Global Mental Health Crisis in Covid Pandemic Era

The COVID-19 pandemic is an infectious disease of severe public health concern for which treatment does not currently exist. The disease originated from Wuhan City, China, and quickly spread worldwide. Because it is highly contagious, the World Health Organization provided several recommendations to curb the spread of COVID-19 [1]. One of these measures is physical distancing, where people were advised to maintain at least a distance of one meter from one another and avoid crowded places [1]. Second, the World Health Organization encouraged people to stay at home as much as possible [1]. People were also told to connect with family and friends via video or calls rather than physical meetings. Even small group activities were discouraged.


Introduction
The COVID-19 pandemic is an infectious disease of severe public health concern for which treatment does not currently exist. The disease originated from Wuhan City, China, and quickly spread worldwide. Because it is highly contagious, the World Health Organization provided several recommendations to curb the spread of COVID-19 [1]. One of these measures is physical distancing, where people were advised to maintain at least a distance of one meter from one another and avoid crowded places [1]. Second, the World Health Organization encouraged people to stay at home as much as possible [1]. People were also told to connect with family and friends via video or calls rather than physical meetings. Even small group activities were discouraged.
People who tested positive for COVID-19 were required to undergo mandatory isolation. At the onset of the pandemic, symptomatic individuals had to self-isolate for at least two weeks. During self-isolation, an infected individual did not have contact with others. Another measure that was used to reduce the spread of COVID-19 is quarantine [1]. In self-quarantine, the patients are required to stay in a separate room, ensures surfaces are disinfected, wear a face mask, and avoid sharing items.
Even though these strategies helped slow down the spread of the virus, they had a detrimental impact on the mental wellbeing of individuals. The deterioration of mental health can be attributed to many factors. For instance, physical distancing, isolation, and quarantine lead to loneliness. Loneliness is a crucial factor in the development of mental disorders. In this article, different types of mental health crises associated with the COVID-19 pandemic will be discussed.

Methods
To understand the impact of COVID-19 on mental health, I conducted a comprehensive review of past literature related to the topic. Only articles published in the past five years were reviewed. The following combination of search terms was used to retrieve relevant peer-reviewed articles from the Google Scholar database: a) Mental Health AND COVID-19 pandemic and b) Mental Disorders AND COVID-19. An in-depth review of the articles was performed to identify relevant themes related to the topic. After that, the results were presented thematically.

Anxiety and Depression in Pregnant Women
Anxiety is one of the mental health crises the general population and healthcare workers during the COVID-19 pandemic era. Different empirical studies have investigated the prevalence of anxiety during the COVID-19 pandemic. For example, [2] revealed that in China, the prevalence of anxiety and depression among pregnant women aged 15 to 59 years was 9.8% and 6.9%, respectively (see figure 1 below). Additionally, Wu F, et al. revealed that the risk of anxiety and depression was higher in widowed/divorced/unmarried, jobless, dysfunctional families, the first trimester, reduced family income, and pregnancy complications. Moreover, there was higher rates of anxiety and depression in pregnant women who did not engage in physical exercise, who smoked, and those who consumed alcohol [2]. However, highly educated women had a lower prevalence of anxiety and depression than those with lower educational attainment. In a related study, Dagklis T, et al. [3] revealed a rapid increase in anxiety levels among pregnant women at the onset of lockdown.
Lu MY, et al. [4] noted that even though pregnant women exhibited maternal anxiety and depression, it varied with age. Specifically, higher rates of these mental health disorders were reported in older women. Specifically, the highest rate of anxiety and depression was found in individuals aged less than 30 years (40.0%), followed by those aged 30-34 years (35.3%) and those above 35 years (24.6%). Increased anxiety and depression symptoms were also linked to the presence of suspected or confirmed COVID-19 cases, subjective risk of contracting COVID-19, self-rated severe life impact, and excessive watching of COVID-19 related news [4]. Anxiety and depression rates among women varied based on whether the pregnant women were nulliparous or multiparous. Anxiety and depression scores were higher in multiparous women than nulliparous [5]. These mental health disorders were linked to the belief that the pandemic would adversely affect their pregnancies.

Anxiety and Depression among Patients
Anxiety and depression were also common among patients during the COVID-19 pandemic. Alirezaei M, et al. [6] noted that in patients with multiple sclerosis, a higher number of hospital admissions linked to multiple sclerosis relapse and fear of the pandemic significantly predicted anxiety and depression. In this study, 51.4% of patients with multiple sclerosis had depressive symptoms. Apart from fear, higher depressive symptoms among patients with multiple sclerosis were lower educational attainment and divorced marital status.

