields in rural areas, children of migrants and street children ( Dalton et al., 2020 ; Rosenthal et al., 2020 ). An increasing number of poor and street children now have no source of income, making them a high risk population to face abuse and mental health issues with greater vulnerability and exposure to unfavorable economic, social and environmental circumstances ( Birla, 2019 ).

A home represents a source of security and safety in most families. However, for the poor and the underprivileged it is just the opposite. With the restriction of movement due to lockdown, these children have increased risk of being exploited and become victims of violence and abuse ( Cooper, 2020 ; United Nations, 2020 ).  The Deputy Director of ‘CHILDLINE 1098’ India, announced that India saw a 50 per cent increase in the calls received on helpline for children since the lockdown began ( PTI, 2020 ). This increase in rate is alarming and has made an increasing number of child victims in their own homes.

During the time of lockdown an increasing number of poor families have no source of daily wages which lead to frustration and feelings of helplessness. By the reason of displacement, the frustration and family conflict may manifest itself in the form of violence towards children. This can make the child more vulnerable to depression, anxiety and suicide ( Jiao et al., 2020 ; Petito et al., 2020 ; Solantaus et al., 2020 ) School closure coupled with economic adversity may force children and adolescents into child labour. Likewise, children without parents or guardians are more prone to exploitation ( United Nations, 2020 ).

In order to cover up the loss of education during lockdown, many schools have offered distance learning or online courses to students. However, this opportunity is not available to underprivileged children as a result of which they face a lack of stimulation and have no access to online resource material to study. A study pointed out that in underprivileged families, in comparison to boys, girls have decreased access to gadgets, this may diminish their involvement in digital platforms of  education ( McQuillan and Neill, 2009 ). Due to this gender inequality, increasing number of girls are prone to bear the consequences of school dropouts once the lockdown is lifted ( Cooper, 2020 ; PTI, 2020 ).

2.5. Impact due to quarantine and separation from parents

COVID-19 infection is expressed differently in children and adolescents. Yet the incidents of infection in the minors have been reported worldwide, which result in children being quarantined. Moreover, in many cases a single parent or both the parents are infected and quarantined. In either condition children are separated from their parents. Many countries have laid down strict quarantine policies as a measure to fight COVID-19 pandemic. Such as in China several adults, adolescents and children have been put in complete isolation to control the spread of infection. Although quarantining measures are for the benefit of the community at large, its psychological effects cannot be ignored ( Liu et al., 2020 ). The children who are in isolation require special attention as these children might be at risk of developing mental health problems due to grief caused by of parental separation. As during the formative years of life, the role of parents is very crucial, any disruption in the form of isolation from parents can have long term effects of perceived attachment of the child. It is found that separation from the primary caregivers can make a child more vulnerable and can pose a threat to a child's mental health ( Cooper, 2020 ; Jiao et al., 2020 ; Liu et al., 2020 ). The children may develop feelings of sadness, anxiety, fear of death, fear of parents’ death and fear of being isolated in the hospital which may have a very detrimental effect on their psychological development ( APA, 2020 ; CDC, 2019 ; Dalton et al., 2020 ). Children have emotionally pent up feelings of distress which may turn inwards into emotional fear or outwards towards acting out behavior ( Liu et al., 2020 ). They might feel separated or alone as they have limited knowledge and level of maturity to understand the implications of the current pandemic situation in their limited world.

2.6. Advisories of international organizations

With the objective of universal prevention and mental health promotion, the International organizations and advisory bodies have issued various guidelines taking into account the mental health needs of children during the COVID-19. They have suggested parents to interact constructively with the children by communicating with them about the current pandemic, according to their maturity level and their ability to comprehend the crisis. Parents should plan their children's tasks one at a time, involve them in various home activities, educate them about following hygiene habits and social distancing, engage in indoor play and creative activities. In addition to these activities, adolescents are advised to be involved in household chores and understand their social responsibilities ( WHO, 2020b ) .  Interventions supervised by adults can help them in understanding their concerns. The activities of children and adolescents should include more structure in home schooling activities. Children should be encouraged to socialize with their friends and classmates through digital forums under adult supervision ( WHO, 2020a ).

The advisory committees have also provided guidelines for managing children with special needs and neurodevelopmental disorders ( UNICEF, 2020a , 2020b; WHO, 2020a ) . The children prone to risk for trauma and heightened anxiety. The children need early identification prompt management involving the parents and experts to prevent long term mental health morbidity.

