Coronavirus Pandemic: Coping with the Psychological Outcomes, Mental Changes, and the “New Normal” During and After COVID-19

Received Date: May 19, 2019 / Accepted Date: May 21, 2019/ Published Date: Jun 01, 2020 Abstract Coronavirus disease 2019 (COVID-19) is a highly infectious disease that has rapidly swept across the world, inducing a considerable degree of fear, worry and concern in the population at large and among certain groups in particular, such as older adults, healthcare providers and people with underlying health conditions. Authorities around the world tried to prevent the virus spread by imposing social distancing measures, quarantining citizens and isolating infected persons. Apart from its physical impact, COVID19 pandemic has brought numerous changes to people’s lives. It changed daily routines, caused worldwide economic crisis, increased unemployment, and placed people under emotional and financial pressures. It affected people psychologically and mentally especially in terms of emotions and cognition. During the acute crisis, everyone to varying degrees experienced fear of infection, somatic concerns, worries about the pandemic’s consequences, loneliness, depression, stress, as well as increased alcohol and drug use. As part of its public health response, the World Health Organization (WHO) has worked with partners to develop a set of new guidelines and messages that can be used to prevent, manage, and support mental and psychological well-being in different vulnerable target groups during the outbreak. Whether people like it or not, the psychological sequela of this pandemic will emerge and persist for months and years to come leading to long-term consequences. New lifestyles and “New Normals” will surely emerge. The main purpose of this review is to summarize the impact of coronavirus pandemic on the psychological and mental health of people around the world especially vulnerable groups. It also presents the relevant intervention actions and recommendations to cope efficiently and effectively with the psychological short-term and long-term outcomes, mental changes, and the “New Normal” during and after COVID-19.


Introduction
Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by Sars-Cov-2 (Severe Acute Respiratory Syndrome Coronavirus 2) [1]. Since its emergence in China, the virus has spread to every continent of the world [2]. The World Health Organization (WHO) has identified it as a pandemic and a public health emergency of major international concern [3,4]. The virus spreads mainly among people through close contact, often via small droplets produced during coughing, sneezing, talking or touching a contaminated surface [5][6][7]. Countries raced to stop the virus spread through testing and treating patients, carrying out contact tracing, recommending hand washing, and enforcing the use of Personal Protective Equipment (PPE) [8][9][10]. In addition, authorities around the world tried to prevent the virus spread by imposing social distancing measures such as restricting travel, canceling large gatherings like sports events, concerts and schools, quarantining citizens and isolating suspected infected persons [11,12]. Dozens of cities around the world were deserted as people stayed indoors, either by choice or by quarantine imposed by their governments [13]. Apart from its physical impact, the COVID-19 pandemic has brought numerous changes to people's lives. This quarantine and social isolation, changed daily routines, caused economic crisis, increased unemployment, and placed people under emotional and financial pressures [14]. The uncertainty and low predictability of COVID-19 affected people psychologically and mentally especially in terms of emotions and cognition. People were concerned about getting sick, how long the pandemic will last, and what the future will bring [15]. In addition, information overload, rumors and misinformation made their lives feel uncontrollable and they had no idea what to do [16,17]. A recent study by medical journal "The Lancet" notes that the psychological impact of quarantine can be great, leading to a range of mental health concerns from anxiety and anger to sleep disturbances, depression and post-traumatic stress disorder (PTSD). Weeks of self-isolation with signs that the coronavirus pandemic is not going to end soon brings the most optimistic person near pessimism wondering just how long will this last [18]. Understanding the psychological and mental health response after a public health emergency could guide authorities, healthcare professionals, and communities in helping populations to cope with current disasters and be prepared for new ones [14,15]. The main purpose of this review is to summarize the impact of coronavirus pandemic on the psychological and mental health of people around the world especially vulnerable groups. It also presents the relevant intervention actions and recommendations to cope efficiently and effectively with the psychological short-term and long-term outcomes, mental changes, and the "New Normal" during and after COVID-19.