Mental Health Problems among Healthcare Professionals
Being at the frontline in the fight against the pandemic, the healthcare workers developed various mental health problems. First, at the onset of COVID-19, healthcare workers had high emotional distress attributed to an elevated risk of exposure, prolonged work hours, ethical paradoxes, and a shortage of personal protective equipment [7]. The prevalence of emotional distress varied across the countries. For example, in Canada, 47% of healthcare workers were emotionally distressed compared to 23% in Pakistan.
Anxiety was also a common mental health problem in healthcare workers during the COVID-19 pandemic. During this period, 23% of healthcare professionals had anxiety symptoms across the globe [7]. However, there were higher rates of anxiety in some countries. For example, in China, 45% of healthcare workers had anxiety [7]. High anxiety scores were reported in healthcare workers who believed their families were at risk of being infected, those concerned about family care and responsibilities, and those who did not have relevant information about the pandemic. [8] reported many factors that increased anxiety symptoms in healthcare workers. They included shortage of personal protective equipment, fear of infecting others, fear of getting infected with COVID-19, limited rapid and swab laboratories, few hospitals that could handle the cases, and high morbidity rates [8]. The anxiety that affects healthcare professionals needs urgent attention because it elevates the risk of adverse events. For example, anxiety in healthcare workers leads to medical errors and work accidents. Volume  In a study conducted in China, Chen J, et al. [9] revealed that the prevalence of anxiety and depression in healthcare workers was 16.63% and 18.29%, respectively. These mental health disorders were attributed to heavy workload, symptoms of respiratory disease, digestive problems, having performed COVID-19 tests, having a sick family member, and work-related stress [9]. In a related study, Sahin MK, et al. [10] reported that healthcare workers in Turkey developed various mental health problems. However, the prevalence of these disorders varied across different sociodemographic categories. For example, insomnia, distress, anxiety, and depression was higher in females than in males [10]. Additionally, the study showed that younger health workers (aged 26 -30 years) had higher anxiety and depression scores than older age groups.
The severity of mental health problems is affected by work experience. Anxiety and depression scores were higher in healthcare workers with more than ten years of experience than those less than ten years [10]. Additionally, the study revealed that healthcare professionals with a history of psychiatric disorders had higher rates of mental illness during the COVID-19 pandemic. In a related study, Wilson W, et al. [11] revealed that female healthcare professionals had a two-fold higher likelihood of developing stress, depression, and anxiety compared to males. Additionally, [12] reported that among Jordanian healthcare professionals, anxiety and depression were linked to being male, more than 40 years old, long working experience, and being married. In Peru, [13] revealed that 21.7% of healthcare professionals developed severe anxiety, while 26.1% developed severe mental distress. Additionally, this study showed that healthcare workers with high educational attainment experienced lower anxiety levels than those with lower educational levels. Additionally, [13] reported that healthcare workers who were geographically situated further from the COVID-19 epicentre in Peru had lower levels of anxiety and mental distress. In Nepal, 38% of healthcare professionals on COVID-19 duty suffered from anxiety and depression. The high prevalence of anxiety among Nepal healthcare workers was attributed to various factors, such as shortage of protective gear and subsequent fear of infection.
Another mental health problem that was reported among healthcare workers during the COVID-19 pandemic is posttraumatic stress disorder. A study conducted by [14] in Wuhan revealed that the prevalence of PTSD symptoms among frontline healthcare workers ranged from 4.7% to 9.3% in the outbreak of COVID-19. Additionally, [14] established that local healthcare professionals had higher risks of developing PTSD symptoms than medical rescue teams. Similarly, doctors showed more PTSD symptoms than nurses. In an earlier study conducted by [15] in Wuhan, the researchers established a high prevalence (20.87%) of PTSD among the healthcare professionals in the first six months following the local outbreak of COVID-19. Additionally, the study revealed that more than 88.88% of the healthcare workers with probable PTSD had anxiety symptoms. Next, 82.09% of healthcare professionals with possible PTSD showed symptoms of depression. Moreover, [15] showed that all healthcare workers with probable PTSD had somatic symptoms. Lastly, 95.52% of the healthcare professionals with plausible PTSD had insomnia.
In Taiwan, 15.4% of the healthcare workers had PTSD symptoms [4]. Further analysis showed that fear of COVID-19 and anxiety symptoms significantly predicted PTSD. This implies that healthcare workers with high anxiety levels and fear of COVID-19 are highly likely to develop PTSD [4]. In the UK, 47 % of the social care and frontline healthcare workers had PTSD and symptoms of depression [16]. These mental health disorders developed because social care and healthcare professionals were worried about infecting others. Additionally, participants who felt stigmatized and did not have reliable access to personal protective equipment were highly likely to meet the criteria for PTSD. Other significant predictors of PTSD are redeployment during the pandemic and being infected with PTSD. However, higher household income was linked to decreased odds of PTSD [16]. In a related study conducted in Wuhan, [17] revealed that medical practitioners had higher levels of stress (16.0%), anxiety (35.6%), and depression (46.7%). When the medics returned home, 31.6% developed PTSD symptoms.

