Effects of COVID-19 on Anxiety, Depression and Other Mental Health Issues: A worldwide scope review

Daiane Borges Machado (  daianedbm@hotmail.com ) CIDACS/FIOCRUZ; Harvard Medical School https://orcid.org/0000-0003-2959-4650 Flávia J.O. Alves1 CIDACS/FIOCRUZ; ISC-UFBA Camila S. S. Teixeira CIDACS/FIOCRUZ; ISC-UFBA Aline S. Rocha CIDACS/FIOCRUZ; ENUFBA Luís FS Castro-de-Araujo CIDACS/FIOCRUZ; Department of Psychiatry -The University of Melbourne Amandeep Singh Department of Psychology, Punjabi University Maurício L. Barreto CIDACS/FIOCRUZ; ISC-UFBA


Background
The COVID-19 pandemic has spread across the world and, along with it, a considerable degree of fear, concerns and uncertainties. 1 The massive number of cases and deaths, the diffusion of dubious information regarding different aspects of the pandemic and insu ciency in knowledge regarding control and adequate treatment measures, arguably worsens uncertainty.1 These uncertainties have consequences on various aspects of societal life, affecting people's daily lives and mental health (MH).2 In times of a pandemic, the main focus of health care is physical health and the control of virus transmission and, therefore, attention to MH may be compromised. 3,4 Nonetheless, measures for the prevention and treatment of mental health problems need to be addressed during the pandemic, since the psychological implications can be immediate but also long-lasting, with enduring effects on individuals, families and communities.
The MH effects of Covid- 19 have not yet been su ciently studied. Still, there is already an increasing number of articles being published that evaluate people's MH, in the context of the pandemic. Symptoms of depression, anxiety and stress have been reported, especially in the groups most affected by  or in more vulnerable sectors of the population, such as health professionals and the elderly. [5][6][7] Understanding how the COVID-19 pandemic affects MH helps to implement interventions and adequate public policies, providing more effective responses and mitigating its effects on people's MH. Thus, the objective of this study was to summarize the scienti c evidence on the possible in uence of the Covid-19 pandemic on individuals' MH worldwide, critically evaluating the methods and scienti c validity of the studies found, as well as summarizing the recommendations on strategic measures to reduce the impact of COVID-19 on subjects' MH.

Methods
The present scoping review was conducted from a screening of 465 articles on COVID-19 and MH outcomes published until April 30, 2020, based on the main database of scienti c references on health, assessed throughout PubMed.

Eligibility criteria
Original studies that assessed the effect of COVID-19 on individuals' MH, including outcomes such as depression, anxiety, psychological suffering, fear, panic, alcohol consumption and drug abuse. There is a growing number of scienti c publications showing the possible relationship between the COVID-19 pandemic, and the presence or worsening of mental disorders, or symptoms of anxiety and depression. However, no controlled or longitudinal studies were found that could more robustly explore the relationships between the COVID-19 pandemic and mental health outcomes (MH). Despite the noted effort to describe the problem (the effect of COVID19 on MH) while it is still occurring, there are problems in generalizing these ndings, since most studies are cross-sectional, with no previous measurement of the outcomes studied for comparison. Also, some studies used samples based on voluntary selections, using online questionnaires. Therefore, selection bias is likely, due to samples concentrated in speci c populations, often included according to availability criteria, in addition to many possible participants not being included because they do not have access to online tools, or have greater di culty of using them.
Another limitation present in the studies was the collection of information in a single period and during different periods of the pandemic. While some studies measured outcomes at the beginning of the pandemic, others evaluated them at more advanced stages, therefore hindering comparisons.2 Long-term exposure was also not measured, which would be important since an increase in mortality and con nement time can in uence the way people evaluate their own MH.3

Mental disorders and symptoms associated with COVID-19
Anxiety Of the 43 articles selected, 77% (n = 33)10,11,14-44 indicated a relationship between anxiety symptoms and the COVID-19 pandemic. High anxiety scores were found associated with the diagnosis of coronavirus, coping with alcohol/drugs, extreme hopelessness and suicidal ideation.35 A study found high levels of anxiety among the population studied, 80% of which reported being concerned with COVID-19.31 Issues associated with the risk of anxiety and depression were related to the fear of the COVID-19 pandemic, and the fragility related to patients' clinical issues, the fear of being infected and becoming ill,40 and that family members would contract COVID-19 (75.2%).38 Anxiety generated by the fear of running out of medication was also one of the issues cited as sources of concern.40 Negative emotions (anxiety, depression and indignation) increased, while positive emotions (measured by the Oxford happiness scores) and satisfaction with life decreased with the pandemic.11 A study carried out with 7,236 Chinese individuals showed a general prevalence of symptoms of anxiety, depressive symptoms and poor sleep quality in 35.1%, 20.1% and 18.2% of those investigated, respectively.29 The prevalence of symptoms of anxiety and depressive symptoms was signi cantly higher in younger participants (<35 years) (p<0.001).29 Another study conducted in China on 5,851 individuals found a prevalence of depression, anxiety and a combination of depression and anxiety during the Covid-19 period among 48, 3% (95% CI 46.9% -49.7%), 22.6% (95% CI 21.4%-23.8%) and 19.4% (95% CI 18.3%-20.6% ) of participants, respectively.48 Lei et al. (2020)27 found the prevalence of anxiety and depression to be approximately 8.3% among the 1,593 survey participants. Moghanibashi-Mansourieh (2020),10 in applying an online questionnaire to 10,754 participants, found that the level of severe anxiety was serious for 9.3% of the participants and very serious for 9.8%. Chew et al. (2020),28 conducting research among health professionals (n = 906), found that 8.7% (n = 79) of participants suffered from moderate to extremely severe anxiety, while Ahmed et al. (2020)30 found a higher anxiety rate (29%), dangerous, harmful alcohol consumption or alcohol dependence (30%), and lower than usual mental well-being (32.1%) among the 1,074 individuals in the Chinese province of Hubei who answered the online questionnaire.
In another study, where 124 questionnaires were distributed, with a response rate of 84.7% (105/124),26 it was found that the prevalence of total, mild, moderate and severe anxiety were 18.1%, 10.5%, 5, 7% and 1.9%, respectively. Respondents who had experience of exposure to COVID-19 reported higher rates of anxiety, accompanied by depression, than those who had no experience of exposure (incidence rates of 31.6% and 12.6%, respectively).26 In addition to these studies, Lei et al. (2020),27 in a study conducted on 1,593 participants in southeastern China, found a prevalence of 8.3% of anxiety, and 14.6% of depression. The prevalence in the affected group (12.9%, 22.4%) was signi cantly higher than in the unaffected group (6.7%, 11.9%). Subjects were considered affected if they or their families/colleagues/classmates/neighbours had been quarantined. Lower average family income, lower education levels, greater concern about being infected by COVID-19, not having psychological support, higher economic losses and poorer self-reported health conditions were statistically signi cant, associated with higher scores on the self-rating anxiety scale (SAS) and self-rating depression scale (SDS).27