Psychological and Mental Health Changes During COVID-19 Pandemic
In response to the accelerating COVID-19 pandemic, increasingly stringent measures are put in place to slow the spread of coronavirus by keeping people apart, banning all nonessential activities and asking residents to stay at home [19]. Worldwide, colleges and offices have gone entirely online, schools and restaurants have closed down, and nursing homes have stopped accepting visitors [12].
In light of these devastating changes, people are facing three immediate responses [20,21] Page: 9 www.raftpubs.com The effects of these responses can translate into a range of individual emotional reactions (e.g., insecurity, confusion, distress or psychiatric conditions, emotional isolation, and stigma) that are then echoed by communities (because of work and school closures, economic loss, inadequate medical resources, and poor distribution of necessities) [22][23][24].
Mental health concerns could be exacerbated by quarantine-related stressors such as fear of infection, boredom, frustration, inadequate supplies, lack of information, financial loss, and stigma associated with contracting the disease. In addition to that, long-term quarantine or complete social isolation (without existing compensatory methods) could aggravate anxiety, depression and a sense helplessness [18,25]. Moreover, COVID-19 can cause psychological responses such as increased worry about children being at home alone (during school shutdowns etc.) while parents have to be at work and risk of deterioration of physical and mental health of vulnerable individuals if care support is not in place [26].

Types of Reactions to the COVID-19 Crisis
In addition to the stresses inherent in the disease itself, mass-home containment directives (including home-stay orders, quarantine and isolation) raise concerns about how people will react individually and collectively. Approximately, there are four types of people's reactions to the COVID-19 crisis and the conditional social isolation [27]

Health care providers: This group is
particularly vulnerable to emotional distress in the current pandemic, given their risk of virus exposure and infection, concern about infecting their loved ones, shortage of personal protective equipment (PPE), exhaustion due to longer working hours, and involvement in resource allocation decisions that are ethically and emotionally draining [27,34,35].

Signs of Psychological and Mental Health Changes During COVID-19
According to the American Psychological Association (APA), there's a spectrum or a range of emotions people are expected to have during this coronavirus pandemic. In addition, the CDC notes that people should look within themselves and others for signs of distressed psychological and mental health in order to distinguish between ordinary fear and the beginnings of a breakdown. Signs and symptoms may include [36,37]:

Fear and anxiety:
It is normal to be worried about contracting or spreading COVID-19. The virus is highly contagious, people are concerned and worried about their own health, worried about falling ill and dying, and worried about losing people they love. All of these feelings lead to fear and anxiety. Moreover, people are worried about unpredictable shortages in food supplies, medications, and regular medical care or community services that may be disrupted by the closure of facilities and public transport [38].

Depression and boredom:
During a lockdown period, the normal daily routines are completely empty. People stay at home rather than go to work, kids take online classes rather than go to school. With so much uncertainty it is almost impossible to get into a rhythm. All of this leads to boredom and depression [36]. 3. Feeling socially isolated: Psychologists note the difference between living alone and loneliness. Some people live alone and have no family, and they usually don't think much about it. But, as the new virus forces them to socially distance, they start feeling lonely. They miss the ability to see, chat, hug, or spend time with friends. Life seems shallower, more like survival than living, especially if they live alone [39]. 4. Anger, frustration or irritability: This trio of feelings has its root in the fact that people have to control so many things at once and to respond to so many emergencies as previously mentioned. All this pressure they are facing will be translated into anger, frustration, and irritability [40]. 5. Changes in sleep patterns: There is a common association between anxiety and sleep disturbances. During this pandemic, people get worried about their job security,  [45]. This mixed bag of emotions could reflect how affected people really are, according to experts, the more severe the isolation, the more severe the psychological impacts and symptoms.

Prevention and Management of Psychological and Mental Health Conditions During COVID-19
Although knowledge is increasingly available for the medical aspects of the pandemic, there is little information and guidance for health care facilities and practitioners about how to handle the psychological implications of large-scale disasters such as COVID-19 Pandemic [46]. Nevertheless, the good news is that some governments have stepped up to address those mental health stressors. They reported what should be done by communicating quarantine guidelines and measures, with an emphasis on special vulnerable target groups. By addressing some of these stressors, governments can help lessen the impact that quarantine can have on the psychological and mental health of people facing this pandemic [47,48]. Moreover, the World Health Organization and the Centers for Disease Control and Prevention have issued guidelines to effectively cope with the COVID-19 outbreak and prevent mental health problems during this pandemic. The summarized guidelines are as follows [37,49]: Page: 13 www.raftpubs.com a noble one: taking care of those in need at a time of great uncertainty. Remember the importance and meaning of your work. 2. Build your resilience: Build resilience through any method, whether physical, psychological, or spiritual to help you face hard times. Resilience helps you bounce back from stressful situations. It helps you view difficulties as challenges and become proactive in your response. Resilience is a feature which can be learnt through practice. 3. Focus on the present: Whatever you are going through shall end, and focusing on the present will give you the opportunity to become your best self. Try not to think about the following weeks or months to come. Focus on doing the best you can with whatever means you have now. Don't stress about things that are out of your control. 4. Be realistic but stay positive: It is easy to lose yourself in negative thoughts. Anticipate upcoming problems, but don't let them turn you down. Remember the patients you helped to recover and those you helped to comfort in the most difficult times. 5. Take breaks from the news and social media: Step away from your computer and smart phone from time to time. When returning online, focus on information from trustful sources, not just sources in your social media feed. You don't have to take in everything produced by a 24/7 news cycle. 6. Practice self-care: Take care of yourself, eat healthy food, stay active, exercise regularly, and rest between shifts. De-stress in healthy ways and avoid smoking or drugs. When being at home, shut off any thoughts related to your work, watch a movie or listen to calm music, connect with your loved ones even if it is only through video-calls.

