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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

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COVID-19, Economic Impact, Mental Health, and Coping Behaviors: A Conceptual Framework and Future Research Directions

Xiaoqian lu.

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Edited by: Giray Gozgor, Istanbul Medeniyet University, Turkey

Reviewed by: Ronnie Das, Audencia Nantes School of Management, France; Morteza Zihayat, Ryerson University, Canada

*Correspondence: Zhibin Lin, [email protected]

This article was submitted to Environmental Psychology, a section of the journal Frontiers in Psychology

Received 2021 Aug 17; Accepted 2021 Oct 22; Collection date 2021.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

The COVID-19 pandemic has caused serious economic and social consequences. Recent research shows that the pandemic has not only caused a physical health crisis but also caused many psychological and mental crises. Based on the contemporary cognitive-behavioral models, this article offers a conceptual analysis of how the pandemic affects individual mental health and coping behaviors from the perspective of individual economic status, individual context, and social context. The analysis shows that (1) the pandemic has led to increased economic uncertainty, increased unemployment and underemployment pressure, increased income uncertainty, and different degrees of employment pressure and economic difficulties; (2) these difficulties have stimulated different levels of mental health problems, ranging from perceived insecurity (environmental, food safety, etc.), worry, fear, to stress, anxiety, depression, etc., and the mental health deterioration varies across different groups, with the symptoms of psychological distress are more obvious among disadvantageous groups; and (3) mental health problems have caused behavior changes, and various stress behaviors such as protective behaviors and resistive behaviors. Future research directions are suggested.

Keywords: COVID-19 pandemic, economic difficulty, employment difficulty, mental health, coping behavior

Introduction

The current COVID-19 pandemic is still ongoing, and it is concerning that we still do not know how long it will last and what long-term effects it will have. Despite the successful development of vaccines, the medical capacity to completely treat this disease is still limited. Non-pharmaceutical interventions (NPIs), such as increasing handwashing, reducing physical contact, wearing masks in public places, maintaining social distance, quarantine, and isolation, are still the main strategies for handling this pandemic ( Van Bavel et al., 2020 ; Gössling et al., 2021 ). The social and economic consequences of the pandemic are devastating: almost half of the global workforce is at risk of losing their livelihoods, tens of millions are at risk of falling into extreme poverty, and millions of companies are facing existential threat ( Alauddin et al., 2021 ). In addition to the pandemic itself, the economic impact of the crisis brings heavy psychological stress to individuals, causing mental health problems, and may trigger long-lasting behavior changes. Other pandemic-related factors may also cause psychological distress, including mandatory use of face masks ( Wang et al., 2020a ), lockdowns ( Le et al., 2020 ), lack of access to medical services ( Hao et al., 2020 ; Tee et al., 2021 ), dissatisfaction with health information ( Tee et al., 2021 ), perceived discrimination ( Wang et al., 2021 ), and stress about returning to work ( Tan et al., 2020 ).

Prior behavioral science research focuses on perceived threats, stress, and coping ( Van Bavel et al., 2020 ). In the early stages of the pandemic, the physical health risks associated with the COVID-19 pandemic have received extensive attention from the academic community ( Mehta et al., 2020 ; Odayar et al., 2020 ), and there is growing research attention on the risks of mental health associated with the spread of the pandemic ( Auerbach and Miller, 2020 ; Xiong et al., 2020 ; Wang et al., 2020a ). The focal attention since the outbreak of the pandemic has been the psychological distress as a result of the pandemic itself ( Jungmann and Witthöft, 2020 ) or the adverse economic impact of the pandemic ( Bierman et al., 2021 ). However, it is still unclear how the pandemic control measures cause mental health problems through economic impact ( Murakami et al., 2021 ). Many scholars believe that the measures taken during the pandemic may cause people to suffer more economic losses and fall into economic difficulties, thereby causing serious mental health problems ( Timming et al., 2021 ), while some scholars believe that although the pandemic may cause huge economic losses, people’s mental health status has not decreased ( Murakami et al., 2021 ). Therefore, it is necessary to conduct a conceptual analysis of the economic impact of the pandemic and mental health by synthesizing the relevant findings in existing literature ( Ali et al., 2021 ).

This study aims to develop a conceptual framework linking the pandemic to individual economic problems, unemployment, mental health, and behavior change. The main research questions are (1) what kind of individual economic stress has the pandemic caused? 2) what mental health problems have this individual economic stress caused, and to what extent? 3) does the mental health problem vary by different groups or individuals? 4) what kind of behaviors may be caused by the deterioration of mental health?

Theoretical Background

According to the World Health Organization, mental health includes subjective well-being, self-efficacy, autonomy, ability, intergenerational dependence, intellectual or emotional potential. When there is a problem with mental health, there will be a decline in subjective well-being and various negative emotions (such as fear, nervousness, loneliness, and despair), and symptoms such as mental distress (such as anxiety, depression, and stress) will appear ( Hossain et al., 2020 ). Mental health issues are considered as public health problems that are often affected by factors related to occupation, employment opportunities, and economic stress ( Ali et al., 2021 ). Many scholars have examined the impact of economic poverty and unemployment on mental health ( Jin et al., 1997 ). Disaster mental health research also shows that people generally suffer emotional or psychological distress following a disaster ( Pfefferbaum and North, 2020 ).

Mental Health Amid the Pandemic

The World Health Organization (2020) proposes mental health indicators for the COVID-19 pandemic: painful symptoms and perceived danger. Mental distress is a short-term state of emotional distress, often driven by limited resources to manage stressors and daily life needs ( Patel and Rietveld, 2020 ). The pandemic can become a major source of stress, especially in chronic anxiety and financial stress ( Van Bavel et al., 2020 ). Mental distress has become the focus of research on mental health problems amid a large-scale crisis ( Cheng et al., 2004 ; Wang et al., 2020b ). Preliminary evidence suggests that symptoms of anxiety, depression, and self-reported stress are common psychological responses to the pandemic ( Rajkumar, 2020 ). Salari et al. (2020) reported that the prevalence of stress was between 29.6 and 33.7%. In addition to mental distress, the pandemic and corresponding interventions or preventive measures may make people feel insecure, fearful, uncertain, lonely, or isolated ( Auerbach and Miller, 2020 ), which exacerbates the psychological distress ( Pfefferbaum and North, 2020 ).

Public Health Interventions

Non-medical interventions or control measures during the pandemic may weaken social relationships that can help people to regulate emotions, cope with stress, and maintain adaptability ( Rimé, 2009 ; Jetten et al., 2017 ; Williams et al., 2018 ), exacerbate feelings of loneliness and isolation ( Hawkley and Cacioppo, 2010 ; Holmes et al., 2020 ), and become a risk factor for more serious mental health disorders ( Cacioppo et al., 2006 ). The stresses experienced during the pandemic, especially the economic stress, may cause difficulties in interpersonal relationships, destroy psychological resources, and make normal interactions difficult ( Karney, 2020 ). The impact of the pandemic interventions on mental health vary across different (employment) groups.

Contemporary Cognitive-Behavioral Models and Mental Health

The contemporary cognitive-behavioral models ( Taylor and Asmundson, 2004 ; Asmundson et al., 2010 ) explore the key role of traits, triggering events, cognition, and behaviors in the development and maintenance of health anxiety, which can be used to analyze mental health problems during the pandemic period. Jungmann and Witthöft (2020) believe that during the pandemic, idiosyncratic health anxiety regulates the relationship between excessive online information search and viral anxiety, and adaptive emotions serve as a buffer between the two. The “Role Tension” model explores mental health issues from the perspective of role conflicts. It believes that individuals with multiple social roles may experience role conflicts, resulting in stress and adverse mental health ( Oomens et al., 2007 ). The broader behavioral immune system theory ( McKay et al., 2020 ) explores the specific path of disease anxiety, and believes that disgust tendency and sensitivity, and emotional response are all part of the behavioral immune system.

Conceptual Framework

Figure 1 summarizes the themes from recent research findings in a conceptual framework.

Conceptual framework.

The Mechanism of COVID-19’s Impact on Mental Health

In addition to the pandemic itself, the lockdown, quarantine, or self-isolation policies that aim at fighting the pandemic, the involuntary underemployment or unemployment have led to individuals’ economic difficulties and mental health problems of varying degrees for many people. The economic impact on individuals seems to further exuberate the suffering from the pandemic ( Bierman et al., 2021 ).

Employment Uncertainty

Employment problems caused by the pandemic include involuntary unemployment ( Piltch-Loeb et al., 2021 ), involuntary underemployment ( Pierce et al., 2020 ; Ferry et al., 2021 ), employment uncertainty and insecurity ( Wilson et al., 2020 ), job instability or inability to work ( Sirviö et al., 2012 ), and others. Studies have shown that involuntary underemployment and/or unemployment are related to poor mental health ( Dooley et al., 2000 ; Pharr et al., 2012 ), especially those who are unemployed during economic crises or recessions ( Uutela, 2010 ; Drydakis, 2015 ; Fiori et al., 2016 ). It is reported that crisis-related unemployment has led to a sharp rise in psychological disorders in low- and middle-income countries ( Uutela, 2010 ). Despite the government measures to limit the economic impact, the involuntary underemployment or unemployment caused by the epidemic is prominent.

The impact of the pandemic on mental health varies ( Pierce et al., 2020 ). Long-term unemployed people are most vulnerable to adverse mental health effects ( Pierce et al., 2020 ), and those who were employed and retired in the months before the pandemic experience worse than expected mental health conditions ( Ferry et al., 2021 ). Reduced work has different effects on the mental health of different groups. People who are in a poor health condition or self-isolated, and those who have their work reduced due to care responsibilities, have a higher degree of psychological distress ( Ferry et al., 2021 ). The higher the work insecurity caused by the pandemic, the more severe the symptoms of depression ( Wilson et al., 2020 ). As the pandemic continues, the fear of the pandemic itself has not increased mental health problems, but the deterioration of the labor market and the increase in the unemployment rate may intensify people’s fear of unemployment, thereby increasing the degree of mental distress ( Timming et al., 2021 ). In addition, due to the lockdown, people’s work routines can be broken. Remote work, interruption of work activities due to lockdown measures, or increased workload due to the needs of the pandemic may also become factors affecting mental health ( Rossi et al., 2020 ).

Economic Uncertainty

The analysis of individual economic distress during the pandemic usually focus on short-term economic distress or economic stress, such as personal income uncertainty, personal financial difficulties, salary reduction and other economic (income) losses ( Piltch-Loeb et al., 2021 ), as well as the expected long-term financial impact, such as depletion of savings and/or retirement funds ( Piltch-Loeb et al., 2021 ).

There are two possible ways in which economic distress mediates the impact of the pandemic on psychological distress. One is the economic hardship or economic threat triggered by the pandemic itself. Individual economic loss, economic hardship, or economic threat was significantly associated with mental health ( Ali et al., 2021 ). The pandemic has led to increased risks of depression, anxiety, stress, despair ( Pettinicchio et al., 2021 ), insomnia ( Hossain and Ali, 2021 ), and other common mental health problems. The negative relationship between economic distress and mental health may be a cumulative process. As exposure to distress extends, the average level of individual sufferings increases ( Bierman et al., 2021 ). At the later stage in the pandemic, economic-related anxiety may be a major predictor of psychological distress ( Timming et al., 2021 ).