Depression
Of the selected articles, 56% (n = 26) 11,15,[18][19][20]22,23,25-30,32,33,36,37,39-41,43,45-48 investigated the relationship between COVID-19 and depression or depressive symptoms. Among these, a study with 1,593 participants in China found a prevalence of depression of approximately 15%.27 Another study carried out in the most affected areas of China found that 634 [50.4%] of participants reported symptoms of depression.38 Multivariate Logistic Regression analysis showed that participants from outside Hubei province were less likely to experience symptoms of distress, compared to those in Wuhan (OR: 0.62; 95% CI: 0.43-0.88).38 A study found a prevalence of depression, and a combination of depression and anxiety, during the Covid-19 period of 48.3% (95% CI 46.9% -49.7%) and 19.4% (95% CI 18.3% -20.6%), respectively.48 Furthermore, a study in Vietnam found an increased prevalence of depression (29.2%) in patients who had COVID-19 infection (p 0.016).46 There was an increase in the prevalence of comorbid depression with anxiety (p 0.086), both in patients with COVID-19 infection (21.1%) and in the general public (22.4%). Patients who had COVID-19 infection (19.3%) and the general public (14.3%) also had a higher proportion of severe depressive symptoms (p 0.002). In addition, patients who experienced  infection, and the general public, were more likely to display a depressed mood (p 0.038) and somatic symptoms (all p <0.01), compared to quarantined individuals. Survey participants (3,947 people recruited from the outpatient departments of nine hospitals and health centres in Vietnam) who were diagnosed with COVID-19 had a higher probability of depression (OR 2.88; p <0.001), and a lower score on the scale that measures health-related quality of life (HRQoL) (B -7.92; p <0.001). Health literacy was a protective factor for depression and HRQoL during the COVID-19 epidemic, especially among people not diagnosed with the disease.46 In a study of 500 individuals, 62% reported no likelihood of psychological distress, while 19.4% and 18.6% had a mild and moderate to severe likelihood.45 Cyclothymic (OR 1.24; p <0.001), depressive (OR 1.52; p <0.001) and anxious temperaments (OR 1.58; p 0.002) and the ASQ "Need for approval" (OR 1.08; p 0.01) were risk factors for moderate-to-severe psychological distress, compared to no distress. On the other hand, the ASQ "Con dence" (OR 0.89; p 0.002) and "Discomfort with closeness" were protective (OR 0.92; p 0.001). The cyclothymic (OR 1.17; p 0.008) and depressive (OR 1.32; p 0.003) temperaments resulted in being risk factors in individuals with moderate to severe psychological distress, compared to mild distress, while the ASQ "Con dence" (OR 0.92; p 0.039) and "Discomfort with closeness" (OR 0.94; p 0.023) were protective.45 In another study in which 124 questionnaires were distributed with a response rate of 84.7% (105/124), the results showed mild (SAS score 53 to 62), moderate (SAS score 63 to 72) and severe depression (SAS score ≥ 73) in 22, 5 and 4 cases, respectively.26 The incidences of cases of total, mild, moderate and severe depression were 29.5%, 21.0%, 4.8% and 3.8 %, respectively. Respondents who had the experience of exposure reported higher rates of anxiety, accompanied by depression, than those who had no experience of exposure (incidence rates of 31.6% and 12.6%, respectively).26 Analyzing the overall prevalence of generalized anxiety disorder (GAD), the public's depressive symptoms and sleep quality were 35.1%, 20.1% and 18.2%, respectively.29 Young people, however, reported a signi cantly higher prevalence of GAD and depressive symptoms than the elderly. Compared to another occupational group, health workers were more likely to have poor sleep quality. Age (<35 years) ( better sleep quality or lower frequency of nighttime waking reported lower PTSD. While anxiety was associated with greater stress and reduced sleep quality, higher levels of social capital were positively associated with increased sleep quality.50 Compared to another occupational group, health professionals were more likely to have poor sleep quality (OR 1.48; 95% CI 1.15-1.95).29 Another study carried out in China, including a total of 1,563 participants, showed that 36.1% of participants (n = 564) had symptoms of insomnia, according to the Insomnia Severity Index (ISI) (total score ≥ 8).22 Insomnia symptoms were associated with education levels (high school or lower) (OR 2.69; p 0.042; 95% CI 1.0-7.0), type of team (physician) (OR 0.44; p 0.007 ; 95% CI 0.2-0.8), current work department (isolation unit) (OR 1.71; p 0.038; 95% CI 1.0-2.8), concern about being infected (OR 2.30 ; p <0.001; 95% CI 1.6-3.4), perceived lack of utility of news or social media in relation to COVID-19, in terms of psychological support (OR 2.10; p 0.001; 95% CI 1,3-3,3) and strong uncertainty regarding effective disease control (OR 3.30; p 0.013; 95% CI 1.3-8.5).22

Obsessive behaviors
Four of the studies included in the current review addressed factors related to obsessive behaviours.13,15,31,44 Among these, a study carried out in China, including 1,060 respondents who accessed the online platform Wenjuanxing, showed a 70% prevalence of symptoms of moderate and higher psychological changes, with speci cally high scores for obsessive-compulsive disorder, interpersonal sensitivity, phobic anxiety and psychoticism.44 People aged over 50, who were better educated, divorced or widowed, and who performed agricultural work, had a higher number of symptoms. People who were younger, and those on a medical team, were in the highest risk group, in terms of the severity of psychological symptoms.44 Another study also conducted in China found that living in rural areas, being a woman, and being at risk of contact with patients diagnosed with COVID-19, were the most common risk factors for being obsessive-compulsive.15 Comparing doctors to other health professionals, the study found that doctors had a higher prevalence of obsessive-compulsive symptoms (5.3 vs. 2.2%; p <0.01).22 They also had higher total scores for obsessive-compulsive symptoms in the Generalized Anxiety Disorder 2-item (GAD-2) psychological test and Revised Symptom Checklist-90-(SCL-90-R)(p ≤0.01).15 Research on 3,947 participants in Vietnam showed that the COVID-19 epidemic led to panic and hypochondria, resulting in the unnecessary seekingout of health care, and increased demand for health care services among people consulted online in the general population.13 Among the concerns that could increase obsessive symptoms, 72% (n = 662) of participants in a survey conducted in India cited excessive concern about the use of gloves and disinfectants.31 Participants reported symptoms such as negative sleep changes (12, 5%), paranoia about the use of social media related to COVID-19 infection (37.8%), and anguish (36.4%).

Post-Traumatic Stress Disorder (PTSD)
In addition to symptoms of anxiety, depression and sleep disorders, Post-Traumatic Stress Disorder (PTSD) has been linked to COVID-19. Liu et al. (2020)49 found a 7% prevalence of PTSD symptoms in the areas most affected by the COVID-19 outbreak in China. Hierarchical regression analysis, and a nonparametric test, suggested that women had higher PTSD, with negative changes in cognition, mood or hyperexcitation. Participants with better sleep quality, or less frequency of nighttime waking, reported lower PTSD.49 Tan et al. (2020),32 found that a prevalence of 10.8% of the 673 respondents to the questionnaire t the diagnosis of PTSD after returning to work, and Chew et al. (2020)28 found a high risk of PTSD (OR 2.20; 95% CI 1.12-4.35, p 0.023) associated with the presence of physical symptoms experienced in the previous month among 906 health professionals who participated in the research. The most common reported symptom was headaches (32.3%), with a large number of participants (33.4%) reporting more than four symptoms.28