2.7. Recommendations

It is imperative to plan strategies to enhance children and adolescent's access to mental health services during and after the current crisis. For this direct and digital collaborative network of various stakeholders is required. Recommendations for ensuring mental well-being of children and adolescents during the COVID-19 pandemic and lockdown and the role of parents, teachers, pediatricians, community volunteers, the health system and policy makers are being discussed. In addition a brief summary of the roles is given in Table 2 .

Mental health care of children and adolescents by various support systems.

2.8. Role of Parents

In the times of paramount stress and uncertainty, a secure family environment which the parents can provide is a strong protective factor ( Schofield et al., 2013 ). There is evidence to show that parental practices and coping measures affect the children's post disaster mental health ( Cobham et al., 2016 ). Parents need to respond to the needs of their children based on the developmental phase of the child is being discussed below:

2.9. Young children

Compared to adolescents, younger children demand  more attention  of their parents They need their parents’ physical presence and need to engage in more indoor play related activities with them. Parents should devote time to provide the child with undivided, positive attention and reassurance.

With the aim to  increase children's awareness about COVID 19,  it is crucial for parents to communicate with  young children in an age appropriate manner by using simple terminologies about COVID-19. Children need to be given fact based information with the help of presentations and video material provided by authorized international organizations like WHO and UNICEF or government resources which have been tailor made especially for children.

To  alleviate the anx iety of children regarding the current uncertain situation ( Wang et al., 2020 ), children's exposure to news should be limited and be through fact based neutral news channels only. The tabloid news should be avoided by all means.

The parents are recommended to  model appropriate preventive measures and coping mechanisms  which the family as a team and children individually are motivated to follow. For this use of reminders through phone may also be used.

Efforts should be made so that a  consistent routine is  followed by the child, with enough opportunities to play, read, rest and engage in physical activity. It is recommended that family plays board games and engages in indoor sports activities with the child to avoid longer durations of video games. Parents should ensure that particularly the bedtime of a child is consistent. It is possible that before the bed time children may need some more time and attention.

Focus should be on the  ‘good behaviour’  more than ‘bad behaviour’ of a child. Parents must tell more about options regarding what to do rather than what  not to do. Provide more praise and social reinforcements to children compared to material reinforcements.

It is quite possible that parents observe some amount of change in the behavior in children during the times of a pandemic. If the  behavior problems  are minor and not harmful for children and others, parents should consider ignoring and stop paying attention to them, this may lead to decrease in the recurrence in behavior and would also help in giving space to each other.

2.10. Adolescents

Apart from areas discussed above, certain areas which need especial focus in the phase of adolescence, are being described below:

Parents are the best ‘role model’  for children and home is practically the best place to learn the ‘life skills’. Hence, this is the best time for parents to model the most important life skills i.e. coping with stress, coping with emotions, and problem-solving with their children. Due to the cancellation of exams handle disappointments and uncertainties more positively. For each disappointment and uncertainty, there should be an alternative. Moreover, to inculcate a sense of control in adolescents whenever possible, parents can include adolescents in the decision-making process especially in matters related to them.

Adolescents are expected to have better  knowledge about COVID 19  compared to young children. Therefore, communication has to be more open and non-directive. On the other hand, judgmental statements about adolescents should be avoided.

This is an opportunity for older children to  learn responsibility, accountability, involvement, and collaboration.  By taking some responsibilities at home on an everyday basis, for instance maintenance of their belongings and utility items. They can learn some of the skills including cooking, managing money matters, learning first aid, organizing their room, contributing to managing chores like laundry, cleaning and cooking.

Excessive internet  use e.g. internet surfing related to COVID-19 should be avoided as it results in anxiety. Similarly, excessive and irresponsible use of social media or internet gaming should be cautioned against. Negotiations with adolescents to limit their time and internet-based activities are recommended. More non-gadget related in door activities and games are to be encouraged.

In such conditions taking up  creative pursuits  like art, music, dance and others can help to manage mental health and well-being for everyone. Inculcating self-driven reading by making them select books of their choice and discussing about them helps in adolescent development.

Adolescence is a phase of enthusiasm and risk-taking, hence some may feel invincible and  try not to follow guidelines  related to distancing and personal hygiene. This has to be addressed with adolescents assertively.

It is crucial to value the  peer support system  of the adolescents. Parents should encourage adolescents who are introverts to keep in touch with their peers and communicate with them about their feelings and common problems they face. This may also lead a way for appropriate problem-solving.

It is advised to  parents to take care of their own mental health  needs and try to cope with stress adaptively.