Second, the unemployment and employment transition triggered by the pandemic affects the financial situation, which in turn affects psychological distress ( Thomas et al., 2007 ). The economic recession triggered by the pandemic and the increase in economic uncertainty has led to business bankruptcy or downsizing, increased involuntary underemployment or unemployment, increased uncertainty in personal income, and increased likelihood of individuals or families experiencing financial difficulties and economic pressure, consequently triggering large scale mental health problems ( Kimhi et al., 2020 ).

Coping Behaviors

The direct consequence of the pandemic’s impact on mental health is the change of personal behavior and habits. Studies on past epidemics and pandemics have shown that negative emotions such as anxiety and stress during the epidemic may lead to different behavior patterns.

Positive Defensive Behavior

Humans are born with a set of defense systems against ecological threats ( Mobbs et al., 2015 ). The main emotional response during a pandemic is fear. When people feel capable of responding to the threat of the pandemic, fear can cause individual behavior changes, but if people feel powerless, a defensive response occurs. Positive defensive behavior includes protective, defensive (avoidance), and substitution behaviors.

Protective Behavior

Mental health problems, such as high anxiety, during the epidemic may produce protective behaviors or compensatory behaviors ( Wheaton et al., 2012 ), including washing hands frequently, wearing masks, increasing cleaning of items, social distancing, and other restrictions. Protective behavior can be voluntary ( Rubin et al., 2009 ) or compliant with government regulation ( Fragkaki et al., 2021 ). In addition, people actively engage in physical activities to cope with stress and anxiety ( Ai et al., 2021 ).

Defensive (Avoidance) Behavior

Such behavior includes avoiding touching public goods, strangers, keeping a distance from “patients,” avoiding densely populated places and public transport ( Rubin et al., 2009 ), or even resigning from jobs that are perceived to be dangerous ( Yin and Ni, 2021 ).

Substitution Behavior (E.g. Using Technologies)

Service provision based on digital and artificial intelligence technology has become a possible solution to replace human service provision ( Nayal et al., 2021 ), triggering changes in consumer behavior by using technology-mediated services (such as robots) to replace manual services ( Kim et al., 2021 ).

Negative Resistance or Disruptive Behaviors

Resisting behavior.

People with low economic status are more likely to be vigilant about the public health information they receive are less willing to take recommended safety measures and may be more susceptible to “fake news” ( Van Bavel et al., 2020 ). Misunderstandings and worries about the pandemic may also cause the public to refuse to comply with preventive measures ( Prati et al., 2011 ). When people are less worried about the pandemic, they are less likely to engage in hygiene behaviors (such as washing hands), comply with social distance regulations, or be vaccinated if vaccines are available ( Taylor, 2019 ). People also resist or refuse to participate in protective actions proposed by the government when they maintain an optimistic bias about the consequences of the outbreak ( Fragkaki et al., 2021 ).

Panic Consumption Behavior

During the pandemic, a large number of customers stocked up on daily necessities to avoid the expected future threat due to uncertainty and panic arising from perceived scarcity, resulting in panic buying ( Omar et al., 2021 ). People flooded hospitals and clinics unnecessarily when they misunderstood their minor illness as a sign of a serious infection ( Asmundson and Taylor, 2020a , 2020b ).

Negative Idleness or Sabotage Behavior

Anxiety is an important driving force of behavior ( Taylor, 2019 ). Overly anxious individuals may engage in socially disruptive behaviors, especially for frontline service workers who are directly exposed to the outbreak (e.g., hotel staff), and may result in negative idleness (e.g., tardiness and absenteeism) or even disruptive behaviors or sabotage ( Karatepe et al., 2021 ).

Excessive Stress Behavior

Anxiety and depression caused by the economic difficulties and employment difficulties caused by the crisis may result in various excessive stress behaviors, such as alcoholism ( Ahmed et al., 2020 ) drug abuse ( Nagelhout et al., 2017 ), even suicide ( Milner et al., 2013 ), etc.

The Boundary Conditions

Sociodemographic factors.

The impact of economic or employment difficulties caused by the pandemic on mental health may be related to socio-demographic factors, including age, gender, ethnicity, family size, occupation, and income ( Ferry et al., 2021 ). Age is one factor. Young people are more likely to have a higher level of anxiety and stress due to the pandemic and corresponding intervention measures than the elderly ( Mann et al., 2020 ; Salameh et al., 2020 ; Hu and Qian, 2021 ; Ribeiro et al., 2021 ). Young people with mental health problems are especially likely to experience adverse health, well-being, and employment outcomes with long-term consequences ( Bauer et al., 2021 ). However, there are also arguments that the elderly may have greater financial difficulties due to the increase in medical expenses during the epidemic, which may trigger mental health problems ( Van Bavel et al., 2020 ), and the elderly’s negative health consequences have been long-term ones ( Van Bavel et al., 2020 ).

Gender is another one. Studies have shown that women are more likely to have higher levels of anxiety and stress when faced with possible physical health problems ( Salameh et al., 2020 ; Ferry et al., 2021 ; Ribeiro et al., 2021 ). However, when there is the fear of losing their job and the economic anxiety surrounding this possibility, the psychological distress level is more serious for male than female employees ( Timming et al., 2021 ). The third factor is ethnicity. Black and ethnic minority respondents have a higher level of economic anxiety ( Mann et al., 2020 ). The study by Timming et al. (2021) shows that, compared with non-Hispanic respondents, Hispanic respondents are significantly more anxious about losing their jobs. The fourth factor is family size and the number of children. Respondents from families with no children have lower levels of economic anxiety ( Mann et al., 2020 ). People living non-marital life have higher levels of psychological distress ( Ferry et al., 2021 ).

Occupation is the fifth factor. People working at the emergency and customer-facing services, such as doctors, medical staff, police forces, frontline volunteer organizations, and bankers, have a higher risk of infection and subsequent mental stress ( Shammi et al., 2020 ). The mental health of the unemployed, self-employed, and private professionals is worse than that of government professionals ( Ali et al., 2020 ) for increased income (or economic) uncertainty caused by the pandemic ( Patel and Rietveld, 2020 ) or for self-isolation or social distancing measures ( Auerbach and Miller, 2020 ).

The sixth factor is income status. Most studies show that economic hardship resulting from the pandemic may make those disadvantaged groups (e.g., those living in poverty, low-income families, homeless, and refugees) the most vulnerable to experience the corresponding negative consequences ( Van Bavel et al., 2020 ; Długosz, 2021 ; Hu and Qian, 2021 ). The mental health of people with disabilities and chronic diseases ( Pettinicchio et al., 2021 ), living alone, and socially marginalized people is even more hostile ( Kwong et al., 2020 ). However, some studies have suggested that the pandemic has a greater impact on the mental health of employees from high-income families ( Ferry et al., 2021 ).

Personality Traits and Psychological Conditions

Personality traits and psychological conditions play an important role in the formation of mental health. Fisher et al. (2021) suggested that depressed and anxious psychological states during the epidemic were associated with diminished energy, functional efficiency, optimism, creativity, engagement, and the ability to focus and solve problems, all of which are necessary for social and economic participation. During the pandemic, those with low collective self-esteem, low responsibility, and low openness to experience have higher levels of economic anxiety, as do those with high levels of neuroticism, perceived vulnerability to illness, and attribution from large group activities ( Mann et al., 2020 ). People with mental and physical health conditions may have higher levels of depression and anxiety because they are more likely to be unemployed and are prone to have higher levels of depression and anxiety ( Hao et al., 2020 ; Kwong et al., 2020 ; Jung et al., 2021 ). Extreme loneliness is the main cause of psychological distress ( Mikocka-Walus et al., 2021 ).

Emotional responses are part of the behavioral immune system. McKay et al. (2020) suggested that emotional reactions such as aversive tendencies and sensitivities are moderators of people’s disease sensitivity and anxiety. High perceived risks, especially economic risks, are significantly associated with less positive emotions and more negative emotions, leading to more severe mental health problems ( Han et al., 2021 ). The “optimism bias” may help individuals to avoid negative emotions ( Van Bavel et al., 2020 ); however, it may not be conducive for people to engage in behavior change in response to non-pharmacological interventions while individuals with high levels of anxiety and high perceived severity are more likely to be involved in behavior change ( Fragkaki et al., 2021 ).

External Environment

The complex factors of population density, health care capacity, limited resources and existing poverty, environmental factors, social structure, cultural norms, the number of people already infected, and the rapidly occurring community transmission of COVID-19 virus in a country or region can all contribute to public fears, which may lead to higher levels of mental health problems ( Shammi et al., 2020 ).

Level of Economic Development or Socio-Economic Crisis

People in low- and middle-income countries may have higher levels of stress, anxiety, and depression than those in high- and middle-income countries ( Tee et al., 2021 ). In lower-middle-income countries with socio-economic crises, political instability, dense population and limited resources, the stress and anxiety during the pandemic are high ( Salameh et al., 2020 ). Even in high-income countries such as Canada and the United Kingdom, deterioration in mental health has been reported, and are increasing along with the extension of the pandemic period ( Zajacova et al., 2020 ).

Government Economic Intervention Policies or Welfare Policies

Policies that reduce economic stress (e.g., economic interventions such as emergency response benefits) may alleviate the level of mental health deterioration in the early stages of a pandemic by reducing economic hardship and making people less worried about their economic situation ( Zajacova et al., 2020 ). Vaccine-based interventions help to mitigate the economic impact of the outbreak ( Meltzer et al., 1999 ).

Future Research Directions

Mental health management, monitoring and preventive measures.

For policymakers, health authorities and health care professionals, it is very important to understand the impact of health anxiety on behavior. Future research should investigate the monitoring and preventive measures for different industries or different groups so as to help the government, service providers and employers understand the groups that should be given priority in mental health support ( Ferry et al., 2021 ) and better conduct mental health rehabilitation. More studies are needed to examine the risk assessment of the pandemic, reliable risk communication with risk groups, the establishment of a cross-departmental management task force, and other measures.

Social Protection Measures and Relief Programs

Social protection measures include daily demand provision and social support ( Jung et al., 2021 ) and cash transfer programs ( Bauer et al., 2021 ). Future research should examine how to effectively use social protection measures (or relief plans) to solve the short-term and long-term effects of economic uncertainty caused by large-scale epidemics or economic crises on mental health. First, it is necessary to study how to support individual and family cash transfer programs to support young people’s future life opportunities and break the vicious circle between mental illness and poverty that puts many young people at a disadvantage in socio-economic and mental health ( Bauer et al., 2021 ). Second, it is essential to study the physical and mental health of the most economically disadvantaged during economic downturns ( Holmes et al., 2020 ; Bierman et al., 2021 ), and specialized relief measures that target low-income populations ( Shammi et al., 2020 ). Third, future research should consider both material and social supports in the examination of social protection measures (or relief programs). Fourth, future research attention needs to be paid to employee assistance programs, with a particular focus on mental health support for male employees.