Speci c populations
In addition to speci c symptoms and disorders, the crisis caused by COVID-19 seems to be characterized by having a distinct in uence on speci c population groups. Two of the selected studies44,53 investigated the in uence of the COVID-19 pandemic on the elderly, and ve others17,22,25,29,39 its in uence on children, schoolchildren or young people. In addition, seven studies addressed the relationship between COVID-19 and MH among women. 10,12,18,20,33,38,49 The elderly Elderly subjects are more susceptible to depressive symptoms, due to losses they experience during their lives and cerebral vascular changes.55 Depression and anxiety in the elderly appear among the most frequent reasons for requesting a psychiatric consultation.56 The elderly population are among the most affected by the COVID-19 pandemic, both in terms of severity and mortality, and are also more likely to suffer psychological impacts during this period.4,57 Tian et al. (2020),44 observed a 70% prevalence of symptoms of moderate and greater psychological changes, with speci cally high scores for obsessive-compulsive disorder, interpersonal sensitivity, phobic anxiety, and psychoticism. People aged over 50, who were better educated, divorced or widowed, and who performed agricultural work, had more symptoms. However, younger people and those in a medical team, were in the highest risk group, in terms of the severity of psychological symptoms.44 Another study indicated that individuals over the age of 60 had higher anxiety scores than the general population.12 Losada-Baltar et al. (2020),53 however, suggested that it is not chronological age itself, but the negative self-perception of ageing that is related to loneliness and psychological suffering in people during a forced stay at home during the COVID-19 crisis. Elderly people with a positive self-perception of ageing seem to be more resistant to loneliness and distress during the COVID-19 outbreak.
Bacon & Corr (2020),21 found that interviewees who were more concerned were older, had negative attitudes towards illness, and scored higher in reactivity of the reward (RR), indicating motivation to adopt a positive attitude, despite prevailing concern/anxiety. Concerns about personal safety were greater in those with negative attitudes towards illness, and with higher scores in the ght-ight-freeze system (FFFS, re ecting fear/prevention). The results suggest that people are experiencing psychological con icts between the desire to remain safe (related to FFFS), and the desire to maintain a normal and pleasant life (related to RR). Ways to reduce the con ict may include maladaptive behaviours (panic buying) re ecting reward-related displacement activity. Self-isolation is intended to be related to FFFS, but is also related to low scores in the behavioural inhibition system (related to anxiety). The elderly reported being less likely to isolate themselves.21 Children, schoolchildren and parents The COVID-19 pandemic can also affect children's thoughts, behaviours and emotional responses, the most affected being those who are separated from their caregivers during this process.58 Yuan et al. (2020),39 found that the anxiety scores of parents of children undergoing epidemic hospitalization can also be altered, and were signi cantly higher (EH) (7.02 ± 3.01) when compared to the anxiety score of parents undergoing non-epidemic hospitalization (NEH) (3.62 ± 2.10) (p <0.001). Likewise, the depression score of parents of children with EH (7.72 ± 2.81) was higher than the depression score of parents of children with NEH (4.54 ± 2.56) (p <0.001). There was a positive correlation between the anxiety, depression and drowsiness scores among parents of children with EH. Parents of children hospitalized during the COVID-19 epidemic face enormous pressure and anxiety. Post-traumatic stress disorder and MH problems can occur in parents, which can affect the child's recovery.39 Zhang & Ma (2020),22 demonstrated that the average behaviour of children with ADHD (M 2.25; SD 0.54) worsened signi cantly, compared to their normal state (95% CI 2.18-2.32); 53.94% of parents reported that their children's ability to stay focused worsened, 67.22% that the frequency of anger increased, and 56.02% that the daily routine worsened. More than half the parents reported that their children's behaviour in other domains had improved, or stayed at the same level. Children's ADHD behaviors were positively linked to acute stress in response to the COVID-19 outbreak (r 0.21; p 0.001), parental attention to the media coverage of COVID-19 news (r 0.13; p 0.048), general mood (negative) of children and parents ((r 0.48; p <0.001) and (r 0.41; p <0.001) respectively) and negatively correlated with the children's study time (r -0.19; p 0.004) and children's interaction with parents' time (r -0.17; p 0.008). In the regression analysis, children's general mood (β 0.17; 95% CI 0.11-0.23; p <0.001), parents' general mood (β 0.13; 95% CI 0.06 -0.20; p <0.001) and children's study time (β -0.09; 95% CI -0.15, -0.02; p 0.010) signi cantly predicted children's ADHD behaviors.22 Young people can also be impacted by COVID-19 contingency measures, especially the most vulnerable population groups, such as informal and unemployed workers, in the face of scenarios in which the possibilities of work become scarcer. Research conducted in China, based on interviews with 7,143 university students, showed that 25% of participants suffered from anxiety. Of these, 0.9% experienced severe anxiety, and 21.3% experienced mild anxiety.17 Protective factors against anxiety were seen to be: living in urban areas, having family income stability, and living with parents.17 On the other hand, having relatives or acquaintances infected with COVID-19 was a risk factor for anxiety among these university students.17 The results reinforce the importance of implementing social protection measures during social distancing, in order to mitigate possible MH impacts on the most vulnerable people in the population.
Research carried out with schoolchildren in home con nement in Wuhan & Huangshi, a province in Hubei, China, showed that of the 1,784 survey participants, 22.6% reported depressive symptoms, and 18.9% anxiety symptoms.25 Wuhan students had signi cantly higher CDI-S scores than those from Huangshi (β 0.092; 95% CI, 0.014-0.170), with a higher risk of depressive symptoms (OR 1.426; 95% CI 1.138-1.786). Students who were not concerned about being affected by COVID-19, or only slightly, had signi cantly lower CDI-S scores than those who were very concerned (β -0.184; 95% CI -0.273 to -0.095), with a reduced risk of depressive symptoms (OR 0.521; 95% CI 0.400-0.679). Those who were not optimistic about the epidemic, compared to those who were quite optimistic, had signi cantly higher scores on the Children's Depression Inventory-ShortForm (CDI-S) (β 0.367; 95% CI 0.250-0. 485), with an increased risk of depressive symptoms (OR 2.262; 95% CI 1.642-3.117). There was no signi cant association between demographic characteristics and symptoms of anxiety.25 Huang & Zhao (2020),29 on the other hand, found a general prevalence of generalized anxiety disorder (GAD), depressive symptoms and sleep quality disturbances in the public in 35.1%, 20.1% and 18.2% of young people, respectively. Young people reported a signi cantly higher prevalence of GAD, and depressive symptoms than the elderly. Age (<35 years) (OR 1.77; 95% CI 1.38-1.95) and the time spent focusing on COVID-19 (≥3 hours per day) (OR 1.91; 95% CI 1.77-2.15) were associated with TAG. A young age was also associated with depressive symptoms (OR 1.80; 95% CI 1.35-2.01), and health professionals were at high risk of having poor sleep quality (OR 1.48; 95% CI 1.15-1.95). Young people who spent more than 3 hours a day thinking about the outbreak had a signi cantly higher prevalence of symptoms of anxiety (p <0.001).29 A previous study found that isolated or quarantined children during epidemics, or in disaster situations were more likely to develop acute stress and adjustment disorders, and suffering.59 Women A study using hierarchical regression analysis and a nonparametric test, in research conducted in the areas most affected by the COVID-19 outbreak in China, suggested that women had higher levels of PTSD.49 Another study in China, carried out among health professionals, found that young women were the most affected psychologically.33 The chance of experiencing anxiety during the pandemic period seems to be greater among women (OR 3.01; 95% CI 1.39-6.52) and among people aged over 40 (OR 0.40; 95% CI 0.16-0.99).18 Almost 35% of respondents experienced psychological distress.12 Multinomial logistic regression analyses showed that women showed signi cantly higher psychological levels of distress than men.12 Female nurses, women, rst-line health professionals, and those working in Wuhan, China reported more severe degrees of all MH measurements than other health professionals.20 Female gender, the presence of Covid-19 symptoms, and poor self-rated health status were signi cantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety and depression (p <0.05).38 Another study, of more than 12,000 people, of which approximately 90% (10,754) completed the questionnaire, showed that the total anxiety level was 8.61 ± 6.95, and the severity of anxiety symptoms in 49.1% of the cases was normal, in 9.3% it was severe, and in 9.8% it was very severe, with the highest level of anxiety being among women (p <0.001). 10 Health professionals Doctors, nurses, and other healthcare professionals may experience trauma while treating patients, especially when they are dealing with a new disease that they are unsure how to treat effectively.
According to Bao et al. (2020),60 the stress they experience can trigger common mental disorders, including post-traumatic stress disorder, anxiety and depressive disorders which, in turn, can result in threats exceeding the consequences of the COVID-19 epidemic itself.
Xu et al. (2020)41 compared MH measurements during and prior to the outbreak among the medical team, and found that the surgical team's anxiety, depression, dream anxiety, and SF-36 scores during the outbreak period were signi cantly higher than in the non-outbreak period (p <0.001).
In India and Singapore, a study showed that of the 906 health professionals who participated in the survey, 5.3% (n =48 had positive results for moderate to very severe depression, 8 Studies have also shown that professionals who are on the front line for the treatment of Covid-19 may be more impacted by the consequences of the pandemic.14,20,29,41,51 For example, a study conducted in China showed that health professionals involved in the diagnosis, treatment and care of patients with COVID-19 were more likely to have symptoms of depression (OR 1.52; 95% CI 1.11-2.09), anxiety (OR 1.57; 95% CI 1.22-2.02), insomnia (OR 2.97; 95% CI 1.92-4.60) and anguish (OR 1.60; 95% CI 1.25-2.04) than those working in other areas.20 Also in China, trauma scores of frontline nurses, including those for psychological and physiological clinical responses, were signi cantly higher than staff who were not on the front line (p <0.001).51 Huang & Zhao (2020),29 also found a higher prevalence of symptoms of anxiety, depressive symptoms and poor sleep quality in health professionals who spent more time caring for COVID-19 patients.29 Sun et al. (2020),14 explained that nurses who care for patients with COVID-19 may have negative emotions, such as fatigue, discomfort and helplessness, caused by high-intensity work, fear, anxiety, and concern for patients and family members. A study carried out in China compared fear, anxiety and depression between two groups of hospital employees,43 with the medical team showing greater symptoms of fear, anxiety and depression than the administrative team. In addition, the analysis also showed that medical staff working in departments that maintain direct contact with patients with pneumonia resulting from coronavirus infection had more psychological disorders and almost twice the risk of experiencing anxiety and depression.43 Other factors can also in uence the mental health of health professionals, such as living in rural areas, being a woman, and being at risk of contact with patients diagnosed with COVID-19. 15 Mo Y. et al.
(2020),16 investigated work-related stress among female nurses who supported the ght against the COVID-19 infection in Wuhan, and found that being an only child, having a greater weekly workload, and anxiety, were the main factors that affected the nurses' stress levels.