Perform regular check-ups for yourself:
Screen yourself for symptoms of depression or stress such as prolonged sadness, extreme fatigue, sleeping difficulties, exaggerated emotional responses, intrusive memories and/or feelings of hopelessness. If symptoms persist or worsen over time, talk to a trusted colleague or seek professional help.

For Managers and Team Leaders in
Healthcare Facilities [58,59] 1. Page: 14 www.raftpubs.com 2. Continue taking your regular medication: It is important for anyone who has to take regular medication to continue with this, especially if you have chronic conditions or other illnesses that requires that.

Eat healthy food and never skip meals:
Changes in the type of food eaten due to changes in food availability during lockdowns may precipitate the exacerbation of chronic illnesses in elderly adults. Therefore, eating healthy food and never skipping meals is highly advisable. 4. Learn and perform simple daily exercises to practice at home: Lack of exercise and movement during lockdown may lead to deconditioning and body deterioration with subsequent weakness and falls. Performing daily exercises and simple movements is recommended. 5. Know in advance where and how to get practical help: Early identification of any health issue may help prevent hospitalization. Where appropriate, do not hesitate to accept available home care services, which may be essential to preserve your health during COVID-19. 6. Keep regular schedules and keep in touch with loved ones: As much as possible, keeping regular phone calls or video conferencing with friends, family, and caregivers can be very helpful during lockdown periods.

Sleep and maintain circadian rhythms:
Sleep is critically important to cognitive functioning and the immune system. One of the simplest recommendations that can be given to older adults to help prevent disease transmission and mitigate anxiety is to sleep well.

For People in Isolation [62]
1. Stay connected and maintain your social network: Try to keep your daily personal routines as much as possible, or create new routines if you can. Stay in touch via phone, e-mail, social media or video conference.

Pay attention to your own needs and feelings:
Engage in healthy activities that you enjoy and find relaxing. Exercise regularly, maintain regular sleep routines and eat healthy food. 3. Stay away from too much news which can create negativity: A continuous stream of news reports about an outbreak can cause anxiety or distress to anyone.
Seek information updates and practical guidance only during the day and at specific times and avoid listening to or following rumors that make you feel uncomfortable.

Long-Term Consequences of COVID-19 Pandemic on Psychological and Mental Health
Even for those who weren't directly affected by COVID-19, the pandemic has been a significant stressor on everyone's life. People may have a strong emotional reaction which may last for decades after the pandemic recedes [63]. Deterioration of social networks and economies, stigma towards survivors of COVID-19, increased anger and aggression of frontline workers, possible mistrust of information provided by official authorities, are some of the long term consequences of COVID-19 predicted by the Inter-Agency Standing Committee on Mental Health and Psychological Support (IASC). [64]. Those who struggle with other mental health conditions, such as anxiety or depression, or who have a previous history of trauma, may be at increased risk of long-term distress. Similarly, healthcare workers providing frontline services, as well as people who have lost their loved ones or jobs due to the disease may be at higher risk of developing long-term problems [65]. Some of these consequences could be due to realistic dangers, but many could be due to lack of knowledge, rumors and misinformation. On the other hand, some people may have positive experiences, such as pride about finding ways of coping with this pandemic [66]. Page: 15 www.raftpubs.com