Intervention and Rehabilitation Measures

Interventions to reduce economic uncertainty and economic risks should be a focus of future research from two aspects. Future research can be conducted around three aspects: First, to examine how to cultivate an individual’s adaptive mentality to epidemics. Second, to explore individual resilience and psychological rehabilitation during and after a pandemic crisis ( Hjemdal et al., 2011 ). Third, to explore the use of online interaction for social and mental health support. During the pandemic, providing remote mental health services is very important ( Salameh et al., 2020 ). Future studies should examine online interactions to cultivate empathy and a sense of connection to enhance mental health ( Schroeder et al., 2017 ; Waytz and Gray, 2018 ).

Consequences of Mental Health

There are currently few studies on the behavioral consequences of mental health, and more research is needed to understand the behavioral consequences of mental health caused by the epidemic. For example, the current research mainly focuses on panic buying behavior, and other compensatory behaviors can be added in the future, such as increasing the number of purchased goods, increasing specific food consumption, online shopping, and so on. Another example is to understand how individual factors (including health anxiety) specifically affect people’s behavior in response to the pandemic ( Asmundson and Taylor, 2020b ). In addition, more research is required to examine the impact of the economic impact of the epidemic on the long-term behavior of individuals, especially stressful behaviors such as alcohol abuse, drug abuse, and suicide.

Impact of Macro-Environmental Factors

In different cultural contexts (e.g., collectivism vs. individualism), economic distress and non-interventional measures such as social distancing may have different effects on mental health. From an evolutionary psychology perspective, when a group encounters a collective threat, strict rules may help the collective to coordinate and survive ( Roos et al., 2015 ). In the face of a pandemic, a culture that is accustomed to putting freedom above safety can make community coordination difficult. However, currently there is little comparative research on mental health and behavior changes specifically for different cultures, and it is worthy of further thinking in the future.

Ethnic Group

People of different ethnic groups may have different attitudes and behaviors toward the epidemic. Further research is needed to examine the different responses of different ethnic groups to the epidemic ( Rubin et al., 2009 ). Moreover, ethnic groups may have different degrees of xenophobia due to fear of coronavirus, and more research is needed to understand the relationship between coronavirus phobia and coronavirus-related xenophobia, and the possible role of individual difference variables (e.g., susceptibility to disease) within an ethnic group ( Taylor, 2019 ).

Economic Development

Future research may examine the relationships between economic development and the impact of the pandemic on mental health based on the economic status of different countries, and explore solutions to the severe psychosocial health phenomena that may be caused by socio-economic crises in economically underdeveloped countries amid a large scale crisis.

Relatively little research is focused on how psychological distress caused by the pandemic varies across countries. Future studies can compare and analyze the differences in the level of psychological distress in different countries with different economic conditions. As countries have achieved varying degrees of success in controlling the spread of the COVID-19 virus ( Patel and Rietveld, 2020 ). Future research based on international data can further explore the level of psychological distress in countries where government interventions are relatively successful, in comparison with those countries that are not so successful.

Long-Term Effects

As the COVID-19 pandemic continues to evolve, the sources of psychological distress surrounding the pandemic and the degree of psychological distress may change ( Piltch-Loeb et al., 2021 ). The extant research mainly focuses on the early or short-term psychological impact of the pandemic. Long-term longitudinal research should be added in the future to investigate the sources of psychological and mental distress at different time points ( Magnavita et al., 2020 ). Although a large number of studies have found a positive relationship between the economic uncertainty (or difficulties) and mental health problems, other studies do not degree with the relationship between deteriorating mental health and the level of job insecurity and financial impact ( Kwong et al., 2020 ). Further empirical research is needed to understand the interrelationships among various antecedents and how different factors mediate or moderate the relationship between the pandemic and mental health.

This conceptual analysis article explores two mechanisms (i.e., economic distress and employment distress) that lead to the deterioration of individuals’ mental health. The proposed conceptual framework explains how the COVID-19 pandemic and public health interventions affect people’s mental health, the responding coping behaviors. The extant literature provides evidence supporting the hypothesis that the COVID-19 pandemic and its associated measures increase individual economic uncertainty and employment uncertainty, thereby triggering mental health problems and coping behaviors. The findings of most studies support this mechanism from the onset of the pandemic to the emergence of economic distress and employment distress, to the deterioration of mental health, and then to changes in people’s behaviors. Supportive evidence was found in different countries (e.g., the United States, China, Bangladesh, Italy, etc.) and in different groups (elderly, young, disabled, mentally ill, etc.).

Author Contributions

XL: conceptualization, methodology, and writing – original draft preparation. ZL: conceptualization and writing – reviewing and editing. All authors contributed to the article and approved the submitted version.

This research was supported by the Educational Commission of Fujian Province of China (grant no. JAS20129) and the Science Foundation of Jimei University, China.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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• Published: 03 October 2022

How COVID-19 shaped mental health: from infection to pandemic effects

• Brenda W. J. H. Penninx   ORCID: orcid.org/0000-0001-7779-9672 1 , 2 ,
• Michael E. Benros   ORCID: orcid.org/0000-0003-4939-9465 3 , 4 ,
• Robyn S. Klein 5 &
• Christiaan H. Vinkers   ORCID: orcid.org/0000-0003-3698-0744 1 , 2  

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• Neurological manifestations
• Psychiatric disorders

The Coronavirus Disease 2019 (COVID-19) pandemic has threatened global mental health, both indirectly via disruptive societal changes and directly via neuropsychiatric sequelae after SARS-CoV-2 infection. Despite a small increase in self-reported mental health problems, this has (so far) not translated into objectively measurable increased rates of mental disorders, self-harm or suicide rates at the population level. This could suggest effective resilience and adaptation, but there is substantial heterogeneity among subgroups, and time-lag effects may also exist. With regard to COVID-19 itself, both acute and post-acute neuropsychiatric sequelae have become apparent, with high prevalence of fatigue, cognitive impairments and anxiety and depressive symptoms, even months after infection. To understand how COVID-19 continues to shape mental health in the longer term, fine-grained, well-controlled longitudinal data at the (neuro)biological, individual and societal levels remain essential. For future pandemics, policymakers and clinicians should prioritize mental health from the outset to identify and protect those at risk and promote long-term resilience.

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In 2019, the COVID-19 outbreak was declared a pandemic by the World Health Organization (WHO), with 590 million confirmed cases and 6.4 million deaths worldwide as of August 2022 (ref. 1 ). To contain the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across the globe, many national and local governments implemented often drastic restrictions as preventive health measures. Consequently, the pandemic has not only led to potential SARS-CoV-2 exposure, infection and disease but also to a wide range of policies consisting of mask requirements, quarantines, lockdowns, physical distancing and closure of non-essential services, with unprecedented societal and economic consequences.

As the world is slowly gaining control over COVID-19, it is timely and essential to ask how the pandemic has affected global mental health. Indirect effects include stress-evoking and disruptive societal changes, which may detrimentally affect mental health in the general population. Direct effects include SARS-CoV-2-mediated acute and long-lasting neuropsychiatric sequelae in affected individuals that occur during primary infection or as part of post-acute COVID syndrome (PACS) 2 —defined as symptoms lasting beyond 3–4 weeks that can involve multiple organs, including the brain. Several terminologies exist for characterizing the effects of COVID-19. PACS also includes late sequalae that constitute a clinical diagnosis of ‘long COVID’ where persistent symptoms are still present 12 weeks after initial infection and cannot be attributed to other conditions 3 .

Here we review both the direct and indirect effects of COVID-19 on mental health. First, we summarize empirical findings on how the COVID-19 pandemic has impacted population mental health, through mental health symptom reports, mental disorder prevalence and suicide rates. Second, we describe mental health sequalae of SARS-CoV-2 virus infection and COVID-19 disease (for example, cognitive impairment, fatigue and affective symptoms). For this, we use the term PACS for neuropsychiatric consequences beyond the acute period, and will also describe the underlying neurobiological impact on brain structure and function. We conclude with a discussion of the lessons learned and knowledge gaps that need to be further addressed.

Impact of the COVID-19 pandemic on population mental health

Independent of the pandemic, mental disorders are known to be prevalent globally and cause a very high disease burden 4 , 5 , 6 . For most common mental disorders (including major depressive disorder, anxiety disorders and alcohol use disorder), environmental stressors play a major etiological role. Disruptive and unpredictable pandemic circumstances may increase distress levels in many individuals, at least temporarily. However, it should be noted that the pandemic not only resulted in negative stressors but also in positive and potentially buffering changes for some, including a better work–life balance, improved family dynamics and enhanced feelings of closeness 7 .

Awareness of the potential mental health impact of the COVID-19 pandemic is reflected in the more than 35,000 papers published on this topic. However, this rapid research output comes with a cost: conclusions from many papers are limited due to small sample sizes, convenience sampling with unclear generalizability implications and lack of a pre-COVID-19 comparison. More reliable estimates of the pandemic mental health impact come from studies with longitudinal or time-series designs that include a pre-pandemic comparison. In our description of the evidence, we, therefore, explicitly focused on findings from meta-analyses that include longitudinal studies with data before the pandemic, as recently identified through a systematic literature search by the WHO 8 .

Self-reported mental health problems

Most studies examining the pandemic impact on mental health used online data collection methods to measure self-reported common indicators, such as mood, anxiety or general psychological distress. Pooled prevalence estimates of clinically relevant high levels of depression and anxiety symptoms during the COVID-19 pandemic range widely—between 20% and 35% 9 , 10 , 11 , 12 —but are difficult to interpret due to large methodological and sample heterogeneity. It also is important to note that high levels of self-reported mental health problems identify increased vulnerability and signal an increased risk for mental disorders, but they do not equal clinical caseness levels, which are generally much lower.

Three meta-analyses, pooling data from between 11 and 61 studies and involving ~50,000 individuals or more 13 , 14 , 15 , compared levels of self-reported mental health problems during the COVID-19 pandemic with those before the pandemic. Meta-analyses report on pooled effect sizes—that is, weighted averages of study-level effect sizes; these are generally considered small when they are ~0.2, moderate when ~0.5 and large when ~0.8. As shown in Table 1 , meta-analyses on mental health impact of the COVID-19 pandemic reach consistent conclusions and indicate that there has been a heterogeneous, statistically significant but small increase in self-reported mental health problems, with pooled effect sizes ranging from 0.07 to 0.27. The largest symptom increase was found when using specific mental health outcome measures assessing depression or anxiety symptoms. In addition, loneliness—a strong correlate of depression and anxiety—showed a small but significant increase during the pandemic (Table 1 ; effect size = 0.27) 16 . In contrast, self-reported general mental health and well-being indicators did not show significant change, and psychotic symptoms seemed to have decreased slightly 13 . In Europe, alcohol purchase decreased, but high-level drinking patterns solidified among those with pre-pandemic high drinking levels 17 . When compared to pre-COVID levels, no change in self-reported alcohol use (effect size = −0.01) was observed in a recent meta-analysis summarizing 128 studies from 58 (predominantly European and North American) countries 18 .