Summary of recommendations and strategies listed by the studies
Although controlled or longitudinal studies related to MH at the time of COVID-19 were not found in this review, research indicates that there may be expected MH consequences for populations. The studies published so far point to the need of emphasising on MH care while the pandemic is still ongoing, in order to avoid extensive future problems, and possibly reduce the duration and cost of treating subsequent psychological effects. Psychotherapy and counselling are fundamental to this aim. They also listed speci c measures for the most vulnerable population groups or those that may be most affected by COVID-19, such as the elderly and health professionals. Cognitive Insomnia Behavior Therapy (CIBT) is a promising intervention for acute sleep pattern alterations, it also can improve patients' selfe cacy and con dence in controlling their sleep problems.22

Mental Health (MH) Professionals
It is recommended that mental health professionals be attentive to individuals' emotional responses during the current pandemic, as well as to pre-existing risk factors, and people with a history of mental illness presenting pathological levels of negative emotions and related behaviours.23 They should suggest limiting the time for taking in information related to COVID-19 to a maximum of two hours a day; maintaining a normal work rhythm, and resting as much as possible; exercising regularly in order to promote sleep quality; and not accessing information about outbreaks before bed.29 They should educate the public about common adverse psychological consequences and promote healthy behaviour, for example using alternative forms of communication, such as virtual networks.10 MH professionals currently have an important role to play in supporting the public's well-being.
Continuous surveillance and monitoring of the psychological consequences of outbreaks of potentially epidemic and life-threatening diseases, and establishing early mental health interventions should become routine, as part of efforts to prepare for outbreaks worldwide.29 Health professionals on the front line The study results pointed to the importance of being prepared to support frontline workers ghting the pandemic through mental health interventions in times of crisis,33 especially those allocated to the respiratory, emergency, ICU, and infectious disease departments.43,51 The main measures cited by the articles were: to increase the availability of specialized treatment with psychologists and psychiatrists;33,44 to enable multidisciplinary interventions, addressing both psychological manifestations and physical symptoms; to provide counselling dedicated to relieving the fear of transmitting the infection to family members, and increase con dence and self-esteem;28 and to develop the strengthening of support from colleagues in the workplace, online forums for teams or advice hotlines, and early identi cation of risk factors by employers,32 through stress management and professional health services in psychological consultancy, and early intervention.32,61 Health professionals also require adequate working conditions, with the provision of su cient protective medical equipment, and adequate rest time, as well as access to programs designed to increase the capacity for resilience and psychological well-being.15 They must be mobilized so that they actively seek out their social support systems. Leisure activities and training on how to relax should be organized, to help staff reduce stress.16 The post-pandemic period is also a concern, it will also involve MH impacts seen during the pandemic. It is highly recommended that health professionals include the promotion of mental health as part of their follow-up after the pandemic, and that they observe symptoms of traumatic stress, which can lead to the development of avoidance behaviours, or passive lifestyles after the pandemic.22 Finally, in order to better prepare for future outbreaks of infectious diseases, greater investment in MH tools is needed, in order to assist and protect the medical and nursing teams working on the front line. Children and young individuals For children and parents, early detection of parental MH problems, and the timely provision of certain psychological interventions will help parents to take better care of their children in hospital, and help children to recover and be discharged as quickly as possible.39 Attention is also needed to identify an appropriate approach for children with Attention De cit Hyperactivity Disorder (ADHD), in terms of disaster risk reduction activities.22 Special attention must also be paid to the psychological health of individuals under the age of 18, and from middle age to the elderly (aged over 50), providing psychological interventions through television, internet and the telephone. For young people, guidance should be given, in order to understand the epidemic, and to alleviate panic and fear.4

Public policies
Governments must rst recognize COVID-19 as an emergency public health concern, in order to improve health literacy and control the disease and its consequences during the outbreak.46 It is necessary to provide the public with transparent, up-to-date, accurate, brief and simple information, and knowledge about the epidemic, pathogenicity and transmissibility, in order to better control the disease.29,46 It could also establish an o cial, integrated and uniform platform for MH counselling, to provide psychological counselling to people in need.29 Identifying those who may be most affected by COVID-19, not exclusively epidemiologically, but also through working and living in the most affected regions, has important implications. This identi cation helps direct resources to those who need most.52 The timely identi cation of psychological distress, and accurate classi cation of MH needs among populations, will facilitate the development of targeted psychological interventions.47 Similarly, it is necessary to adopt preventive measures for PTSD, and other mental problems.49 Professional psychological assistance and counselling should focus on the psychological health of vulnerable populations, those with lower levels of education, women and susceptible groups, such as the divorced or widowed,44 suspected and diagnosed patients, young people and health professionals, especially doctors and nurses who work directly with patients or quarantined people.29 In summary, it is necessary to formulate psychological interventions to improve MH and psychological resilience during the COVID-19 epidemic.38 The government should aim to adopt appropriate subsidy policies to alleviate the economic pressure on the general population caused by the epidemic,44 and increase medical support,27 in addition to implementing public policies that stimulate social capital during isolation.50 Social support not only reduces psychological pressure during epidemics, but also changes attitudes towards methods for seeking help.17 The Media The use of social media data can provide a timely understanding of the impact of public health emergencies on the public's MH during the epidemic period.11 However, the media can also have negative consequences on people's MH. Research has found that more than 80% (95% CI 80.9%-83.1%) of participants reported being frequently exposed to social media,48 and high chances of anxiety (OR 1.72; 95% CI 1.31-2.26) and a combination of depression and anxiety (CDA) (OR 1.91; 95% CI 1.52-2.41) were observed among users who were frequently exposed.48 A study conducted in Iran also showed a higher level of anxiety among the people who followed coronavirus-related news the most (p <0.001).10 Therefore, the feeling of distress and panic that takes hold of the population due to the amount of information in the media, or ¨ infodemia¨, is also of concern. Monitor, lter out false information and promote accurate information by means of collaboration between professionals from distinct backgrounds could reduce the impact of this type of distress.48 It is also recommended that MH services be disseminated through various channels, including hotlines, online consultations, online courses and outpatient consultations, with special attention to signs of depression and anxiety.48 The media should aim at reporting the progress of the epidemic and increase publicity for psychological counseling.44