2.11. Role of school teachers/school counselors

In the present times when most schools and colleges are organizing online academic activities, teachers are in regular touch with students, and therefore are in a position to play a critical role in the promotion of psychological well being among youngsters. Their role during COVID-19 pandemic and lockdown are as follows:

Teachers can devote some time related to  educating about COVID-19  and preventive health behavior by using the guidelines of the international organizations, according to the maturity level of the students. They can explain to the students about the need to act with responsibility during the current pandemic. They can model and enact through their behavior the preventive measures.

They can  conduct creative online  academic and non-academic sessions by making their classes more interactive, engaging students in the form of quizzes, puzzles, small competitions, and giving more creative home assignments to break the monotony of the online classes. Standard educational material can be used. For instance, UNESCO has offered many online educational sources (UNESCO, 2020)

Teachers have a role to play in the  promotion of mental health among students . They can discuss what is wellbeing and how it is important for students. They can assist in teaching simple exercises, including deep breathing, muscle relaxation, distraction, and positive self -talk. Virtual workshops can be conducted in which ‘life skills’ related to coping in stress can be in focus by using more practical examples.

Teachers can make children understand the importance of  prosocial behavior  and the importance of human virtues like empathy and patience among others. This can help them to understand their role in the society and understand how social distancing is not equivalent to emotional distancing.

The teachers need to  interact with parents  online or through phone regarding feedback about students and their mental health. Because of the digital divide they can call parents, make their contact available to parents and devote a time slot when they can be available to parents to communicate.

They can serve as a doorway for  identification and referral to specialty mental health providers . They have a role act as a catalyst between the parent based on their interaction with students and findings of screening tools. If they observe any problem in the child, they can talk to parents and refer children and adolescents to mental health professionals.

With the support of school authorities, teachers need to make arrangements to ensure that the  reading material  related academics and life skills is made available to the underprivileged children  who do not have access to the internet. If possible arrangements can be made for them to use internet.

2.12. Role of pediatricians

During a child's formative years when their personalities are shaped,  parents are in regular  touch with pediatricians, as parents reach out to their local pediatricians whenever they encounter health/ behavioral complaints associated with their children. Parents expect answers from them as they trust them. Hence a pediatrician's role is paramount in promoting mental health, developing resilience, recognizing mental health problems, and coordinate with the mental health care providers when it comes to mental health care of children. In the backdrop of COVID 19 specific roles of  pediatricians are enlisted below:

They must be equipped with a  teleconsultation  facility and must use it as much as possible. They must generously keep the option open for tele or online consultation for parents.

They should  educate parents  about the developmental needs of the children in various phases of childhood and also disseminate simple and specific mental health promotion reading material online or through handouts to parents.

Paediatrician is in a position to  recognize the physical manifestations  of stress and emotional health problems in children e.g. the various internalization and externalizing conditions, for instance, aches, pains, or acts of self-harm.

They also need to ask about the relevant information related to various  predisposing factors associated with the child  i.e. temperament, functioning, adjustment in school, peer group, routine and general activities of the child.

Various  psychosocial and medical determinants and stressors  of mental health like family history, economic stressors, family environment, neighborhood, etc. which may lead to underlying problems can be assessed.

Mental health check-ups  should be conducted with the help of brief standardized screening tools by which they can easily screen various mental health problems in children especially including ADHD, autism, anxiety disorders, and depression.

They need to  develop stronger networks  and build partnerships with mental health providers, for instance, clinical psychologists, child psychologists, and psychiatrists. They should work in collaboration with them and refer children to them as and when the need arises for special mental health care. There is a need to develop online CMEs with the help of partnerships with Psychologists.

2.13. Mental healthcare workers

During times of paramount stress when the mental health of children and adolescents around the globe is directly or indirectly impacted, the role of mental health care workers, including clinical psychologists, psychiatrists, and psychiatric social workers is crucial keeping in mind their professional responsibilities and social challenges.

There is a need for  ‘tele mental health compatibility’  in place of in-person assessments and interventions. The objective of the mental health care providers should be to reach out to the general public at large. They need to work towards the production and dissemination of audio-video material related to healthy parenting, mental health awareness, reduction of stigma, practice mental health hygiene, promote health behavior, and psycho-educational material associated with the mental health care of children and adolescents.

There is an urgent requirement of  coordinated and innovative mental health  care delivery. For this, coordination with people who are playing a key role in the mental health care of children and adolescents e.g. parents, pediatricians, teachers, school counselors, community volunteers, NGOs, police, etc. should be involved and oriented about the mental health condition and briefly trained in providing basic psychological support and psychological first aid.

Providing online orientation for teachers  or the creation of material for school teachers and school counselors related to mental health promotion, life skill training, coordination with parents, and referral to mental health care professionals.