What is the time trajectory of self-reported mental health problems during the pandemic? Although findings are not uniform, various large-scale studies confirmed that the increase in mental health problems was highest during the first peak months of the pandemic and smaller—but not fully gone—in subsequent months when infection rates declined and social restrictions eased 13 , 19 , 20 . Psychological distress reports in the United Kingdom increased again during the second lockdown period 15 . Direct associations between anxiety and depression symptom levels and the average number of daily COVID-19 cases were confirmed in the US Centers for Disease Control and Prevention (CDC) data 21 . Studies that examined longer-term trajectories of symptoms during the first or even second year of the COVID-19 pandemic are more sparse but revealed stability of symptoms without clear evidence of recovery 15 , 22 . The exception appears to be for loneliness, as some studies confirmed further increasing trends throughout the first COVID-19 pandemic year 22 , 23 . As most published population-based studies were conducted in the early time period in which absolute numbers of SARS-CoV2-infected individuals were still low, the mental health impacts described in such studies are most likely due to indirect rather than direct effects of SARS-CoV-2 infection. However, it is possible that, in longer-term or later studies, these direct and indirect effects may be more intertwined.

The extent to which governmental policies and communication have impacted on population mental health is a relevant question. In cross-country comparisons, the extent of social restrictions showed a dose–response relationship with mental health problems 24 , 25 . In a review of 33 studies worldwide, it was concluded that governments that enacted stringent measures to contain the spread of COVID-19 benefitted not only the physical but also the mental health of their population during the pandemic 26 , even though more stringent policies may lead to more short-term mental distress 25 . It has been suggested that effective communication of risks, choices and policy measures may reduce polarization and conspiracy theories and mitigate the mental health impact of such measures 25 , 27 , 28 .

In sum, the general pattern of results is that of an increase in mental health symptoms in the population, especially during the first pandemic months, that remained elevated throughout 2020 and early 2021. It should be emphasized that this increase has a small effect size. However, even a small upward shift in mental health problems warrants attention as it has not yet shown to be returned to pre-pandemic levels, and it may have meaningful cumulative consequences at the population level. In addition, even a small effect size may mask a substantial heterogeneity in mental health impact, which may have affected vulnerable groups disproportionally (see below).

Mental disorders, self-harm and suicide

Whether the observed increase in mental health problems during the COVID-19 pandemic has translated into more mental disorders or even suicide mortality is not easy to answer. Mental disorders, characterized by more severe, disabling and persistent symptoms than self-reported mental health problems, are usually diagnosed by a clinician based on the International Classification of Diseases, 10th Revision (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria or with validated semi-structured clinical interviews. However, during the COVID-19 pandemic, research systematically examining the population prevalence of mental disorders has been sparse. Unfortunately, we can also not strongly rely on healthcare use studies as the pandemic impacted on healthcare provision more broadly, thereby making figures of patient admissions difficult to interpret.

On a global scale and based on imputations and modeling from survey data of self-reported mental health problems, the Global Burden of Disease (GBD) study 29 estimated that the COVID-19 pandemic has led to a 28% (95% uncertainty interval (UI): 25–30) increase in major depressive disorders and a 26% (95% UI: 23–28) increase in anxiety disorders. It should be noted that these estimations come with high uncertainty as the assumption that transient pandemic-related increases in mental symptoms extrapolate into incident mental disorders remains disputable. So far, only four longitudinal population-based studies have measured and compared current mental (that is, depressive and anxiety) disorder prevalence—defined using psychiatric diagnostic criteria—before and during the pandemic. Of these, two found no change 30 , 31 , one found a decrease 32 and one found an increase in prevalence of these disorders 33 . These studies were local, limited to high-income countries, often small-scale and used different modes of assessment (for example, online versus in-person) before and during the pandemic. This renders these observational results uncertain as well, but their contrast to the GBD calculations 29 is striking.

Time-series analysis of monthly suicide trends in 21 middle-income to high-income countries across the globe yielded no evidence for an increase in suicide rates in the first 4 months of the pandemic, and there was evidence of a fall in rates in 12 countries 34 . Also in the United States, there was a significant decrease in suicide mortality in the first pandemic months but a slight increase in mortality due to drug overdose and homicide 35 . A living systematic review 36 also concluded that, throughout 2020, there was no observed increase in suicide rates in 20 studies conducted in North America, Europe and Asia. Analyses of electronic health record data in the primary care setting showed reduced rates of self-harm during the first COVID-19 pandemic year 37 . In contrast, emergency department visits for self-harm behavior were unchanged 38 or increased 39 . Such inconsistent findings across healthcare settings may reflect a reluctance in healthcare-seeking behavior for mental healthcare issues. In the living systematic review, eight of 11 studies that examined service use data found a significant decrease in reported self-harm/suicide attempts after COVID lockdown, which returned to pre-lockdown levels in some studies with longer follow-up (5 months) 36 .

In sum, although calculations based on survey data predict a global increase of mental disorder prevalence, objective and consistent evidence for an increased mental disorder, self-harm or suicide prevalence or incidence during the first pandemic year remains absent. This observation, coupled with the only small increase in mental health symptom levels in the overall population, may suggest that most of the general population has demonstrated remarkable resilience and adaptation. However, alternative interpretations are possible. First, there is a large degree of heterogeneity in the mental health impact of COVID-19, and increased mental health in one group (for example, due to better work–family balance and work flexibility) may have masked mental health problems in others. Various societal responses seen in many countries, such as community support activities and bolstering mental health and crisis services, may have had mitigating effects on the mental health burden. Also, the relationship between mental health symptom increases during stressful periods and its subsequent effects on the incidence of mental disorders may be non-linear or could be less visible due to resulting alternative outcomes, such as drug overdose or homicide. Finally, we cannot rule out a lag-time effect, where disorders may take more time to develop or be picked up, especially because some of the personal financial or social consequences of the COVID pandemic may only become apparent later. It should be noted that data from low-income countries and longer-term studies beyond the first pandemic year are largely absent.

Which individuals are most affected by the COVID-19 pandemic?

There is substantial heterogeneity across studies that evaluated how the COVID pandemic impacted on mental health 13 , 14 , 15 . Although our society as a whole may have the ability to adequately bounce back from pandemic effects, there are vulnerable people who have been affected more than others.

First, women have consistently reported larger increases in mental health problems in response to the COVID-19 pandemic than men 13 , 15 , 29 , 40 , with meta-analytic effect sizes being 44% 15 to 75% 13 higher. This could reflect both higher stress vulnerability or larger daily life disruptions due to, for example, increased childcare responsibilities, exposure to home violence or greater economic impact due to employment disruptions that all disproportionately fell to women 41 , thereby exacerbating the already existing pre-pandemic gender inequalities in depression and anxiety levels. In addition, adolescents and young adults have been disproportionately affected compared to younger children and older adults 12 , 15 , 29 , 40 . This may be the result of unfavorable behavioral and social changes (for example, school closure periods 42 ) during a crucial development phase where social interactions outside the family context are pivotal. Alarmingly, even though suicide rates did not seem to increase at the population level, studies in China 43 and Japan 44 indicated significant increases in suicide rates in children and adolescents.

Existing socio-cultural disparities in mental health may have further widened during the COVID pandemic. Whether the impact is larger for individuals with low socio-economic status remains unclear, with contrasting meta-analyses pointing toward this group being protected 15 or at increased risk 40 . Earlier meta-analyses did not find that the mental health impact of COVID-19 differed across Europe, North America, Asia and Oceania 13 , 14 , but data are lacking from Africa and South America. Nevertheless, a large-scale within-country comparison in the United States found that the mental health of Black, Hispanic and Asian respondents worsened relatively more during the pandemic compared to White respondents. Moreover, White respondents were more likely to receive professional mental healthcare during the pandemic, and, conversely, Black, Hispanic, and Asian respondents demonstrated higher levels of unmet mental healthcare needs during this time 45 .

People with pre-existing somatic conditions represent another vulnerable group in which the pandemic had a greater impact (pooled effect size of 0.25) 13 . This includes people with conditions such as epilepsy, multiple sclerosis or cardiometabolic disease as well as those with multiple comorbidities. The disproportionate impact may reflect this groupʼs elevated COVID-19 risk and, consequently, more perceived stress and fear of infection, but it could also reflect disruptions of regular healthcare services.

Healthcare workers faced increased workload, rapidly changing and challenging work environments and exposure to infections and death, accompanied by fear of infecting themselves and their families. High prevalences of (subthreshold) depression (13% 46 ), depressive symptoms (31% 47 ), (subthreshold) anxiety (16% 46 ), anxiety symptoms (23% 47 ) and post-traumatic stress disorder (~22% 46 , 47 ) have been reported in healthcare workers. However, a meta-analysis did not find a larger mental health impact of the pandemic as compared to the general population 40 , and another meta-analysis (of 206 studies) found that the mental health status of healthcare workers was similar to or even better than that of the general population during the first COVID year 48 . However, it is important to note that these meta-analyses could not differentiate between frontline and non-frontline healthcare workers.

Finally, individuals with pre-existing mental disorders may be at increased risk for exacerbation of mental ill-health during the pandemic, possibly due to disease history—illustrating a higher genetic and/or environmental vulnerability—but also due to discontinuity of mental healthcare. Already before the pandemic, mental health systems were under-resourced and disorganized in most countries 6 , 49 , but a third of all WHO member states reported disruptions to mental and substance use services during the first 18 months of the pandemic 50 , with reduced, shortened or postponed appointments and limited capacity for acute inpatient admissions 51 , 52 . Despite this, there is no clear evidence that individuals with pre-existing mental disorders are disproportionately affected by pandemic-related societal disruptions; the effect size for pandemic impact on self-reported mental health problems was similar in psychiatric patients and the general population 13 . In the United States, emergency visits for ten different mental disorders were generally stable during the pandemic compared to earlier periods 53 . In a large Dutch study 22 , 54 with multiple pre-pandemic and during-pandemic assessments, there was no difference in symptom increase among patients relative to controls (see Fig. 1 for illustration). In absolute terms, however, it is important to note that psychiatric patients show much higher symptom levels of depression, anxiety, loneliness and COVID-fear than healthy controls. Again, variation in mental health changes during the pandemic is large: next to psychiatric patients who showed symptom decrease due to, for example, experiencing relief from social pressures, there certainly have been many patients with symptom increases and relapses during the pandemic.

Trajectories of mean depressive symptoms (QIDS score), anxiety symptoms (BAI score), loneliness (De Jong questionnaire score) and Fear of COVID-19 score before and during the first year of the COVID-19 pandemic in healthy controls (blue line, n  = 378) and in patients with depressive and/or anxiety disorders (red line, n  = 908). The x -axis indicates time with one pre-COVID assessment (averaged over up to five earlier assessments conducted between 2006 and 2019) and 11 online assessments during April 2020 through February 2021. Symbols indicate the mean score during the assessment with 95% CIs. As compared to pre-COVID assessment scores, the figure shows a statistically significant increase of depression and loneliness symptoms during the first pandemic peak (April 2020) in healthy controls but not in patients (for more details, see refs. 22 , 54 ). Asterisks indicate where subsequent wave scores differ from the prior wave scores ( P  < 0.05). The figure also illustrates the stability of depressive and anxiety symptoms during the first COVID year, a significant increase in loneliness during this period and fluctuations of Fear of COVID-19 score that positively correlate with infection rates in the Netherlands. Raw data are from the Netherlands Study of Depression and Anxiety (NESDA), which were re-analyzed for the current plots to illustrate differences between two groups (healthy controls versus patients). BAI, Beck Anxiety Inventory; QIDS, Quick Inventory of Depressive Symptoms.