Conclusion
Most of the reviewed studies indicated that the Covid-19 pandemic could impact people's Mental Health (MH), especially among the most vulnerable population groups, with the development and maintenance of MH actions being important, in conjunction with activities to control Covid-19. The most addressed MH outcomes were anxiety, depression or depressive symptoms, obsessive behaviours, obsessive-compulsive disorder, trauma or post-traumatic stress disorder (PTSD), psychological distress, stress and fear.
However, most studies presented signi cant methodological limits. Investigations showing greater methodological robustness, including representative and randomized samples, and with longitudinal designs, would be necessary in order to assess the long-term impact of COVID-19 on MH. Pending such studies, given the effects (during and after) of previous epidemics on MH, government measures need to be implemented to reduce the potential catastrophic effects of the current COVID-19 pandemic on MH, and the burden that will remain after the pandemic.
In terms of policies, the population's access to medical resources and public health system services must be strengthened and improved, especially after review of the initial COVID-19 pandemic response and management process, including MH support. To this end, (A) national strategic planning and coordination of psychological rst aid should be established, and potentially carried out via telemedicine; and (B) comprehensive care must be established, with a prevention and intervention system, including epidemiological monitoring, screening, referral and targeted intervention, in order to reduce psychological distress and prevent new MH problems.   Sources of stress related to COVID-19 were considered: conditions such as the physical health risks for doctors, fears for their own health and the huge amount of information about the pandemic. Family resources were measured through questions about their satisfaction with support and their type of feeling regarding family ties, with answers ranging from "almost never" to 2 "always". Ad hoc questions were included to measure various personal resources related to regulating emotions, behavioral, cognitive and social strategies chosen from the many and diverse potential variables of resources analyzed in the literature on stress and coping. Perceived loneliness was measured using the item "How lonely do you feel?", With answers ranging from 0 "I don't feel lonely" to 10 "I feel completely lonely". Psychological stress was estimated considering a wide range of psychological responses to COVID-19, including anxiety and depression, anger or fear. An ad-hoc scale of 5 items was used, which measured anxiety, anger, sadness, fear and hope, respectively. Responses ranged from 0 "I don't feel (...)" to 10 "I feel totally (...)". In addition to descriptive and correlational analyses, two hierarchical regression analyses This was an online cross-sectional survey, with data obtained through Amazon MTurk, in exchange for payment (US $ 0.50). The people recruited gave consent, full details and followed the instructions for item validity. Information gathered included age, sex, ethnicity, education, current residence, coronavirus diagnosis and history of anxiety. A five-item scale (Coronavirus Anxiety Scale -CAS) was used for validation, each representing the symptoms of physiological arousal associated with clinically elevated fear and anxiety: Dizziness, which is an important symptom of panic attacks, and a characteristic associated with generalized anxiety disorder; Sleep disturbance, which is a common symptom of generalized anxiety disorder and post-traumatic stress disorder; Tonic immobility, which is not an important symptom of any psychiatric condition, but motor inhibition is an involuntary response to extreme fear and the perception of inevitability and is typically experienced by victims of highly traumatic situations, such as sexual assault; Loss of appetite, which is a common symptom of major depressive disorder, a condition that often occurs together with panic disorder; nausea or abdominal distress, which reflect digestive changes associated with a response to fear. The criteria for determining the five symptoms on the scale were based on the properties of a psychometrically correct item. Participants answered questions ranging from 0 (not at all) to 4 (almost every day in the past 2 weeks). Factor analysis was applied to anxiety symptoms, in order to identify a small and reliable subset of symptoms that best represents the latent construct of coronavirus anxiety. Four scales were used to assess the mental health state of doctors and nursing staff. The item questionnaire, the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder (GAD-7), the 7-item Insomnia Severity Index (ISI) and the 22-item Impact of Event Scale-Revised (IESR) were used to assess depression, anxiety, insomnia and distress, respectively. The clustering method was used to select the sample of students from Changzhi Faculty of Medicine, and structured questionnaires were applied to assess the mental health of these students during the COVID-19 outbreak. Univariate analysis (nonparametric test) was used to explore the significant associations between sample characteristics and the level of anxiety during the COVID-19 epidemic. Statistically significant variables were tracked and included in the multivariate logistic regressions and Spearman's correlation coefficient was used to assess the association between stressors related to COVID-19, including economic factors, and day-to-day related stressors, as well as those related to delays in academic activities and levels of anxiety. A total of 605 questionnaires on psychological status were distributed to the general population through online questionnaires from 6 to 9 February 2020. 600 valid questionnaires were returned. The scales used to assess mental health were: The Self-Rating Anxiety Scale (SAS) and The Self-Rating Depression Scale (SDS). A cross-sectional study carried out with 906 health professionals from 5 large hospitals, involved in caring for COVID-19 patients in Singapore and India, who were invited to participate in a study, using a self-administered questionnaire from February 19 to 17 April 2020. The health professionals included doctors, nurses, allied health workers, administrators, administrative staff and maintenance workers. The questionnaire collected information on demographic data, medical history, symptom prevalence in the past month, Depression Anxiety Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R). Evaluation was made of the prevalence of physical symptoms presented by health professionals and the associations between physical symptoms and the psychological results of depression, anxiety, stress and post-traumatic stress disorder (PTSD). Linear regression was used to assess associations between baseline characteristics, risk status, physical symptoms and the average scores of the components DASS-21 and IES-R.
The crosssectional nature of the study means that mental health is measured at just one point in time.
The use of a selfadministered questionnaire is subject to recall bias, in addition to important variables not being recorded, such as socioeconomic status and education levels.
China 2 State/Provincial (2,330 students from 2 primary schools in Hubei province) A cohort study was carried out with 2,330 students from the 2nd to 6th grades in two primary schools in Hubei province, of which 845 were from Wuhan and 1,485 were from Huangshi. The students were asked to complete a survey between February 28 and March 5, 2020, and completed the investigation through an online crowdsourcing platform, the link to the survey and the declaration of consent were sent to their guardian's cell phone. This is a cross-sectional study carried out through an online survey between April 10 and 13, 2020. The snowball sampling method was used to recruit participants, initially selecting five subjects from a wide range of age, sex, occupation, education and geographical area. Each participant was asked to choose five people they considered suitable for the research, and to send them the questionnaire. Additional participants were contacted in the same way until data saturation occurred, being recruited from all Italian regions. Sociodemographic and lockdown-related information was collected and distress, temperament and attachment were assessed using the Kessler 10 Psychological Distress Scale (K10), the Memphis, Pisa, Paris and San Diego Temperament Assessment short version (TEMPS-A) and the validated Italian version of the Attachment Style Questionnaire (ASQ). The factors significantly associated with mild or moderate to severe psychological distress in the bivariate analyses were subjected to multivariate multiple logistic regression.
The research design involved an online invitation, thus leaving the population that does not use internet devices unexplored, and it is not possible to assess the participation rate, since it is not clear how many subjects received the study. In addition, the reliability of selfadministered questionnaires may be partially biased.
Zhang, J. et al. A cross-sectional study, in which data was collected through an anonymous and self-assessed questionnaire. The questionnaire consisted of three parts: basic demographic data, the Self-Rating Depression Scale (SDS) and the Self-Rating Anxiety Scale (SAS). Individuals who had worked in highrisk settings, such as COVID-19 wards, fever clinics, infectious disease departments, emergency rooms, pulmonary medicine departments, or Xray labs, were classified as having exposure to high-risk work..
Self-assessment scales were used, being subject to recall bias. There is no information about the mental health of individuals before the outbreak.
Author(s) Principal mental health findings Article recommendations (measures and strategies) Losada-Baltar, A. (1) The data in this study suggests that it is not chronological age itself, but a negative selfperception of aging that is related to loneliness and psychological suffering in people during lockdown at home during the COVID-19 crisis. Elderly people with a positive self-perception of aging seem to be more resistant to loneliness and distress during the outbreak of COVID-19.
The study does not make any recommendations, nor mention strategies to mitigate the effects of loneliness and psychological distress.
Lee, S.A. (2) High anxiety scores were associated with a coronavirus diagnosis, coping with alcohol/drugs, negative religious coping, extreme hopelessness and suicidal ideation.
In addition, coronavirus-related anxiety also significantly influenced social attitudes, such as approval of President Trump's responses to the coronavirus outbreak. A positive correlation was found between coronavirus anxiety and avoidance of Chinese foods and products, which reflects xenophobic attitudes.
The study does not make any recommendations, nor mention strategies to mitigate the effects of coronavirus-related anxiety, since it involves validation of a scale. The recommendations are only restricted to the potential use of the measurement when assessing the affected people's mental health.
Pulvirenti, F. et al. (3) The issues associated with the risk of anxiety/depression were related to the fear of the COVID-19 pandemic, and to fragility concerning the patients' clinical issues (being afraid of being infected and becoming ill).
The anxiety of running out of medication was a major concern.
The importance of carrying out a periodic assessment of the health-related quality of life of patients under clinical-home care is highlighted. At-risk patients need to be cared for, planning personalized medical and psychological support throughout life, especially in exceptional cases, such as in the COVID-19 pandemic. Huang, Y. & Zhao, N. (4) The general prevalence of anxiety symptoms, depressive symptoms, and poor sleep quality was 35.1%, 20.1% and 18.2%, respectively. The prevalence of anxiety symptoms and depressive symptoms was significantly higher in younger participants (<35 years old) (p<0.001). The prevalence of anxiety symptoms, depressive symptoms and poor sleep quality was significantly higher in health professionals who spent a large amount of time (≥3 hours day) caring for COVID-19 patients compared to those spending less time (<1 hour/day and 1-2 hours/day). Young people who spent more than 3 hours a day thinking about the outbreak had a significantly higher prevalence of anxiety symptoms (p <0.001).
Governmental organizations, and various communication vehicles, must further disseminate the right information, to ease the mental health burden among people. The national public health organization should establish an official, integrated and uniform mental health counseling platform, to provide psychological counseling to people in need. Vulnerable populations, such as suspected and diagnosed patients, younger people and health professionals, especially doctors and nurses who work directly with patients, or people in quarantine, deserve special attention for follow-up. People should try to balance their free time with other activities (for example, exercising at home) and the amount of time they spend accessing outbreak information (<2 hours/day). In addition, people should try to carry on working and resting normally as much as possible, exercise regularly to promote quality sleep, and not pay too much attention to epidemic information before bedtime. Gao, J. et al.
The prevalence of depression was 48.3% (95% CI 46.9%-49.7%). For anxiety it was 22.6% (95% CI 21.4%-23.8%) and the combination of depression/anxiety (CDA) was 19.4% (95% CI 18.3%-20.6%) during the Covid-19 period. More than 80% (95% CI Mental health services are recommended through different channels, including a direct line, online consultation, online courses and outpatient consultation, with special attention given to signs of depression and anxiety. It is also necessary to combat the 80.9%-83.1%) of the research participants reported being frequently exposed to social media. A high risk of anxiety (OR 1.72, 95% CI 1.31-2.26) and CDA (OR 1.91, 95% CI 1.52-2.41) was observed among users frequently exposed to social media.
"infodemic" (feelings of distress and panic that are established in the population due to the amount of information in the media), monitoring and filtering false information, and promoting accurate information through cross-sectional collaborations. Yuan, R. et al. (6) y The anxiety score of parents with hospitalized children in the epidemic (EH) (7.02 ± 3.01) was significantly higher, compared to the anxiety score of parents of non-epidemic hospitalized children (NEH) (3.62 ± 2, 10) (p <0.001). Likewise, the depression score of parents of EH children (7.72 ± 2.81) was higher than the depression score of parents of NEH children (4.54 ± 2.56) (p <0.001). There was a positive correlation between anxiety, depression and sleep scores among parents of EH children. Therefore, parents of children hospitalized during the COVID-19 epidemic face enormous pressure and anxiety. Post-traumatic stress disorder and mental health problems can occur in the parents, which can affect the child's recovery.
Early detection of these parents' mental health, and the timely provision of certain psychological interventions, will help parents to take better care of their children in hospital, and help children to recover and be discharged as quickly as possible.
Xu, J. et al. (7) The anxiety score of the surgical team during the outbreak period (7.817 ± 2.550) was significantly higher than in the non-outbreak period (5.283 ± 1.738) (p <0.001). The depression score of professionals in the surgical team was also higher during the outbreak period (7.333 ± 2.550), compared to the non-outbreak period (4.933 ± 2.154) (p <0.001). Also, the dream anxiety score and the SF-36 of the surgical team during the outbreak were significantly higher than in the non-outbreak period (p <0.001). All of these indicators (anxiety, depression and dream anxiety scores) measured in the surgical team during the outbreak period were positively correlated.