Conducting brief online training of  pediatricians  for mental health screening of vulnerable children, assessment of psychosocial factors, providing inputs relevant for the management of mild stress and anxiety in children, and referring to mental health care professionals is included.

Creating material for  special schools  for mental health promotion and management of behavior problems using contingency management, providing psychological first aid, referring to mental health care professionals would be required.

Create material for  community volunteers  for identification of high-risk children, e.g. underprivileged children, children of migrants, provide psychological first aid, and coordinate with caregivers and mental health care professionals.

Mental health care workers should focus on the construction and administration of  online questionnaires  to detect psychological distress and other stress symptoms in children if they or their parents are quarantined and also provide extra ad hoc supportive interventions.

Clinical Psychologists should design and implement tele based or in-person  short term focused behavioral interventions  for the management of known conditions in children [e.g. ADHD, autism, intellectual disabilities] mostly parent-focused, initiated using digital and electronic medium. The pathological consequences of crisis e.g. PTSD, depression, substance abuse in adolescents should also be addressed on similar lines. There is a requirement for creative solutions, often on a case-by-case basis.

Psychiatrists need to carefully weigh  the risks and benefits of psychotropic medications  for children and adolescents e.g. anti-depressants, anxiolytics, anticonvulsants, etc., and if possible, arranging medicines for those who cannot arrange.

There is a need for mental health care workers carry out longitudinal  and developmental studies  on short term and long term mental health impact of the COVID 19 pandemic and lock down on children and adolescents.

2.14. Health system and policy makers

It has been recognized by the world that the traditional pre-COVID-19 models and policies for children and adolescents' mental health are no longer applicable during COVID 19 era. Hence, the need is felt for the transformation of policies that can take into account not only lock down duration but also times following the lockdown. The following recommendations may be useful for guiding the functioning of the health system and policy making related to mental health care  of children and adolescents :

The focus of the health care system should be prevention, promotion, and treatment according to the  public mental health system  to meet population- mental health needs of the general population at large.

No single umbrella policy would be able to take into account various mental health aspects of children and adolescents dwelling in different environments. Hence the health system and policies should be based on  contextual parameters  that are different for each country or region depending on the degree of infection and the phase of infection they are in.

Since there is a dearth of mental health care workers in most developing countries. There is a need for  inclusive approaches  in which health care workers e.g. pediatricians, general physicians, schools, non-governmental organizations sectors are involved. Moreover, brief basic mental health care training for these arms should be planned.

Separate rules for the rural, suburban, and concrete domiciles in growing countries spotting the variance among college districts, which includes city, suburban, and rural districts.

It is critically important to develop  flexible strategies  that can be revised and adapted to school and throughout the community and done with close communication with state and/or local public health authorities.

Policies should be formulated taking into account the  developmental stage of the child  e.g. preschoolers, school age, adolescents.

There is a need for full translation dominant therapy approaches to  telehealth compatibility, but clear rules and regulations regarding the same are mandatory.

It should be ensured that the vulnerable sections of the society (medically prone, underprivileged, having developmental challenges, or having disabilities) are not neglected.

The  school re-entry policies  should be defined considering strict implimentation of key principles of social distancing and hygiene. This should be done keeping in mind the importance of in-person learning for children in the school set up.

Ensure adequate  fund allocation  and proper monitoring and utilization of the funds for policy implementation.

2.15. Critical appraisal of the studies included

The studies included in the review were collected after setting criteria to have a comprehensive view of the global vision in managing the crisis of children in the COVID-19 pandemic. The majority of the studies included in the review were based on online self-reports( Bhat et al., 2020 ; Jiao et al., 2020 ; Oosterhoff et al., 2020b ). The adults and older children were the respondents of the study( Lee, 2020 ; Liu et al., 2020 ; Viner et al., 2020b ; Wang et al., 2020 ).  The studies are mainly carried out in the developed nations and the East Asian countries. Studies have reported the concerns may not be generalizable throughout the globe. There are variations in the number of samples as well, thus they make it difficult to generalize the findings of their study alone.

The cross sectional studies are useful in understanding the immediate or short term impact apparent at a certain point of time. However the limitations of these cross sectional studies are that these studies cannot conclude about the long term impact of COVID-19, given that certain pre-existing vulnerabilities, high risk factors and stressors could be multiple, ongoing or recurrent and also the manner through which they work may vary. Consequently, there is a pressing need for carrying out longitudinal and developmental studies to be able to apprehend multiple layers of dynamic determinants playing role during this time of global crisis ( Holmes et al., 2020 ).The literature suggests the need for evidence based elaborative strategies and plan of action to cater to the mental health needs of children and adolescents during the period of pandemic ( Wade et al., 2020 ).