Impact of COVID-19 infection and disease on mental health and the brain

Not only the pandemic but also COVID-19 itself can have severe impact on the mental health of affected individuals and, thus, of the population at large. Below we describe acute and post-acute neuropsychiatric sequelae seen in patients with COVID-19 and link these to neurobiological mechanisms.

Neuropsychiatric sequelae in individuals with COVID-19

Common symptoms associated with acute SARS-CoV-2 infection include headache, anosmia (loss of sense of smell) and dysgeusia (loss of sense of taste). The broader neuropsychiatric impact is dependent on infection severity and is very heterogeneous (Table 2 ). It ranges from no neuropsychiatric symptoms among the large group of asymptomatic COVID-19 cases to milder transient neuropsychiatric symptoms, such as fatigue, sleep disturbance and cognitive impairment, predominantly occurring among symptomatic patients with COVID-19 (ref. 55 ). Cognitive impairment consists of sustained memory impairments and executive dysfunction, including short-term memory loss, concentration problems, word-finding problems and impaired daily problem-solving, colloquially termed ‘brain fog’ by patients and clinicians. A small number of infected individuals become severely ill and require hospitalization. During hospital admission, the predominant neuropsychiatric outcome is delirium 56 . Delirium occurs among one-third of hospitalized patients with COVID-19 and among over half of patients with COVID-19 who require intensive care unit (ICU) treatment. These delirium rates seem similar to those observed among individuals with severe illness hospitalized for other general medical conditions 57 . Delirium is associated with neuropsychiatric sequalae after hospitalization, as part of post-intensive care syndrome 58 , in which sepsis and inflammation are associated with cognitive dysfunction and an increased risk of a broad range of psychiatric symptoms, from anxiety to depression and psychotic symptoms with hallucinations 59 , 60 .

A subset of patients with COVID-19 develop PACS 61 , which can include neuropsychiatric symptoms. A large meta-analysis summarizes 51 studies involving 18,917 patients with a mean follow-up of 77 days (range, 14–182 days) 62 . The most prevalent neuropsychiatric symptom associated with COVID-19 was sleep disturbance, with a pooled prevalence of 27.4%, followed by fatigue (24.4%), cognitive impairment (20.2%), anxiety symptoms (19.1%), post-traumatic stress symptoms (15.7%) and depression symptoms (12.9%) (Table 2 ). Another meta-analysis that assessed patients 12 weeks or more after confirmed COVID-19 diagnosis found that 32% experienced fatigue, and 22% experienced cognitive impairment 63 . To what extent neuropsychiatric symptoms are truly unique for patients with COVID remains unclear from these meta-analyses, as hardly any study included well-matched controls with other types of respiratory infections or inflammatory conditions.

Studies based on electronic health records have examined whether higher levels of neuropsychiatric symptoms truly translate into a higher incidence of clinically overt mental disorders 64 , 65 . In a 1-year follow-up using the US Veterans Affairs database, 153,848 survivors of SARS-CoV-2 infection exhibited an increased incidence of any mental disorder with a relative risk of 1.46 and, specifically, 1.35 for anxiety disorders, 1.39 for depressive disorders and 1.38 for stress and adjustment disorders, compared to a contemporary group and a historical control group ( n  = 5,859,251) 65 . In absolute numbers, the incident risk difference attributable to SARS-CoV-2 for mental disorders was 64 per 1,000 individuals. Taquet et al. 64 analyzed electronic health records from the US-based TriNetX network with over 81 million patients and 236,379 COVID-19 survivors followed for 6 months. In absolute numbers, 6-month incidence of hospital contacts related to diagnoses of anxiety, affective disorder or psychotic disorder was 7.0%, 4.5% and 0.4%, respectively. Risks of incident neurological or psychiatric diagnoses were directly correlated with COVID-19 severity and increased by 78% when compared to influenza and by 32% when compared to other respiratory tract infections. In contrast, a medical record study involving 8.3 million adults confirmed that neuropsychiatric disorders were significantly elevated among COVID-19 hospitalized individuals but to a similar extent as in hospitalized patients with other severe respiratory disease 66 . In line with this, a study using language processing of clinical notes in electronic health records did not find an increase in fatigue, mood and anxiety symptoms among COVID-19 hospitalized individuals when compared to hospitalized patients for other indications and adjusted for sociodemographic features and hospital course 67 . It is important to note that research based only on hospital records might be influenced by increased health-seeking behavior that could be differential across care settings or by increased follow-up by hospitals of patients with COVID-19 (compared to patients with other conditions).

Consequently, whether PACS symptoms form a unique pattern due to specific infection with SARS-CoV-2 remains debatable. Prospective case–control studies that do not rely on hospital records but measure the incidence of neuropsychiatric symptoms and diagnoses after COVID-19 are still scarce, but they are critical for distinguishing causation and confounding when characterizing PACS and the uniqueness of neuropsychiatric sequalae after COVID-19 (ref. 68 ). Recent studies with well-matched control groups illustrate that long-term consequences may not be so unique, as they were similar to those observed in patients with other diseases of similar severity, such as after acute myocardial infarction or in ICU patients 56 , 66 . A first prospective follow-up study of COVID-19 survivors and control patients matched on disease severity, age, sex and ICU admission found similar neuropsychiatric outcomes, regarding both new-onset psychiatric diagnosis (19% versus 20%) and neuropsychiatric symptoms (81% versus 93%). However, moderate but significantly worse cognitive outcomes 6 months after symptom onset were found among survivors of COVID-19 (ref. 69 ). In line with this, a longitudinal study of 785 participants from the UK Biobank showed small but significant cognitive impairment among individuals infected with SARS-CoV-2 compared to matched controls 70 .

Numerous psychosocial mechanisms can lead to neuropsychiatric sequalae of COVID-19, including functional impairment; psychological impact due to, for example, fear of dying; stress of being infected with a novel pandemic disease; isolation as part of quarantine and lack of social support; fear/guilt of spreading COVID-19 to family or community; and socioeconomic distress by lost wages 71 . However, there is also ample evidence that neurobiological mechanisms play an important role, which is discussed below.

Neurobiological mechanisms underlying neuropsychiatric sequelae of COVID-19

Acute neuropsychiatric symptoms among patients with severe COVID-19 have been found to correlate with the level of serum inflammatory markers 72 and coincide with neuroimaging findings of immune activation, including leukoencephalopathy, acute disseminated encephalomyelitis, cytotoxic lesions of the corpus callosum or cranial nerve enhancement 73 . Rare presentations, including meningitis, encephalitis, inflammatory demyelination, cerebral infarction and acute hemorrhagic necrotizing encephalopathy, have also been reported 74 . Hospitalized patients with frank encephalopathies display impaired blood-brain barrier (BBB) integrity with leptomeningeal enhancement on brain magnetic resonance images 75 . Studies of postmortem specimens from patients who succumbed to acute COVID-19 reveal significant neuropathology with signs of hypoxic damage and neuroinflammation. These include evidence of BBB permeability with extravasation of fibrinogen, microglial activation, astrogliosis, leukocyte infiltration and microhemorrhages 76 , 77 . However, it is still unclear to what extent these findings differ from patients with similar illness severity due to acute non-COVID illness, as these brain effects might not be virus-specific effects but rather due to cytokine-mediated neuroinflammation and critical illness.

Post-acute neuroimaging studies in SARS-CoV-2-recovered patients, as compared to control patients without COVID-19, reveal numerous alterations in brain structure on a group level, although effect sizes are generally small. These include minor reduction in gray matter thickness in the various regions of the cortex and within the corpus collosum, diffuse edema, increases in markers of tissue damage in regions functionally connected to the olfactory cortex and reductions in overall brain size 70 , 78 . Neuroimaging studies of post-acute COVID-19 patients also report abnormalities consistent with micro-structural and functional alterations, specifically within the hippocampus 79 , 80 , a brain region critical for memory formation and regulating anxiety, mood and stress responses, but also within gray matter areas involving the olfactory system and cingulate cortex 80 . Overall, these findings are in line with ongoing anosmia, tremors, affect problems and cognitive impairment.

Interestingly, despite findings mentioned above, there is little evidence of SARS-CoV-2 neuroinvasion with productive replication, and viral material is rarely found in the central nervous system (CNS) of patients with COVID-19 (refs. 76 , 77 , 81 ). Thus, neurobiological mechanisms of SARS-CoV-2-mediated neuropsychiatric sequelae remain unclear, especially in patients who initially present with milder forms of COVID-19. Symptomatic SARS-CoV-2 infection is associated with hypoxia, cytokine release syndrome (CRS) and dysregulated innate and adaptive immune responses (reviewed in ref. 82 ). All these effects could contribute to neuroinflammation and endothelial cell activation (Fig. 2 ). Examination of cerebrospinal fluid in patients with neuroimaging findings revealed elevated levels of pro-inflammatory, BBB-destabilizing cytokines, including interleukin-6 (IL-6), IL-1, IL-8 and mononuclear cell chemoattractants 83 , 84 . Whether these cytokines arise from the periphery, due to COVID-19-mediated CRS, or from within the CNS, is unclear. As studies generally lack control patients with other severe illnesses, the specificity of such findings to SARS-CoV-2 also remains unclear. Systemic inflammatory processes, including cytokine release, have been linked to glial activation with expression of chemoattractants that recruit immune cells, leading to neuroinflammation and injury 85 . Cerebrospinal fluid concentrations of neurofilament light, a biomarker of neuronal damage, were reportedly elevated in patients hospitalized with COVID-19 regardless of whether they exhibited neurologic diseases 86 . Acute thromboembolic events leading to ischemic infarcts are also common in patients with COVID-19 due to a potentially increased pro-coagulant process secondary to CRS 87 .

(1) Elevation of BBB-destabilizing cytokines (IL-1β and TNF) within the serum due to CRS or local interactions of mononuclear and endothelial cells. (2) Virus-induced endotheliitis increases susceptibility to microthrombus formation due to platelet activation, elevation of vWF and fibrin deposition. (3) Cytokine, mononuclear and endothelial cell interactions promote disruption of the BBB, which may allow entry of leukocytes expressing IFNg into the CNS (4), leading to microglial activation (5). (6) Activated microglia may eliminate synapses and/or express cytokines that promote neuronal injury. (7) Injured neurons express IL-6 which, together with IL-1β, promote a ‘gliogenic switch’ in NSCs (8), decreasing adult neurogenesis. (9) The combination of microglial (and possibly astrocyte) activation, neuronal injury and synapse loss may lead to dysregulation of NTs and neuronal circuitry. IFNg, interferon-g; NSC, neural stem cell; NT, neurotransmitter; TJ, tight junction; TNF, tumor necrosis factor; vWF, von Willebrand factor.