To protect the mental health of the medicalsurgical team, adequate rest time and psychological intervention measures need to be guaranteed, and must be carried out early when necessary.
A 70% prevalence of symptoms for moderate to severe psychological disturbance was observed, with scores specifically high for obsessive compulsive disorder, interpersonal sensitivity, phobic anxiety and psychoticism. Those who were aged over 50, well educated, divorced or widowed, and who worked in agriculture had more symptoms. The youngest participants and medical staff were in the highest risk group, in terms of the severity of psychological symptoms.
Special attention needs to be paid to the psychological health of individuals under the age of 18, and middle-aged to elderly people (aged over 50), providing psychological interventions through television channels, the internet and telephone. For young people, guidelines should be given to understand the epidemic and to alleviate panic and fear. A professional organization for psychological care should be established to guarantee the health and safety of frontline medical staff, regularly checking their psychological status, and providing psychological intervention services, both for the medical staff and their families. For groups such as other company employees and agricultural workers, the government must adopt appropriate policies for subsidies to ease economic pressure on the general population caused by the epidemic. The media must objectively report on the epidemic's progress and increase publicity for psychological counseling. Actions should focus on the psychological health of people with lower levels of education. Also, special attention should be paid to the psychological health of women and sensitive groups, such as divorced or widowed people, with professional psychological help and counseling. Roy, D. et al. (9) High levels of anxiety were observed; 80% of the research participants were worried, having thoughts about COVID-19, and 72% reported a lot of worry about the use of gloves and disinfectants. Symptoms such as negative changes in sleep (12.5%), paranoia about the use of social media related to COVID-19 infection (37.8%) and distress (36.4%) were reported. The perceived need for mental health care was observed in more than 80% of the participants.
The possibility of mental health consultations online or on the doorstep need to be considered as forms of intervention.
Zhang, J. et al. (10) An increased prevalence of depression (29.2%) was observed in patients infected with COVID-19 (p 0.016). There was an increase in the prevalence of comorbid depression with anxiety (p 0.086) both in patients infected with COVID-19 (21.1%), and in the general public (22.4%). Patients infected with COVID-19 (19.3%) and the general public (14.3%) also had a higher proportion of severe depressive symptoms (p 0.002). In addition, infected patients and the general public were more likely to have a depressed mood (p 0.038) and somatic symptoms (p <0.01), compared to quarantined individuals. Anxious behavior, including becoming easily irritated or irritable, was manifested mainly in the general public and in patients infected with COVID-19 (p <0.01).
The timely identification of psychological distress, and the precise classification of mental health needs among populations will facilitate the development of psychological interventions focused on individuals in emerging infectious disease epidemics.
Identifying who may be most affected by COVID-19 can help prioritize those who need the most help. Psychologists, mental health professionals and social workers can provide services to address mental health problems, even during the lockdown.
Lu, W. et al. (12) The study compared fear, anxiety and depression between two groups of hospital staff. The medical staff showed greater fear, anxiety and depression than the administrative staff. The extra analysis showed that medical staff working in departments that maintain direct contact with patients with pneumonia resulting from coronavirus infection had more psychological disorders and had almost twice the risk of experiencing anxiety and depression.
Effective strategies to improve mental health must be provided for frontline medical staff combating COVID-19, in ICUs, emergency rooms, and respiratory and infectious disease departments. adequate working conditions, for example, the provision of sufficient personal protective equipment, adequate rest time, as well as access to programs designed to increase resilience and psychological well-being.
Mo, Y. et al.
Work stress was investigated among female nurses supporting the fight against COVID-19 infection in Wuhan. The results showed widespread pressure on nurses in Hubei who helped fight COVID-19. Being an only child, having a greater weekly workload and anxiety were the main factors that affected the nurses' stress levels.
Nursing sector managers should guide nurses on how to care for their psychological health and mobilize them to actively seek out their social support systems. Leisure activities and training on how to relax should be organized to help staff reduce stress.
The results showed that the COVID-19 epidemic caused panic and hypochondria, leading to unnecessary behavior in seeking healthcare, and increased demand for healthcare services among patients.
Hospitals providing online care (Internet hospitals) can carry out targeted and personalized medical interventions for various types of patient, helping to prevent and control the COVID-19 epidemic in China. Based on its own results, the study also indicated that remote medical services are very necessary when the public is panicking. Zhang, Y. & Ma, Z.F. (16) After the start of the pandemic, more than half (69.2%) of the study's participants reported not having increased stress at work, 76.8% did not experience increased financial stress due to the pandemic and 74.5% did not experience increased stress at home. On the other hand, 52.1% of the participants reported feeling horrified and apprehensive due to the COVID-19 pandemic, and 46% felt powerless due to the pandemic.
It is highly recommended that health professionals include mental health promotion as part of their follow-ups after the pandemic and that they observe traumatic stress symptoms, which can lead to the development of avoidance behaviors or passive lifestyles after the pandemic. Research participants who were diagnosed with COVID-19 had a higher probability of depression (OR, 2.88; p <0.001) and a lower score on the scale measuring health and quality of life (HRQoL) (B, -7.92; p <0.001). Health literacy was a protective factor for depression and HRQoL during the COVID-19 epidemic, especially among people not diagnosed with the disease.
Governments must first recognize COVID-19 as a public health emergency, in order to improve health literacy and disease control, and its consequences during the outbreak. It is also necessary to seek a balance between public health, civil liberties and being culturally sensitive. The government needs to provide the public with transparent, up-todate, accurate, brief and simple information and knowledge about the epidemic, its pathogenicity and transmissibility, in order to better control the disease. Liu, N. et al.
The prevalence of Post-traumatic Stress Disorder (PTSD) symptoms in the areas most affected by the COVID-19 outbreak in China was 7%. Hierarchical regression analysis and non-parametric testing suggested that women had higher PTSD, with negative changes in cognition, mood or hyperexcitation. Participants with better sleep quality, or who woke up at night less frequently, reported lower PTSD.
Public attention should be given to the high prevalence of PTSD, adopting measures to prevent PTSD and other mental problems, especially among women.
Among the 994 medical and nursing staff surveyed in Wuhan, 36.9% had mental health disorders below the threshold (PHQ-9: 2.4 average), 34.4% had mild disorders (PHQ-9: 5.4), 22.4% had moderate disorders (PHQ-9: 9.0) and 6.2% had severe disorders (average PHQ-9: 15.1), shortly after the COVID-19 epidemic. Young women were the most affected. Of the total participants, 36.3% had access to psychoeducational materials (such as books on mental health), 50.4% accessed psychological resources available in the media (such as online messages on methods of self-help coping for mental health) and 17.5 % participated in counseling or psychotherapy. Although the team had limited access to mental healthcare services, they considered these services to be important resources for alleviating acute mental health disorders among health professionals.
The results indicate the importance of being prepared to support frontline workers through mental health interventions in times of crisis. Increasing the availability of specialized treatment from psychologists and psychiatrists could benefit them. Finally, in order to better prepare for future outbreaks of infectious diseases, greater investment in mental health tools is needed to assist and protect medical and nursing staff working on the front line.
Approximately 25% of university students experienced anxiety due to the COVID-19 outbreak. Living in urban areas, living with parents, and having a stable family income were protective factors for university students against anxiety experienced during the COVID-19 outbreak. However, having a relative or acquaintance infected with COVID-19 was an independent risk factor for anxiety. The stressors related to COVID-19 included economic factors, effects on daily life and academic delays that were associated with higher levels of anxiety symptoms among Chinese university students during the epidemic, while social support correlated with less anxiety.
Social support not only reduces psychological pressure during epidemics, but also changes attitudes towards methods of seeking help. The results found suggest that robust social support is necessary during public health emergencies.
The likelihood of experiencing anxiety during the pandemic period was higher among women (OR: 3.01; 95% CI 1.39-6.52) and among people aged over 40 (OR: 0.40; 95% CI 0, 16-0.99). Compared to people with a Master's degree, or higher qualification, those in the undergraduate group had a 0.39 times lower risk of depression (95% CI 0.17-0.87).
The public should pay attention to the information presented by the media and advertising, and avoid absorbing misleading information that can lead to panic and depression. Anxiety and depression are common psychological phenomena in disasters and can be a barrier to rational medical and mental health interventions.
Adequate support for mental health should be provided through effective public policies. Qiu, J. et al.
Almost 35% of respondents experienced psychological distress. Multinomial logistic Greater attention for the most vulnerable groups of the population is needed. The (22) regression analyses showed that women had significantly higher psychological levels of distress than men. Individuals aged over 60 had higher scores than the general population, and migrant workers had the highest level of distress, among all occupations population's accessibility to medical resources and the public health service system must be reinforced and improved, mainly following a review of the initial process of coping and managing the COVID epidemic. National strategic planning and coordination of psychological first aid during major disasters, potentially carried out remotely, must be established. Comprehensive care should be constructed, with a prevention and intervention system, including epidemiological monitoring, screening, referral and targeted intervention, to reduce psychological distress and prevent new mental health problems. Li, S. et al.
The results showed that negative emotions (anxiety, depression and indignation) increased while positive emotions (measured by Oxford happiness scores) and life satisfaction decreased with the pandemic. Regarding concerns during the outbreak, people were more concerned about their health and family, and less about leisure and friends.
The use of social media data can provide a timely understanding of the impact of public health emergencies on public mental health during the epidemic period. It is also important to prepare clinicians to provide the corresponding therapeutic support for risk groups and affected people. The protection of health professionals is an important component of public health measures to combat the COVID-19 epidemic, requiring interventions to promote the mental well-being of health professionals exposed to COVID-19.
Low levels of social capital have been associated with increased levels of anxiety and stress and increased levels of social capital have been positively associated with increased quality of sleep. Anxiety was associated with increased stress and reduced quality of sleep.
The study warned of the need for public policies that stimulate social capital during the necessary isolation period.
Traumatization scores, including scores for psychological and physiological clinical responses, were significantly lower for nurses who were not on the frontline than for There is a need to pay greater attention to the psychological problems of medical staff, especially female nurses who are on the frontline, and the general public in the nurses who were on the frontline of Covid-19 care (p <0.001).
situation where COVID-19 is being disseminated and controlled. Wang, C. et al.
The results showed that 53.8% of the interviewees classified the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. Most respondents spent 20 to 24 hours a day at home (84.7%); were concerned about family members contracting COVID-19 (75.2%); and were satisfied with the amount of health information available (75.1%). Being a woman, having Covid-19 symptoms, and self-reporting health as poor, were significantly associated with a greater psychological impact of the outbreak and with higher levels of stress, anxiety and depression (p <0.05). The study points out the need to think of and adopt strategies for the prevention and treatment of insomnia among health professionals. Cognitive insomnia behavior therapy (CBTI) can effectively treat acute insomnia, improve patients' self-efficacy and confidence in controlling their sleep problems, and is recommended as a first-line treatment for acute insomnia in adults.
et al (30) The authors found a small-to-moderate positive relationship between PROMIS Anxiety and self-reported risk of COVID-19, meaning that those who showed more anxiety symptoms and believed themselves to be at risk of contracting the virus changed their behavior more than those who did not. They also found, moderate-to-strong correlations For mental health professionals, it is recommended that these professionals are attentive to the emotional responses of individuals during the current pandemic, along with pre-existing risk factors, and people with a history of mental illness, presenting pathological levels of negative emotions and related behaviors.
between the FCV-19S scale and PROMIS Anxiety and Depression, suggesting that this new measure of fear was highly related to anxiety symptomatology. Increased FCV-19S scores were also moderately correlated with an increased self-reported risk of getting infected by COVID-19. Lei, L. et al.
A prevalence was found of 8.3% of anxiety and 14.6% of depression. The prevalence in the affected group (12.9%, 22.4%) was significantly higher than in the unaffected group (6.7%, 11.9%), whether they or their families/colleagues/classmates/neighbors had been quarantined. A lower average family income, lower level of education, greater concern about being infected by COVID-19, not having psychological support, greater economic losses and lower selfreported health conditions were statistically significant, associated with higher scores on the self-rating anxiety scale (SAS) and selfrating depression scale (SDS).
Governments should focus on providing economic and medical support, in order to improve the general population's mental state.