The "New Normal" After the COVID-19 Outbreak
COVID -19 crisis is different from any other crisis. It's like being diagnosed with cancer.
The year or years that follow the lifting of stayat-home orders won't be true recovery, but something better understood as "adaptive recovery" or as the "New Normal", in which we learn to live with the virus even as we look forward to medical progress in eradicating it. Life during COVID-19 and after it is the "New Normal" There is no returning to memories of what was before [67]. Meanwhile, during our "New Normal", we will need to continue monitoring and testing for COVID -19, applying a vigorous public health approach to slow down the virus spread by isolating, treating, contact tracking, and taking appropriate measures, to physically distance ourselves from others [68]. After this crisis ends, what does our "New Normal" look like? How are we going to reinvent ourselves? How optimistic or pessimistic shall we be? There is a spectrum of possible post-coronavirus futures, no straight line from here to there. Futurists have begun to imagine the postcoronavirus era. It is rather the beginning of a "New Normal" for all of us. A way that minimizes the risks of COVID -19 but allows us to earn our living, educate our children and keep our healthcare systems functioning. Below are some of the "New Normals" where COVID-19 is predicted to change our lives in the near future and beyond [67,69,70]: 1. A "New Normal" when restrictions on social distancing are lifted. Many people will not grasp that this is not over. Despite the "happy talk," people will not emerge suddenly immune from the lockdown. The vast majority will remain susceptible to the virus. The virus will spread. It will keep hitting the population. Mostly everyone will be exposed over the next year until 60 to 70 percent of herd immunity is achieved. 2. A "New Normal" where we lock down the lockdown. The changes will become permanent until someone wins the billiondollar prize for a vaccine. The cost will be loss of schools, economic hardship, mass unemployment, psychological pain, shattered marriages. A crisis as big as the "Great Depression". 3. A "New Normal" of alternation between easing of restrictions to turn the economy back and between permanent lockdown again when new outbreaks occur. This cycle will alternate until herd immunity increases and physical distancing no longer becomes necessary. 4. A "New Normal" where the world will trend towards working at home, shopping at home, conferencing from home, and maybe even virtually travelling to other cities from home. There will be a trend to make one's home self-sufficient. This trend could lead to more recluses, more shut-ins, and more people who create cocoons in their homes or apartments to protect themselves from germs in the outside world. 5. A "New Normal" where fear of infection could make people more weary, more anxious, more germaphobic about trains, planes and shared cars. Masks will become a wardrobe priority. No kisses, no highfives, no handshakes. We are going to move into a world where every 'contact' will have to be scheduled on Zoom, or managed in a non-spontaneous manner, keeping distance, observing rules, and checking on others if they are following them too. 6. A "New Normal" where there will be cleaner and safer job sites. The virus has made everyone aware of the importance of health and safety. Companies will respond by implementing new job site policies such as alternating shifts, temperature checks for employees and top-to-bottom disinfections.
Managers and supervisors will promote social distancing and health regulations for employees, including a carpooling ban, a 100% mask and glove policy, and wellstocked handwashing stations. Employers will no longer be doing business in the same way they have done in the past. They Page: 16 www.raftpubs.com will need to be flexible and creative as they will need to think about new ways to perform certain tasks. 7. A "New Normal" for projects' timelines.
Projects will take longer. Many of the major workplace safety changes will add to the time it takes to complete projects. While crucial to keep employees healthy, techniques such as keeping up with PPE, allowing only a limited number of employees on a site at the same time and alternating work shifts will slow down progress of projects, and the days of fasttracking a project may be over -at least for a long period of time. 8. A "New Normal" will be teleworking. The coronavirus will bring major changes to office work. Forced to stay at home, many office employees will keep business operations running via remote work, relying on technology like videoconferencing, emailing and texting to stay in touch. This nationwide tele working experiment will likely cause many leaders to think about making the practice permanent. Companies will move most of their office workforce to permanently remote positions. While the trend toward remote work will lead to a dramatic reduction in the need for office space for many companies, others might think about expanding. These firms may seek to take advantage of lower rents in order to expand their office space allowing for greater social distancing in the workplace. This could mean a moving away from the popular open office space layouts to allow for additional private spaces.

Conclusion
The psychological impact of this quarantine is wide-ranging, substantial, and long lasting. It has caused tremendous psychological problems in different subpopulations. Despite that authorities have announced relevant policies and guidelines in a strategic manner, the COVID-19 outbreak has posted an emerging serious challenge for the psychological and mental health worldwide. With the disruptive effects of this pandemic, it is important that we stay mindful and sensitive to our mental health needs and to that of the ones we care for. Our anxiety and fears should be acknowledged and not ignored, but better understood and addressed by individuals, communities and governments. The issue facing each and every one of us is how we manage and react to the stressful situation unfolding so rapidly in our lives and communities. The further we look into the future, the more we can imagine how global society may well be reinvented by this pandemic. The experience from this public health emergency should guide governments and authorities how to efficiently intervene in any future crisis around the world.