It is also unclear whether hospitalized patients with COVID-19 may develop brain abnormalities due to hypoxia or CRS rather than as a direct effect of SARS-CoV-2 infection. Hypoxia may cause neuronal dysfunction, cerebral edema, increased BBB permeability, cytokine expression and onset of neurodegenerative diseases 88 , 89 . CRS, with life-threatening levels of serum TNF-α and IL-1 (ref. 90 ) could also impact BBB function, as these cytokines destabilize microvasculature endothelial cell junctional proteins critical for BBB integrity 91 . In mild SARS-CoV-2 infection, circulating immune factors combined with mild hypoxia might impact BBB function and lead to neuroinflammation 92 , as observed during infection with other non-neuroinvasive respiratory pathogens 93 . However, multiple studies suggest that the SARS-CoV-2 spike protein itself may also induce venous and arterial endothelial cell activation and endotheliitis, disrupt BBB integrity or cross the BBB via adoptive transcytosis 94 , 95 , 96 .

Reducing neuropsychiatric sequelae of COVID-19

The increased risk of COVID-19-related neuropsychiatric sequalae was most pronounced during the first pandemic peak but reduced over the subsequent 2 years 64 , 97 . This may be due to reduced impact of newer SARS-CoV-2 strains (that is, Omicron) but also protective effects of vaccination, which limit SARS-CoV-2 spread and may, thus, prevent neuropsychiatric sequalae. Fully vaccinated individuals with breakthrough infections exhibit a 50% reduction in PACS 98 , even though vaccination does not improve PACS-related neuropsychiatric symptoms in patients with a prior history of COVID-19 (ref. 99 ). As patients with pre-existing mental disorders are at increased risk of SARS-CoV-2 infection, they deserve to be among the prioritization groups for vaccination efforts 100 .

Adequate treatment strategies for neuropsychiatric sequelae of COVID-19 are needed. As no specific evidence-based intervention yet exists, the best current treatment approach is that for neuropsychiatric sequelae arising after other severe medical conditions 101 . Stepped care—a staged approach of mental health services comprising a hierarchy of interventions, from least to most intensive, matched to the individual’s need—is efficacious with monitoring of mental health and cognitive problems. Milder symptoms likely benefit from counseling and holistic care, including physiotherapy, psychotherapy and rehabilitation. Individuals with moderate to severe symptoms fulfilling psychiatric diagnoses should receive guideline-concordant care for these disorders 61 . Patients with pre-existing mental disorders also deserve special attention when affected by COVID-19, as they have shown to have an increased risk of COVID-19-related hospitalization, complications and death 102 . This may involve interventions to address their general health, any unfavorable socioenvironmental factors, substance abuse or treatment adherence issues.

Lessons learned, knowledge gaps and future challenges

Ultimately, it is not only the millions of people who have died from COVID-19 worldwide that we remember but also the distress experienced during an unpredictable period with overstretched healthcare systems, lockdowns, school closures and changing work environments. In a world that is more and more globalized, connectivity puts us at risk for future pandemics. What can be learned from the last 2 years of the COVID-19 pandemic about how to handle future and longstanding challenges related to mental health?

Give mental health equal priority to physical health

The COVID-19 pandemic has demonstrated that our population seems quite resilient and adaptive. Nevertheless, even if society as a whole may bounce back, there is a large group of people whose mental health has been and will be disproportionately affected by this and future crises. Although various groups, such as the WHO 8 , the National Health Commission of China 103 , the Asia Pacific Disaster Mental Health Network 104 and a National Taskforce in India 105 , developed mental health policies early on, many countries were late in realizing that a mental health agenda deserves immediate attention in a rapidly evolving pandemic. Implementation of comprehensive and integrated mental health policies was generally inconsistent and suboptimal 106 and often in the shadow of policies directed at containing and reducing the spread of SARS-CoV-2. Leadership is needed to convey the message that mental health is as important as physical health and that we should focus specific attention and early interventions on those at the highest risk. This includes those vulnerable due to factors such as low socioeconomic status, specific developmental life phase (adolescents and young adults), pre-existing risk (poor physical or somatic health and early life trauma) or high exposure to pandemic-related (work) changes—for example, women and healthcare personnel. This means that not only should investment in youth and reducing health inequalities remain at the top of any policy agenda but also that mental health should be explicitly addressed from the start in any future global health crisis situation.

Communication and trust is crucial for mental health

Uncertainty and uncontrollability during the pandemic have challenged rational thinking. Negative news travels fast. Communication that is vague, one-sided and dishonest can negatively impact on mental health and amplify existing distress and anxiety 107 . Media reporting should not overemphasize negative mental health impact—for example, putative suicide rate increases or individual negative experiences—which could make situations worse than they actually are. Instead, communication during crises requires concrete and actionable advice that avoids polarization and strengthens vigilance, to foster resilience and help prevent escalation to severe mental health problems 108 , 109 .

Rapid research should be collaborative and high-quality

Within the scientific community, the topic of mental health during the pandemic led to a multitude of rapid studies that generally had limited methodological quality—for example, cross-sectional designs, small or selective sampling or study designs lacking valid comparison groups. These contributed rather little to our understanding of the mental health impact of the emerging crisis. In future events that have global mental health impact, where possible, collaborative and interdisciplinary efforts with well-powered and well-controlled prospective studies using standardized instruments will be crucial. Only with fine-grained determinants and outcomes can data reliably inform mental health policies and identify who is most at risk.

Do not neglect long-term mental health effects

So far, research has mainly focused on the acute and short-term effects of the pandemic on mental health, usually spanning pandemic effects over several months to 1 year. However, longer follow-up of how a pandemic impacts population mental health is essential. Can societal and economic disruptions after the pandemic increase risk of mental disorders at a later stage when the acute pandemic effects have subsided? Do increased self-reported mental health problems return to pre-pandemic levels, and which groups of individuals remain most affected in the long-term? We need to realize that certain pandemic consequences, particularly those affecting income and school/work careers, may become visible only over the course of several years. Consequently, we should maintain focus and continue to monitor and quantify the effects of the pandemic in the years to come—for example, by monitoring mental healthcare use and suicide. This should include specific at-risk populations (for example, adolescents) and understudied populations in low-income and middle-income countries.

Pay attention to mental health consequences of infectious diseases

Even though our knowledge on PACS is rapidly expanding, there are still many unanswered questions related to who is at risk, the long-term course trajectories and the best ways to intervene early. Consequently, we need to be aware of the neuropsychiatric sequelae of COVID-19 and, for that matter, of any infectious disease. Clinical attention and research should be directed toward alleviating potential neuropsychiatric ramifications of COVID-19. Next to clinical studies, studies using human tissues and appropriate animal models are pivotal to determine the CNS region-specific and neural-cell-specific effects of SARS-CoV-2 infection and the induced immune activation. Indeed, absence of SARS-CoV-2 neuroinvasion is an opportunity to learn and discover how peripheral neuroimmune mechanisms can contribute to neuropsychiatric sequelae in susceptible individuals. This emphasizes the importance of an interdisciplinary approach where somatic and mental health efforts are combined but also the need to integrate clinical parameters after infection with biological parameters (for example, serum, cerebrospinal fluid and/or neuroimaging) to predict who is at risk for PACS and deliver more targeted treatments.

Prepare mental healthcare infrastructure for pandemic times

If we take mental health seriously, we should not only monitor it but also develop the resources and infrastructure necessary for rapid early intervention, particularly for specific vulnerable groups. For adequate mental healthcare to be ready for pandemic times, primary care, community mental health and public mental health should be prepared. In many countries, health services were not able to meet the population’s mental health needs before the pandemic, which substantially worsened during the pandemic. We should ensure rapid access to mental health services but also address the underlying drivers of poor mental health, such as mitigating risks of unemployment, sexual violence and poverty. Collaboration in early stages across disciplines and expertise is essential. Anticipating disruption to face-to-face services, mental healthcare providers should be more prepared for consultations, therapy and follow-up by telephone, video-conferencing platforms and web applications 51 , 52 . The pandemic has shown that an inadequate infrastructure, pre-existing inequalities and low levels of technological literacy hindered the use and uptake of e-health, both in healthcare providers and in patients across different care settings. The necessary investments can ensure rapid upscaling of mental health services during future pandemics for those individuals with a high mental health need due to societal changes, government measures, fear of infection or infection itself.

Even though much attention has been paid to the physical health consequences of COVID-19, mental health has unjustly received less attention. There is an urgent need to prepare our research and healthcare infrastructures not only for adequate monitoring of the long-term mental health effects of the COVID-19 pandemic but also for future crises that will shape mental health. This will require collaboration to ensure interdisciplinary and sound research and to provide attention and care at an early stage for those individuals who are most vulnerable—giving mental health equal priority to physical health from the very start.

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The authors thank E. Giltay for assistance on data analyses and production of Fig. 1 . B.W.J.H.P. discloses support for research and publication of this work from the European Union’s Horizon 2020 research and innovation programme-funded RESPOND project (grant no. 101016127).

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The COVID-19 pandemic has triggered a global mental health crisis. Yet, we know little about the lasting effects of COVID-19 infection on mental health. This prospective longitudinal study aimed to investigate the trajectories of mental health changes in individuals infected with COVID-19 and to identify potential predictors that may influence these changes.

A web-survey that targeted individuals that had been infected with COVID-19 was used at three time-points: T0 (baseline), T1 (six months), and T2 (twelve months). The survey included demographics, questions related to COVID-19 status, previous psychiatric diagnosis, post-COVID impairments, fatigue, and standardized measures of depression, anxiety, insomnia. Linear mixed models were used to examine changes in depression, anxiety, and insomnia over time and identify factors that impacted trajectories of mental health outcomes.

A total of 236 individuals completed assessments and was included in the longitudinal sample. The participants’ age ranged between 19 and 81 years old (M = 48.71, SD = 10.74). The results revealed notable changes in mental health outcomes over time. The trajectory of depression showed significant improvement over time while the trends in anxiety and insomnia did not exhibit significant changes over time. Younger participants and individuals who experienced severe COVID-19 infection in the acute phase were identified as high-risk groups with worst mental ill-health. The main predictors of the changes in the mental health outcomes were fatigue and post-COVID impairments.

Conclusions

The findings of our study suggest that mental health outcomes following COVID-19 infection exhibit a dynamic pattern over time. The study provides valuable insights into the mental health trajectory following COVID-19 infection, emphasizing the need for ongoing assessment, support, and interventions tailored to the evolving mental health needs of this population.

Peer Review reports

The SARS-CoV-2 infection (COVID-19) outbreak has led to mental health problems in the general population [ 1 , 2 , 3 ], most profoundly affected by demographical variables such as age, sex, and education as well as pre-exiting mental health problems [ 4 , 5 ]. In addition, there have been notable changes in mental health problems since the onset of the pandemic, marked by a spike during the first wave of the COVID-19 pandemic and a subsequent decline from the initial baseline assessment to subsequent follow-ups [ 6 , 7 , 8 , 9 ]. However, levels of mental ill-health have been found to be more elevated in individuals infected with COVID-19 compared to the general population [ 10 ], suggesting that the mechanisms through which COVID-19 infection impacts mental health may differ from those observed in the general population.