N. (32)
The average level of anxiety in terms of the Beck Anxiety Inventory was 25.72 ± 6.53 in patients with multiple sclerosis who were in the moderate to severe range. The level of anxiety was severe in 15 patients, and moderate and low in 18. There was no statistically significant correlation between the level of anxiety and the patients' diseasemodifying medications.
The study did not make any recommendations.
The authors aimed to quantify the immediate psychological effects and psychoneuroimmunity prevention measures of a workforce returning to work during the COVID-19 epidemic. They found that 10.8% of the 673 respondents met the diagnosis of post-traumatic stress disorder (PTSD) after returning to work, and a low prevalence of anxiety (3.8%), depression (3.7%), stress (1.5%) and insomnia (2.3%). They also found no significant differences in the severity of psychiatric symptoms between workers/technicians and executives/managers. Being single/divorced/widowed, the presence of physical symptoms, poor physical health and viewing return to work as a health hazard (p<0.05) were associated with the severity of psychiatric symptoms. While personal psychoneuroimmunity prevention measures, including hand hygiene and wearing face masks, as well as organizational measures, including significant improvement of workplace hygiene and concerns from the company were associated with less severe psychiatric symptoms (p<0.05).
Employees can benefit from strengthening peer support in the workplace; online staff forums or direct lines of advice and early identification of risk factors by employers, stress management and professional psychological consultancy services, and early intervention.
Sun, N. et al.
The authors found that the negative emotions present in the initial stage, such as fatigue, discomfort and helplessness, were caused by Self-coping strategies and psychological growth are important for nurses to maintain high-intensity work, in addition to fear, anxiety and concern for patients and family members. Among the self-coping strategies adopted by female nurses, they included altruistic acts, team support, rational cognition, greater affection and gratitude, the development of professional responsibility and self-reflection. Lastly, it was shown that positive emotions occurred simultaneously with negative emotions during the fight against the pandemic. their mental health while providing care for patients infected by COVID-19.