The Impact of COVID-19 Pandemic on Eating Disorders
Studies conducted on the relationship between the COVID-19 pandemic and eating disorders shows that the pandemic exacerbated the problem [18,19]. For example, [18] revealed that 35.5% showed increased binge eating behaviors, while 18.9% exhibited enhanced purging behaviors. In participants with anorexia nervosa, 67.1% showed increased restricting behaviors, while 20.5% showed elevated binge eating and 18.2% had enhanced purging. Additionally, [18] revealed that in the general population with no history of an eating disorder, 27.6% of the participants reported an increased food restriction, whereas 34.6% showed elevated binge eating behaviors [18]. These results suggest that even at the onset of the pandemic, individuals with an existing eating disorder reported increased symptoms that show that COVID-19 exacerbated their disordered eating symptoms. The increased prevalence of eating disorders during the COVID-19 pandemic may be attributed to stress, anxiety, and depression that developed because of social distancing implemented to reduce the spread of the virus.
In a study conducted in Germany, [19], the majority of the participants who had eating disorder symptoms revealed that the COVID-19 pandemic aggravated their symptoms. Additionally, 20% of the patients developed new disordered eating symptoms. Regarding the exact symptoms, most of the patients had eating disorders cognitions, e.g., fear of gaining weight and shape concerns. [20] revealed that the increased prevalence of disordered eating during COVID-19 could be attributed to stressful life events. Psychological distress is a common characteristic of communicable disease outbreaks. The current pandemic led to the separation of people and decreased social activities because of lockdowns, isolation, and quarantine. These factors led to the development of stress and were precursors to eating disorders development and relapse.
An increase in the prevalence of eating disorders during the COVID-19 pandemic may also be linked to anxiety [20]. Because the pandemic was a public health threat, many people have experienced increased anxiety because of uncertainty. Because people with eating disorders usually reported high intolerance of uncertainty, they became more vulnerable to distress which worsened their disorders. Public health messaging has also been blamed for increased rates of eating disorders during the COVID-19 pandemic. Public health messages encouraged people to be vigilant of the possible physical symptoms of COVID-19, e.g., fever and shortness of breath. Some people became hyper vigilant towards the possible symptoms of the pandemic, resulting in increased distress and fear. Consequently, such individuals developed anxiety and subsequent eating disorder symptoms.
Stressful life events during the COVID-19 pandemic contributed to elevated anxiety, where people respond to heightened stress in their homes or workplace through ineffective coping mechanisms [20]. Examples of maladaptive coping strategies in the eating disorder include enhanced frequency of eating disorder cognition (e.g., rumination) and behaviors (e.g., purging behaviors and binge eating). Another critical challenge to eating disorders during COVID-19 is social distancing and self-isolation. To curb the spread of COVID-19, the World Health Organization mandated physical distancing between oneself and others. However, social distancing increased the likelihood of being isolated and lonely. Isolation and loneliness are risk factors for the development of eating disorders.

Discussion
This study aimed to identify the mental health disorders during the COVID-19 pandemic. To understand the impact of COVID-19 on mental health, a comprehensive review of past literature was performed. An in-depth review of the articles led to various mental health issues. The most common mental health problem experienced by the general population and healthcare professionals during the COVID-19 period is anxiety. The review revealed that anxiety was common in pregnant women. The prevalence of this disorder in pregnant women ranged from 9.8% [2] to 40% [4]. In healthcare workers, the worldwide prevalence of anxiety disorder is 23% [7]. However, some countries (e.g., China) had higher rates of anxiety among healthcare professionals [7]. Increased prevalence of anxiety was attributed to various factors. In the general population, it was linked to reduced income, joblessness, and dysfunctional families. Some of the causes of anxiety in healthcare workers included an elevated risk of exposure, prolonged work hours, ethical dilemmas, and a shortage of personal protective equipment [7].
Another mental health disorder found in the general population and healthcare workers is depression. In the general population, depression was linked to the presence of suspected or confirmed COVID-19 cases, subjective risk of contracting COVID-19, self-rated severe life impact, and excessive watching of COVID-19 related news [4]. Some of the factors that predicted depression in healthcare workers included heavy workload, symptoms of respiratory disease, digestive problems, having performed COVID-19 tests, having a sick family member, and work-related stress [9]. Another mental health crisis found in healthcare workers during the COVID-19 pandemic is PTSD. This disorder was attributed to worry about infecting others, stigmatization, and shortage of personal protective equipment. Redeployment during the pandemic and being infected with COVID-19 contributed to PTSD. Furthermore, the review showed that COVID-19 aggravated eating disorders. [18] reported that 35.5% of participants showed increased binge eating behaviors, whereas 18.9% exhibited enhanced purging behavior. Additionally, people with no history of eating disorders developed them. Increased prevalence of eating disorders during the COVID-19 pandemic was linked to stress, anxiety, and depression that developed because of social distancing implemented to reduce the spread of the virus. The COVID-19 pandemic separated people and reduced social activities because of lockdowns, isolation, and quarantine. These factors led to an increase in stress and the development of eating disorders.

Conclusion
Taken together, this review revealed that the COVID-19 pandemic had a devastating impact on the mental health of the general population and healthcare professionals. First, this study suggests that COVID-19 led to anxiety disorders. Anxiety disorders are attributed to many factors, such as reduced income, joblessness, dysfunctional families, and a shortage of personal protective equipment. Second, this review revealed that the COVID-19 pandemic aggravated depressive symptoms. In individuals who did not have depression, the pandemic led to the development of this disorder. Lastly, this study suggests that the COVID-19 pandemic worsened eating disorders. Overall, the results of this study show that there is an urgent need to address the mental health problems developed or aggravated by the COVID-19 pandemic.