Studies investigating mental ill-health following COVID-19 infection shed light on a bidirectional association between SARS-CoV-2 infection and mental ill-health [ 11 , 12 , 13 , 14 , 15 ]. However, the impact of COVID-19 infection on mental health becomes more intricate in the context of long-term complaints of COVID-19. Follow-up studies on COVID-19 survivors highlighted the associations between mental ill-health and post-COVID complications [ 10 , 16 ]. Long term impacts after COVID-19-infection include multi-systemic problems, disabilities, and mental health problems, of which fatigue has emerged as the most reported symptom [ 17 , 18 , 19 ]. As many as almost half of all who have a history of probable or confirmed COVID 19-infection experience symptoms after recovery from infection [ 18 ], and about 40% of COVID-19 survivors experience fatigue three months after infection, with anxiety, depression and psychiatric comorbidity generating elevated risk [ 20 ]. We have previously shown in a cohort study that individuals with a history of probable or confirmed COVID-19 infection/infections are more likely to suffer from mental health problems, with post-COVID impairments and fatigue appearing as the main predictors of mental ill-health [ 10 ].

To summarize, available data highlights that COVID 19-patients are a high-risk group for mental ill-health, and points to an interplay between COVID-19-infection and mental ill-health and a possible bi-directional association. However, more knowledge is needed regarding the specific role of post-COVID impairments, especially fatigue, on mental health following COVID-19 infection. Hence, we aimed to investigate the trajectories of mental health changes over time in individuals infected with COVID-19; and to explore potential predictors that may influence these changes.

Participants

In this longitudinal study, we used data from a web-based longitudinal project to study the impacts of COVID-19 infection on a sample of Swedish population [ 10 , 17 ]. To recruit participants, we used convenience sampling by spreading e-posters on platforms of COVID-19-related Facebook groups, Swedish COVID-organization (Svenska Covidföreningen), and the Karolinska Institutet website. Participants could access the web-survey through an online platform, Research Electronic Data Capture (REDCap), hosted locally at Karolinska institutet [ 21 , 22 ]. Inclusion criteria were: ( i ) having been infected with COVID-19; ( ii ) age (≥ 18 years); ( iii ) ability to understand Swedish, and use the internet in order to complete the web-survey. The main exclusion criteria in the current study was absence of a prior COVID-19 infection, serving as a key parameter for participating.

The web-based survey was conducted at three time points: (i) at baseline or T0 (February/March 2022), (ii) first follow-up or T1 (September/October 2022), and (iii) second follow-up or T2 (February/March 2023). The number of participants in each cross-sectional data collection varied. A total of 501 participants responded at the baseline (T0), while the response rate was 60.1% at T1 and 57.3% at T2. The longitudinal analysis included 236 (47.1%) participants who completed the survey at all time points.

Ethical considerations

The study was approved by the Swedish national ethical board (Dnr 2021–06617-01). Informed consent was obtained from all participants. All procedures utilized in collecting data for the current paper followed the ethical standards of the Helsinki Declaration of 1964 and subsequent amendments [ 23 ].

Time-invariant covariates

Time-invariant covariates in the current study consisted of sociodemographic variables, COVID-19-related variables, and previous psychiatric diagnosis, which were obtained at T0 and assumed to remain unchanged across the study. Sociodemographic variables included age, gender, educational level, work status, and economic status. The ages were grouped by decades.

COVID-19-related variables included time of first infection, hospitalization for COVID-19, being vaccinated against COVID-19, and COVID-19 severity in the acute phase. Time of first infection was measured by a single item in which respondents stated date of first infection (year and month). The variable was dichotomized into during the year 2020 versus during the year 2021 and 2022, in line with our previous study that revealed that individuals who were infected for the first time during the first and second pandemic waves in Sweden (the spring and autumn of 2020) experienced more COVID-19 related problems [ 17 ]. Hospitalization for COVID-19 was measured using a single item in which respondents stated on a binary question if they had been hospitalized because of COVID-19 (yes/no). Being vaccinated against COVID-19 was measured with a single item in which respondents indicated if they have received vaccine against COVID-19 on a binary question (yes/no). COVID-19 severity in the acute phase was measured with a 15-item scale describing common symptoms of the COVID-19 infection, namely fever, fatigue, cough, loss of smell and taste, difficulty breathing or shortness of breath, headache/migraine, aches or pain in the body, diarrhoea, skin rash, runny or blocked nose, nausea/vomiting, arrhythmia/palpitations , sore throat, cognitive difficulties such as memory and attention, and mental health problems such as sleep problems, depression, and anxiety [ 24 , 25 ]. Participants rated symptoms that they have had at the beginning of the infection and those the following 4 weeks on a 4-point scale (0 = no, 1 = mild, 2 = moderate, 3 = severe). The respondents’ answers to 15 symptoms of COVID-19 items were summed up to calculate a COVID-19 severity in the acute phase (range 0—45, α = 0.77).

Previous psychiatric diagnosis was assessed using a single item in which respondents stated on a binary question if they had received a psychiatric diagnosis before COVID-19 infection (yes/no).

Time-varying covariates

Fatigue and post-COVID impairments were treated as time-varying covariates and assumed to be subject to change across the study. Time-varying covariates were assessed at all three time points (T0, T1, and T2).

The Multidimensional Fatigue Inventory (MFI) is a self-report instrument aiming to measure fatigue. The MFI is a 20-item scale and consists of five subscales namely general fatigue, physical fatigue, reduced motivation, reduced activity, and mental fatigue. Each scale contains four items, each rated on 5-point scale, from 1 (Yes, that is true) to 5 (No, that is not true) [ 26 ], and total score is calculated by summing all items. Higher scores indicate higher fatigue levels [ 27 ], and total score > 60 has been reported as clinically significant fatigue in a previous study [ 28 ]. In this study, we used the Swedish version, which has shown adequate psychometric properties [ 29 , 30 ].

Post-covid impairments

Post-covid impairments were measured using a scale consisting of 54 items rated on a 4-point Likert scale (0 = no, 1 = mild, 2 = moderate, 3 = severe), developed and used in our previous studies [ 10 , 17 ]. Items were categorized into four sub-categories according to the International Classification of Functioning, Disability and Health [ 31 ] as impairments in mental functions, impairments in sensory functions and pain, impairments in body system functions, and impairments in activities and participation. The respondents’ answers to each sub-category of post-COVID impairments were summed up and divided by the number of items to obtain the mean for each sub-category.

Study outcomes

Mental health variables were considered as study outcomes and consisted of depression, anxiety, and insomnia. Depression was measured with the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 consists of nine items answered on a four-point Likert scale (0–3), with the total score ranging from 0 to 27 [ 32 , 33 , 34 ]. Anxiety was assessed with the General Anxiety Disorder-7 item scale (GAD-7), which contains seven items answered on a four-point Likert scale (0–3) and with a score range from 0 to 21 [ 35 , 36 , 37 , 38 ]. Insomnia was measured with the Insomnia Severity Index (ISI), that consists of seven items to assess the nature, severity, and impact of insomnia answered on a five-point Likert scale (0–4), the total score ranges from 0 to 28 [ 39 , 40 ]. The recommended cutoff score of ≥ 10 on each scale was considered as clinically significant depression, anxiety, and insomnia in the current study [ 33 , 36 , 40 ].

Statistical analysis

Descriptive statistics for sociodemographic variables are provided in terms of percentages, means, and standard deviations for both the baseline and longitudinal samples. Moreover, descriptive statistics for fatigue, post-COVID impairments, and study outcomes are presented in the form of means and standard deviations. Additionally, we computed the intraclass correlation coefficient (ICC) to evaluate variations between the initial baseline and subsequent follow-up assessments for time-varying covariates and study outcomes. An ICC less than 0.4 was categorized as very low, 0.4 to 0.74 as low to acceptable, and 0.75 or higher as excellent [ 41 ].

To assess the potential impact of the covariates, we used mixed-effects models, which are well-suited statistical tools for longitudinal data analysis. Participants were included in the model only if data from all three measurements were available for a given mental health outcome. The alpha value of the two-tailed level of significance was set at 0.05.

We ran linear mixed models with random intercepts to examine differences in mental health outcomes (PHQ-9, GAD-7, and ISI scores) over time with adjustment for sociodemographic variables, COVID-19-related variables, and previous psychiatric diagnosis. Furthermore, we ran linear mixed models to identify factors that impacted the trajectories of depression, anxiety, and insomnia by including both time-invariant and time-varying covariates in the model. We considered AIC (Akaike Information Criterion) and BIC (Bayesian Information Criterion) as model fit in the current study. A lower AIC or BIC value indicates a better fit. Statistical analysis was performed using statsmodel library (version 0.13.5) in Python, and IBM Statistical Software Package of Social Science (SPSS; version 26).

Descriptive statistics

Descriptive statistics for sociodemographic variables are presented for the baseline sample and the longitudinal sample (Table  1 ). We compared whether sociodemographic variables could predict whether participants completed surveys at each time point. The results showed that there were no significant differences between participants who completed the survey at all time points and those who did not complete the survey regarding sex, age, education level, marital status, work status, and economic status.

The majority of the longitudinal sample had been infected with COVID-19 for the first time during the year 2020 (69.5%), had not been hospitalized for COVID-19 (85%), and had been vaccinated against COVID-19 (83.9%). The average severity of COVID-19 in the acute phase was 24.7 (standard deviation = 7.8, ranging from 4 to 44). Furthermore, 27.6% of the respondents reported that they had received a psychiatric diagnosis before COVID-19 infection.

Table 2 presents descriptive statistics for fatigue, post-COVID impairments, and mental health outcomes over time in the longitudinal sample. A decline in mean total fatigue score was observed from T0 to T2. In addition, the prevalence of fatigue (scores > 60 points) decreased constantly from 90.5% to 83.5% from T0 to T2. The mean values of post-COVID impairments decreased slightly from T0 to T2. Figure  1 presents the proportion of clinically significant levels of depression (≥ 10 points on PHQ-9), anxiety (≥ 10 points on GAD-7), and insomnia (≥ 10 points on ISI) over time.

Proportion of people reporting clinically significant levels of depression, anxiety, and insomnia over time

Predictors of the trajectories of depression, anxiety, and insomnia

Adjusted estimates of the changes in depression, anxiety, and insomnia scores over time from the linear mixed models are shown in Table  3 . The results demonstrated a significant decline in depression over time, while no significant changes were observed in anxiety and insomnia. We also studied the interaction between time and other variables including sociodemographic variables, COVID-19-related variables, and previous psychiatric diagnosis, but none of the interactions proved significant. The model fit metrics (AIC and BIC) suggested that adding the interactions only diminished the model fit.

Table 4 presents estimates derived from the linear mixed models examining the associations between sociodemographic variables, COVID-19-related variables, previous psychiatric diagnosis and the outcome variables. Separate models were employed for depression, anxiety, and insomnia. The findings indicated that younger adults and individuals experiencing more severe COVID-19 infection in the acute phase exhibited poorer mental health outcomes (Table  4 ).

The outcome of the linear mixed model, examining the associations between fatigue, post-COVID impairments and the outcome variables (depression, anxiety, and insomnia) are presented in Table  5 . We conducted the analysis at the individual level, ensuring implicit adjustment for sociodemographic factors, COVID-related variables, and previous psychiatric diagnosis. The results showed that fatigue appeared to be a significant predictor for all outcomes, and impairments in mental function were an additional significant predictor for depression and anxiety. Both variables had a positive impact on all outcomes, with fatigue being the strongest predictor.

