What are the effects of the COVID-19 pandemic and SARS-CoV-2 infection on mental health?

In a recent study published in Natural medicineresearchers reviewed the direct and indirect effects of the coronavirus disease 2019 (COVID-19) and the COVID-19-induced pandemic on mental health.

Study: How COVID-19 Shaped Mental Health: From Infection to Pandemic Effects. Image credit: Ahmet Misirligul/Shutterstock

Background

The indirect effects of COVID-19 encompass stress-inducing and disruptive social changes that adversely affect the mental state of the population as a whole. COVID-19 also caused many direct effects, such as acute and long-lasting neuropsychiatric complications that occurred at the time of the primary infection or three to four weeks later and persisted 12 weeks or more in some cases after the initial infection.

About the research

In the current study, researchers first summarized empirical findings on how the COVID-19 pandemic affected mental health at the population level by reviewing reports of mental health symptoms and prevalent mental disorders and suicide rates. They then described the mental health consequences of COVID-19 (eg, symptoms of cognitive impairment and fatigue). In addition, they reviewed the neurobiological impact on brain structure and function. Finally, the researchers addressed knowledge gaps and discussed lessons learned to suggest the best strategies for managing and mitigating mental health issues in future crises.

Survey results

The majority of the general population demonstrated remarkable resilience and adaptation, as the researchers observed a slight increase in mental health symptom levels across the population. However, they found alternative explanations for the same; for example, community support activities may have reduced mental health burden. Drug overdoses or murder may have masked cases of mental disorder. Due to the lag effect, some social/financial consequences of the COVID-19 pandemic may have appeared later.

Additionally, studies show that women consistently report more mental health problems than men. They have been under greater stress due to increased childcare, domestic violence and economic hardship due to employment disruption. Adolescents and young adults were also inexplicably affected. Worryingly, studies in China and Japan have shown significant increases in child and adolescent suicide rates during periods of school closures. Blacks, Hispanics, and Asians demonstrated higher unmet mental health needs during the COVID-19 pandemic in the United States (US). Similarly, people with multiple co-morbidities represent another vulnerable group that has been adversely affected by the COVID-19 pandemic. They may have felt more stress and fear of infection due to interruption of regular health services.

A meta-analysis of almost 206 studies found that the mental well-being of healthcare workers (HCW) was comparable to the general population. However, this analysis does not take into account the different conditions faced by frontline and non-frontline health workers. However, medical workers had an increased workload during the pandemic, accompanied by the fear of infecting themselves and their families. Several reports have documented a higher incidence of depression and anxiety in healthcare workers.

Even before the COVID-19 pandemic, most countries had disorganized and understaffed mental health systems. To add to their plight, during the first 18 months of the pandemic, doctors shortened or postponed appointments and emergency hospitalizations.

The wider neuropsychiatric impact is heterogeneous and depends on the severity of the infection. Several asymptomatic cases of COVID-19 had no neuropsychiatric symptoms. However, others had transient non-serious neuropsychiatric symptoms. For example, a meta-analysis that evaluated patients 12 weeks after a confirmed diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) found that 32% suffered from fatigue and 22% had cognitive impairment. Unfortunately, these studies did not have well-matched controls with other types of respiratory infections or inflammatory conditions.

During hospitalization related to COVID-19, the most common neuropsychiatric outcome is delirium, which occurs in one-third of patients and over 50% of patients requiring intensive care unit (ICU) admission. In another one-year follow-up study using the US Veterans Affairs database, the difference in the risk of accidents due to mental disorders caused by COVID-19 was 64 per 1,000 people.

A study analyzed US TriNetX electronic health records of 236,379 COVID-19 survivors and found that the risks of incident neurological diagnoses were related to disease severity and increased by 78% and 32% compared to influenza and other infections of the respiratory tract, respectively. Yet, whether the post-acute consequences of SARS-COV-2 infection form a unique pattern remains controversial.

Studies have found that acute neuropsychiatric symptoms among patients with severe COVID-19 correlate with the level of serum inflammatory markers. Neuroimaging deciphers leukoencephalopathy, acute disseminated encephalomyelitis, and cytotoxic lesions in the corpus callosum. Examination of postmortem specimens revealed significant neuropathology with signs of hypoxic injury and neuroinflammation. Post-acute neuroimaging studies in patients recovered from SARS-CoV-2, compared to control patients without COVID-19, show numerous changes in brain structure. For example, such patients had a nonsignificant reduction in gray matter thickness in the cerebral cortex and in the corpus callosum and reduced overall brain size.

All of these findings are consistent with the finding of anosmia, tremor, affective problems, and cognitive impairment problems in patients with COVID-19. Yet, the neurobiological mechanisms of SARS-CoV-2-mediated neuropsychiatric consequences remain unclear. It is also unclear whether hospitalizations associated with COVID-19 cause brain abnormalities due to hypoxia or whether this is a direct effect of SARS-CoV-2 infection.

Lessons learned and future perspective

First and foremost, mental health is as important as physical health and requires attention. There should be provisions for early intervention for those at highest risk, including those who are vulnerable due to low socio-economic status. Thus, adolescents and young adults, women, people with poor physical health and early life trauma, or those with greater exposure to pandemic-related job changes (eg, healthcare workers) should be prioritized for such interventions.

Another key takeaway was that media communication during crises should give concrete and actionable advice to avoid polarization and increase vigilance. It should also promote resilience and help prevent the rise of mental health problems. Most importantly, longer follow-up periods of how the pandemic affects the mental health of the population are essential. There is an urgent need to prepare research and health infrastructures to monitor the long-term mental health consequences of the COVID-19 pandemic and future crises. Overall, collaborative and interdisciplinary efforts with well-controlled prospective studies using standardized instruments will be crucial.

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