Moghanibashi-Mansourieh,
A. (35) More than 12,000 people answered the questionnaire and about 90% (10,754) of them completed the questionnaire. The results showed that the total level of anxiety was 8.61 ± 6.95 and the degree of anxiety symptoms in 49.1% of cases was normal, in 9.3% it was serious and in 9.8% it was very serious. The level of anxiety was higher among women (p <0.001), people who followed the news related to coronavirus the most (p <0.001), those aged 21 to 40 (p <0.001) and among people who had at least one family member, relative or friend who contracted COVID-19 (95% CI [1.2, 35.03], p <0.001).
Mental health professionals should educate the public about common adverse psychological consequences, promote healthy behavior, advise people to decrease their exposure to negative news, prevent social isolation, and use alternative forms of communication, such as virtual networks. Responsible organizations should design and implement a gender-sensitive psychosocial protocol to reduce anxiety. Use NGO services, since they are more efficient and effective in the service delivery process, due to their closer relationship with people, and less bureaucratic operations. The results revealed an elevated risk of psychological distress of 11.5% among the research participants. High psychological stress was found among those with an underlying illness (OR = 3.023; 95% CI: 1.186-7.705), fear of contracting COVID-19 from a patient (OR = 2.110 95% CI: 1.236-3.603) and a greater subjective burden (OR = 1.073; 95% CI: 1.010-1.141). Less psychological distress was associated with being in a committed relationship (OR = 3.023; 95% CI: 1.186-7.705) and having greater self-efficacy (OR = 0.889; 95% CI: 0.833-0.968).
It is recommended that methods be introduced to improve the dental team's selfefficacy, in addition to providing a broader understanding of mental health Chew, N.W.S. et al. (37) After adjusting for age, gender and comorbidities, the authors found that depression (OR 2.79, 95% CI 1.54-5.07,p=0.001), anxiety (OR 2.18, 95% CI 1.36-3.48, p=0.001), stress (OR 3.06, 95% CI 1.27-7.41, p=0.13), and PTSD (OR 2.20, 95% CI 1.12-4.35, p=0.023) remained significantly associated with the presence of physical symptoms experienced in the preceding month. Running static analysis using linear regression, they also found that the presence of physical symptoms was associated with higher mean scores in the IES-R, DASS Anxiety, Stress and Depression subscales.
The authors mention that multidisciplinary interventions are needed to support health professionals, addressing both psychological manifestations and physical symptoms, in addition to offering psychological support and interventions after the exclusion of acute infection. Counseling can be offered to alleviate the fear of transmitting the infection to family members, and increasing the confidence and self-esteem of health professionals.
Among the 1,784 (76.6%) who completed the survey, 22.6% reported depressive symptoms and 18.9% symptoms of anxiety. Wuhan students had significantly higher CDI-S scores than those from Huangshi (β 0.092; The study did not make any recommendations. 95% CI, 0.014-0.170), with a higher risk of depressive symptoms (OR 1.426; 95% CI, 1.118-1.786). Students who were slightly, or not worried about being affected by COVID-19, had significantly lower CDI-S scores than those who were very concerned (β -0.184; 95% CI, -0.273 to -0.095), presenting a reduced risk of depressive symptoms (OR 0.521; CI 95% 0.400-0.679). Those who were not optimistic about the epidemic, compared to those who were quite optimistic, had significantly higher CDI-S scores (β 0.367; 95% CI, 0.250-0.485), with an increased risk of depressive symptoms (OR 2,262; 95% CI 1,642-3,117). There was no significant association between demographic characteristics and symptoms of anxiety. Huang, Y. & Zhao, N. (4) The overall prevalence of generalized anxiety disorder-GAD, depressive symptoms and sleep quality in the population were 35.1%, 20.1% and 18.2%, respectively. Young people reported a significantly higher prevalence of GAD and depressive symptoms than the elderly. Compared to another occupational group, health workers were more likely to have poor sleep quality. Age (<35 years) (OR = 1.77, 95% CI 1.38-1.95) and time spent focusing on COVID-19 (≥ 3 hours per day) (OR = 1.91, CI 95% 1.77-2.15) were associated with GAD. Young age was also associated with depressive symptoms (OR = 1.80, 95% CI 1.35-2.01) and health professionals were more likely to have poor sleep quality (OR = 1.48, 95 CI % 1.15-1.95).
Psychological interventions should target vulnerable populations, such as controlling and limiting time spent receiving information related to COVID-19 to less than two hours a day, maintaining a normal work pattern and resting as much as possible, exercising regularly to promote quality of sleep and not paying too much attention to information about outbreaks before bedtime. The ongoing surveillance and monitoring of the psychological consequences of outbreaks of potentially epidemic and life-threatening diseases, establishing early mental health interventions, should become routine as part of preparedness efforts worldwide. 500 individuals participated in the study, of which 62% did not report any probability of psychological distress, while 19.4% and 18.6% had mild and moderate to severe probability. Cyclothymic (OR: 1.24; p <0.001), depressive (OR: 1.52; p <0.001), anxious temperaments (OR: 1.58; p = 0.002) and ASQ "Need for approval" (OR: 1.08; p = 0.01) were risk factors for moderate to severe psychological distress, compared to no distress, while ASQ "Confidence" (OR: 0.89; p = 0.002) and "Discomfort with closeness" were protective (OR: 0.92; p = 0.001). The cyclothymic (OR: 1.17; p = 0.008) and depressive (OR: 1.32; p = 0.003) temperaments resulted in risk factors in individuals with moderate to severe psychological distress, compared to mild distress, while ASQ "Confidence" (OR: 0.92; p = 0.039) and 'Discomfort with closeness" (OR: 0.94; p = 0.023) were protective.
The study did not make any recommendations.
Zhang, J. et al. (10) The average behavior of children with ADHD (M = 2.25, SD = 0.54) worsened significantly compared to those children who did not present any behavioral disturbances (95% CI = 2.18-2.32). 53.94% of parents reported that Attention is needed to identify an appropriate approach for children with ADHD, in terms of disaster risk reduction activities. their children's ability to stay focused worsened, 67.22% described an increase in the frequency of anger, and 56.02% became worse in their daily routine. More than half the parents reported that their children's behavior in other domains had improved or maintained the same level. Children's ADHD behaviors were positively linked to acute stress in response to the COVID-19 outbreak (r = 0.21, p = 0.001), parental attention to media coverage of COVID-19 news (r = 0.13, p = 0.048), general (negative) mood of children and parents (r = 0.48, p <0.001 and r = 0.41, p <0.001, respectively), and negatively correlated with the children's study time (r = -0.19, p = -004) and children's time interacting with parents (r = -0.17, p = 0.008). In regression analysis, the children's general mood (β 0.17, 95% CI 0.11-0.23, p <0.001), the parents' general mood, β = 0.13, 95% CI 0.06 -0.20, p <0.001) and the children's study time (β -0.09, 95% CI -0.15, -0.02, 0.010) significantly predicted the children's ADHD behaviors. Ahmed, Z. et al. (40) The results showed that 29% of those surveyed suffered from anxiety (mild 10.1%, moderate 6.0% and severe 12.9%), while 37.1% suffered from different levels of depression (mild 10.2%, moderate 17.8%, and severe 9.1%). There was also a 29% increase in hazardous alcohol consumption, harmful drinking increased to 9.5%, and alcohol dependency reached 1.6%. Approximately one-third of people (32.1%) had lower mental well-being.
It is very important to quickly implement a multifaceted approach at personal, social and international levels. Therefore, the following is recommended: restriction of media exposure, a treatment and training plan, use of an online counseling platform, specific care for vulnerable people, and a rehabilitation program.
124 questionnaires were distributed with a response rate of 84.7% (105/124). The average SAS and SDS scores were significantly higher than the SAS norms in the Chinese population in general (40.3 ± 11.5 vs. 29.8 ± 10.1 in SAS, 47.1 ± 10.5 vs. 41.9 ± 10.6 in SDS, Ps <0.001). The results showed mild (SAS scores from 50 to 59), moderate (SAS scores from 60 to 69) and severe anxiety (SAS scores ≥ 70) in 11, 6 and 2 cases, respectively. The incidences of total, mild, moderate and severe anxiety were 18.1%, 10.5%, 5.7% and 1.9%, respectively. In addition, the results showed mild (SAS score of 53 to 62), moderate (SAS score of 63 to 72) and severe depression (SAS score ≥ 73) in 22, 5 and 4 cases, respectively. The incidences of cases of total, mild, moderate and severe depression were 29.5%, 21.0%, 4.8% and 3.8%, respectively. Respondents who had experienced exposure reported higher rates of anxiety accompanied by depression than those who had not (incidence rates of 31.6% and 12.6%, respectively).
Mental health services for frontline pediatricians should receive more attention and are urgently needed during this epidemic outbreak of COVID-19.