We investigated trajectories of mental health outcomes over one year in Swedish adults with COVID-19, using a three-wave survey. Our results demonstrated a significant decline in depression over time, while small, nonsignificant fluctuations were observed in anxiety and insomnia. Furthermore, younger adults and individuals who experienced more severe COVID-19 infections in the acute phase at baseline exhibited poorer mental health outcomes. Fatigue emerged as the most consistent predictor of changes in depression, anxiety, and insomnia. Impairments in mental function due to COVID-19 infection appeared as one of the main predictors of changes in depression and anxiety but not insomnia.

In this study, levels of depression decreased constantly, anxiety exhibited a slight increase, followed by a subsequent decrease, remaining below the baseline level, and insomnia increased slightly and then decreased, consistently remaining above the baseline level. Our findings are in line with previous studies indicating that mental health problems remained more prevalent among individuals who have had COVID-19 infection [ 42 , 43 , 44 , 45 , 46 , 47 ]. However, symptoms of depression and anxiety decreased over time regardless of the initial severity of the disease [ 48 , 49 ]. There are several possible explanations for these findings. Firstly, depression and anxiety symptoms have shown a decreasing trend in the general population, including our participants, during the COVID-19 pandemic [ 50 ]. During the COVID-19 pandemic in Sweden, individuals were encouraged to work from home when possible. Additionally, gatherings of more than 50 people were prohibited, many businesses and higher education institutions voluntarily transitioned to video conferencing, and non-essential travel was significantly reduced. However, at the onset of the study period in February 2022, Swedish authorities changed their strategies in response to the pandemic similar to other European nations, leading to the lifting of the majority of COVID-19 restrictions [ 51 ]. The relaxation or removal of COVID-19-related restrictions, facilitated by the global vaccination campaign, has enabled people to resume their pre-pandemic lifestyles and activities. This transition may have alleviated depression and anxiety symptoms, as individuals restore a sense of normality and participate in activities that provide them with joy and fulfillment. Another potential factor is the enactment of mental health recovery strategies by policymakers in various countries, including Sweden. Strategies include initiatives to monitor, inform, educate, intervene, and research mental health issues in society [ 52 ], and efforts target both immediate and long-term mental health outcomes. The third possible explanation for these findings is sustained recovery of COVID-19-related persistent symptoms over time. A substantial proportion of individuals infected with COVID-19 reports experiencing at least one moderate-to-severe impairment due to COVID-19 infection, with fatigue being the most commonly reported symptom [ 17 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 ]. Furthermore, our previous cross-sectional study revealed that post-COVID impairments and fatigue emerged as significant predictors of mental ill-health in individuals who were infected with COVID-19 infection [ 10 ]. However, a progressive improvement has been observed in a wide array of symptoms over time [ 48 , 62 , 63 ]. Our study results indicate that impairments in mental function and fatigue affect depression and anxiety changes over time. These factors shape the dynamics of depression and anxiety and are key for their longitudinal course, thus, managing these complaints may improve mental well-being. In summary, the reduction of symptoms of depression and anxiety observed in this study may be linked to the global recovery from the COVID-19 pandemic and the improvement of post-COVID complaints, especially fatigue.

We found that insomnia, unlike depression and anxiety, increased slightly before decreasing during COVID-19 recovery, but remained above baseline throughout the study period. This indicates a complex interaction of factors affecting sleep quality in this population. These findings are consistent with a previous study which demonstrated a decrease in the symptoms of depression and anxiety whereas increased symptoms of insomnia among COVID-19 patients over time [ 64 ]. Additionally, another study indicated that there was no significant change in insomnia over time among COVID-19 patients [ 65 ]. Several factors may contribute to this pattern of insomnia exhibiting a different pattern than other symptoms of mental ill-health. First, the rates of insomnia increased significantly during the COVID-19 pandemic like other mental health issues [ 4 ] and the prevalence of insomnia was higher in COVID-19 infected patients compared with the general population [ 10 , 64 , 66 ]. The initial increase in insomnia could be attributed to the physiological and psychological effects of the acute phase of COVID-19 infection and the side effects of COVID-19-related medications which disrupted sleep quality and quantity during the early stages of recovery and increased the risk of developing chronic insomnia later after recovery [ 55 , 67 , 68 , 69 ]. Second, sleep-related problems were reported as one of the most common remaining symptoms experienced after recovering from COVID-19 [ 17 , 48 ]. However, post-COVID impairments did not significantly contribute to changes in insomnia following COVID-19 infection in the current study. Interestingly, it was observed that fatigue emerged as a significant predictor in relation to insomnia. The co-occurrence of fatigue and insomnia has previously been found to be highly prevalent among individuals following recovery from COVID-19 infection [ 70 ]. This finding suggests that these two symptoms frequently manifest together in individuals who have experienced the illness. Additionally, several studies have highlighted the presence of fluctuations and relapses in post-COVID-19 fatigue over time [ 48 , 71 ]. The interplay between fatigue and insomnia can create a vicious cycle, particularly among patients with long-term COVID [ 72 ]. Fatigue can contribute to increased sleep difficulties, while insomnia can exacerbate feelings of fatigue and prolong recovery. This bidirectional relationship between fatigue and insomnia may lead to a chronic cycle of symptoms and further impact overall well-being. Lastly, it is essential to consider the bidirectional relationship between mental health and sleep. Insomnia can exacerbate persistent symptoms of depression and anxiety, while these mental health conditions can also contribute to sleep disturbances [ 73 ]. To reduce symptoms of depression and anxiety may help to improve insomnia in COVID-19 survivors, and better mental health and coping skills can improve sleep quality. Insomnia needs ongoing assessment and treatment in individuals infected with COVID-19. In addition, addressing fatigue and mood may also reduce insomnia.

Further analysis revealed that younger adults and individuals who experienced more severe COVID-19 infections in the acute phase exhibited poorer mental health outcomes. Previous studies have demonstrated that younger adults have been more profoundly affected by the pandemic and exhibit higher levels of mental health problems [ 4 , 74 , 75 ]. Younger adults, despite primarily experiencing mild COVID-19 infections, faced greater challenges related to the long-term impacts of COVID-19 infection, which significantly disrupted their presentation and performance in their work, education, and daily activities. Hence, it can be concluded that young adults remain within the at-risk group for mental ill-health following COVID-19 infection. Moreover, prior research has consistently demonstrated that the severity of COVID-19 infection in the acute phase is strongly linked to persistent post-infection symptoms [ 53 , 55 , 56 , 61 ], emerging as the most robust predictor of post-COVID impairments (Badinlou et al., 2023). Additionally, it has been shown to contribute to higher levels of mental ill-health following COVID-19 infection [ 10 ]. Therefore, it is reasonable to conclude that individuals who experienced severe COVID-19 infection in the acute phase continue to be at risk for mental ill-health. These findings highlight the importance of considering sociodemographic and COVID-19-related factors when examining the impact of COVID-19 on mental well-being.

The primary objective of our study was to explore the potential trajectories of mental health changes following COVID-19 infection. To achieve this goal, we focused on minimizing the risk of overlooking real effects (i.e., Type II errors) rather than strictly controlling the risk of falsely identifying effects (i.e., Type I errors). This approach was deemed more appropriate for our exploratory research, since it allowed us to prioritize detecting patterns in the data, even if it meant there was a slightly increased risk of overlooking some effects.

The current study has several practical implications. First, understanding changes in mental health outcomes following COVID-19 infection and identifying risk factors could help healthcare providers to develop targeted interventions to support those who have been infected and may be experiencing psychological problems. Second, the findings provide policymakers with evidence-based insights to implement strategies that can mitigate the long-term mental health impact of the COVID-19 infection, and promote mental well-being in individuals infected with COVID-19, even those who experienced a mild infection. Finally, it contributes to the broader body of research on the mental health consequences of infectious diseases, potentially guiding future pandemic preparedness and response efforts.

Nevertheless, it is important to interpret the results of the study in the context of its limitations and consider potentially confounding factors. First, the current study uses self-reported data for mental health outcomes, which may be biased or inaccurate compared to clinical assessments. Second, it uses a convenience sample, which may limit the generalizability of the findings. Hence, future studies should use more representative samples. Third, it may suffer from non-response bias, as participants who continued or dropped out may differ in important ways. Fourth, we could not establish causality between COVID-19 infection and mental health changes, as there may be other confounding factors. Fifth, it lacks a control group that did not contract COVID-19, which makes it hard to isolate the effects of the infection on mental health. Sixth, majority of participant in the current study was female, introducing the possibility of gender-related biases and potentially limiting the generalizability of the findings to a more balanced demographic.

This study provides a longitudinal perspective on mental health issues following COVID-19 infection, shedding light on the dynamic nature of mental health outcomes over time and underscoring the importance of continued support and interventions tailored to the changing mental health requirements of this affected population. Further research is needed to understand the underlying factors contributing to these changes and to develop targeted interventions for individuals experiencing persistent mental health symptoms.

Availability of data and materials

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

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We would like to thank all athletes that took part in this study.

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Farzaneh Badinlou, Maria Hedman-Lagerlöf, Tobias Lundgren & Markus Jansson-Fröjmark

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Farzaneh Badinlou

RISE Research Institutes of Sweden, Department of Computer Science, Stockholm, Sweden

Fatemeh Rahimian

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Tamar Abzhandadze

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F.B., M.J.F., and T.L. conceptualized the study. F.B. administered the project and collected the data. F.B., and F.R. prepared the data and performed the statistical analyses. F.B., F.R., and M.H–L. wrote the first draft. F.B, F.R., M.H–L., T.L., T.A., and M.J.F. revised the article. F.B, F.R., M.H–L. T.A., and M.J.F. edited the article. All authors have read and approved the manuscript.

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Badinlou, F., Rahimian, F., Hedman-Lagerlöf, M. et al. Trajectories of mental health outcomes following COVID-19 infection: a prospective longitudinal study. BMC Public Health 24 , 452 (2024). https://doi.org/10.1186/s12889-024-17997-x

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• COVID-19 infection
• Post-COVID impairments

BMC Public Health

ISSN: 1471-2458

• General enquiries: [email protected]

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

Affiliations.

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

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

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

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

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

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

Copyright © 2020 Elsevier Inc. All rights reserved.

Publication types

• Research Support, Non-U.S. Gov't
• Systematic Review
• Anxiety / psychology*
• Betacoronavirus
• Coronavirus Infections / epidemiology
• Coronavirus Infections / psychology*
• Depression / psychology*
• Disease Progression
• Health Personnel / psychology*
• Mental Disorders / psychology
• Mental Health
• Mentally Ill Persons / psychology*
• Pneumonia, Viral / epidemiology
• Pneumonia, Viral / psychology*
• Psychological Distress
• Stress Disorders, Post-Traumatic / psychology*

• 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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Ethical permission was obtained from the Ethics Committee of the Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University in Bratislava (Reference number: ULBGaKG-02/2022). The need for informed consent was waived by the Ethics Committee of the Institute of Medical Biology, Genetics and Clinical Genetics, Faculty of Medicine, Comenius University in Bratislava due to the anonymous design of the study. This study did not process any personal data and the dataset does not contain any direct or indirect identifiers of participants. This study was performed in line with the principles of the Declaration of Helsinki. All methods were carried out following the institutional guidelines.

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

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DOI : https://doi.org/10.1186/s40359-023-01130-5

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