3. Limitations

The review articles for this review have been selected during the time of global lockdown, where the issues and challenges were new and the global crisis was at peak times. In our review, we were unable to track the measures of management targeted towards the children. The strategies reported in the studies were isolated to geopolitical conditions. The recommendations provided in this review can be modified to suit the needs of the places according to their local resources and geopolitical scenarios. Due to strict selection criteria and the short period of data collection and the only use of electronic databases for our research, there is a possibility of missing studies relevant to the care of children and adolescents.

4. Conclusion

Although the rate of COVID-19 infection among young children and adolescents is low, the stress confronted by them poses their condition as highly vulnerable. Many cross-sectional studies have been conducted to analyze the impact of COVID-19 and lock down on children and youth. The results of these studies show that the nature and extent of this impact depend on several vulnerability factors such as the developmental age, educational status, pre-existing mental health condition, being economically underprivileged or being quarantined due to infection /fear of infection. Studies show that young children show more clinginess, disturbed sleep, nightmares, poor appetite, inattentiveness, and significant separation problems.

The containment measures like school and activity centers closures for long periods together expose the children and youth to the debilitating effects on educational, psychological, and developmental attainment as they experience loneliness, anxiety, and uncertainty. Compulsive use of internet gaming and social media puts them at higher risk. Children and adolescents with mental health conditions are not used to variation in the environment. Hence there could be an exacerbation in symptoms and behavioral problems.

The children who receive training, therapy, and other treatments are at high risk of being derailed from therapy and special educations. Economically underprivileged children are particularly prone to exploitation and abuse. Children quarantined are at high risk for developing higher risk for mental health-related challenges.

There is a need to ameliorate children and adolescent's access to mental health services by using both face to face as well as digital platforms. For this collaborative network of parents, psychiatrists, psychologists, pediatricians, community volunteers, and NGOs are required. There is a need for ‘tele mental health compatibility’ and be accessible to the public at large. This would be crucial to prevent during and post-pandemic mental challenges in the most vulnerable and underprivileged section of the society. The focal point of the health care system and policymaking should be prevention, promotion, and interventions corresponding to the public mental health system to meet the mental health needs of the population at large by taking the regional contextual parameters into account.

Disclosure of prior presentation of study data

This paper has not been submitted in full or part in any conference and is not being considered for publication elsewhere.

Financial disclosure

This is a completely researcher initiated study without any external funding whatsoever.

CRediT authorship contribution statement

Shweta Singh: Writing - review & editing, Software, Validation, Supervision, Data curation, Writing - original draft, Conceptualization, Methodology. Deblina Roy: Validation, Visualization, Investigation, Data curation, Writing - original draft, Software. Krittika Sinha: Visualization, Investigation, Data curation, Writing - original draft. Sheeba Parveen: Visualization, Investigation. Ginni Sharma: Visualization, Investigation, Data curation, Writing - original draft. Gunjan Joshi: Visualization, Investigation, Data curation, Writing - original draft.

Declaration of Competing Interest

There is no known conflict of interest.The authors whose names are listed below certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants, participation in spakers’ bureaus arrangements, consultancies, memberships, stock ownerships, or other equity interest, or expert testimony and patent licencing arangements) or non financial interests such as ( personal or professional relationships, affiliations, knowledge or beliefs)in the subject matter or materials discussed in this manuscript. All the authors confirm that, all of them has contributed in the conception of design; analysis, interpretation of data; drafting the article; critically revisiting the article for important intellectual inputs; and approval of the final version. This paper has not been submitted elsewhere or is under review at another journal or publishing venue. The authors have no affiliation with any organization, with a direct or indirect financial interest in the subject matter discussed in the manuscript.

Acknowldegment

We would like to Acknowldge the efforts of Mrs. Meenakshi Seth and Mr. Prakhar Bhanu, who were involved in improving the language of the manuscript. Additionally the authors are gratefull to the CORONA Warriers i.e. the Health Care Workers for their selfless and tremendous service to the mankind.

This paper is aimed at reviewing articles related to mental-health aspects of children and adolescents impacted by COVID-19 pandemic and lockdowns. There is a need to carry out longitudinal and developmental studies and plan strategies to enhance children's and adolescent's access to mental health services during and after the current crisis. For this direct and digital collaborative network of psychiatrists, psychologists, pediatricians, and community volunteers are of vital importance.

Supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.psychres.2020.113429 .

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