how to maintain your mental health during covid essay

• COVID-19 and your mental health

Worries and anxiety about COVID-19 can be overwhelming. Learn ways to cope as COVID-19 spreads.

At the start of the COVID-19 pandemic, life for many people changed very quickly. Worry and concern were natural partners of all that change — getting used to new routines, loneliness and financial pressure, among other issues. Information overload, rumor and misinformation didn't help.

Worldwide surveys done in 2020 and 2021 found higher than typical levels of stress, insomnia, anxiety and depression. By 2022, levels had lowered but were still higher than before 2020.

Though feelings of distress about COVID-19 may come and go, they are still an issue for many people. You aren't alone if you feel distress due to COVID-19. And you're not alone if you've coped with the stress in less than healthy ways, such as substance use.

But healthier self-care choices can help you cope with COVID-19 or any other challenge you may face.

And knowing when to get help can be the most essential self-care action of all.

Recognize what's typical and what's not

Stress and worry are common during a crisis. But something like the COVID-19 pandemic can push people beyond their ability to cope.

In surveys, the most common symptoms reported were trouble sleeping and feeling anxiety or nervous. The number of people noting those symptoms went up and down in surveys given over time. Depression and loneliness were less common than nervousness or sleep problems, but more consistent across surveys given over time. Among adults, use of drugs, alcohol and other intoxicating substances has increased over time as well.

The first step is to notice how often you feel helpless, sad, angry, irritable, hopeless, anxious or afraid. Some people may feel numb.

Keep track of how often you have trouble focusing on daily tasks or doing routine chores. Are there things that you used to enjoy doing that you stopped doing because of how you feel? Note any big changes in appetite, any substance use, body aches and pains, and problems with sleep.

These feelings may come and go over time. But if these feelings don't go away or make it hard to do your daily tasks, it's time to ask for help.

Get help when you need it

If you're feeling suicidal or thinking of hurting yourself, seek help.

• Contact your healthcare professional or a mental health professional.
• Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential.

If you are worried about yourself or someone else, contact your healthcare professional or mental health professional. Some may be able to see you in person or talk over the phone or online.

You also can reach out to a friend or loved one. Someone in your faith community also could help.

And you may be able to get counseling or a mental health appointment through an employer's employee assistance program.

Another option is information and treatment options from groups such as:

• National Alliance on Mental Illness (NAMI).
• Substance Abuse and Mental Health Services Administration (SAMHSA).
• Anxiety and Depression Association of America.

Self-care tips

Some people may use unhealthy ways to cope with anxiety around COVID-19. These unhealthy choices may include things such as misuse of medicines or legal drugs and use of illegal drugs. Unhealthy coping choices also can be things such as sleeping too much or too little, or overeating. It also can include avoiding other people and focusing on only one soothing thing, such as work, television or gaming.

Unhealthy coping methods can worsen mental and physical health. And that is particularly true if you're trying to manage or recover from COVID-19.

Self-care actions can help you restore a healthy balance in your life. They can lessen everyday stress or significant anxiety linked to events such as the COVID-19 pandemic. Self-care actions give your body and mind a chance to heal from the problems long-term stress can cause.

Take care of your body

Healthy self-care tips start with the basics. Give your body what it needs and avoid what it doesn't need. Some tips are:

• Get the right amount of sleep for you. A regular sleep schedule, when you go to bed and get up at similar times each day, can help avoid sleep problems.
• Move your body. Regular physical activity and exercise can help reduce anxiety and improve mood. Any activity you can do regularly is a good choice. That may be a scheduled workout, a walk or even dancing to your favorite music.
• Choose healthy food and drinks. Foods that are high in nutrients, such as protein, vitamins and minerals are healthy choices. Avoid food or drink with added sugar, fat or salt.
• Avoid tobacco, alcohol and drugs. If you smoke tobacco or if you vape, you're already at higher risk of lung disease. Because COVID-19 affects the lungs, your risk increases even more. Using alcohol to manage how you feel can make matters worse and reduce your coping skills. Avoid taking illegal drugs or misusing prescriptions to manage your feelings.

Take care of your mind

Healthy coping actions for your brain start with deciding how much news and social media is right for you. Staying informed, especially during a pandemic, helps you make the best choices but do it carefully.

Set aside a specific amount of time to find information in the news or on social media, stay limited to that time, and choose reliable sources. For example, give yourself up to 20 or 30 minutes a day of news and social media. That amount keeps people informed but not overwhelmed.

For COVID-19, consider reliable health sources. Examples are the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).

Other healthy self-care tips are:

• Relax and recharge. Many people benefit from relaxation exercises such as mindfulness, deep breathing, meditation and yoga. Find an activity that helps you relax and try to do it every day at least for a short time. Fitting time in for hobbies or activities you enjoy can help manage feelings of stress too.
• Stick to your health routine. If you see a healthcare professional for mental health services, keep up with your appointments. And stay up to date with all your wellness tests and screenings.
• Stay in touch and connect with others. Family, friends and your community are part of a healthy mental outlook. Together, you form a healthy support network for concerns or challenges. Social interactions, over time, are linked to a healthier and longer life.

Avoid stigma and discrimination

Stigma can make people feel isolated and even abandoned. They may feel sad, hurt and angry when people in their community avoid them for fear of getting COVID-19. People who have experienced stigma related to COVID-19 include people of Asian descent, health care workers and people with COVID-19.

Treating people differently because of their medical condition, called medical discrimination, isn't new to the COVID-19 pandemic. Stigma has long been a problem for people with various conditions such as Hansen's disease (leprosy), HIV, diabetes and many mental illnesses.

People who experience stigma may be left out or shunned, treated differently, or denied job and school options. They also may be targets of verbal, emotional and physical abuse.

Communication can help end stigma or discrimination. You can address stigma when you:

• Get to know people as more than just an illness. Using respectful language can go a long way toward making people comfortable talking about a health issue.
• Get the facts about COVID-19 or other medical issues from reputable sources such as the CDC and WHO.
• Speak up if you hear or see myths about an illness or people with an illness.

COVID-19 and health

The virus that causes COVID-19 is still a concern for many people. By recognizing when to get help and taking time for your health, life challenges such as COVID-19 can be managed.

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• Mental health during the COVID-19 pandemic. National Institutes of Health. https://covid19.nih.gov/covid-19-topics/mental-health. Accessed March 12, 2024.
• Mental Health and COVID-19: Early evidence of the pandemic's impact: Scientific brief, 2 March 2022. World Health Organization. https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1. Accessed March 12, 2024.
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• Negative coping and PTSD. U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/gethelp/negative_coping.asp. Accessed March 15, 2024.
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• HIV stigma and discrimination. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/basics/hiv-stigma/. Accessed March 15, 2024.
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• Phelan SM, et al. Patient and health care professional perspectives on stigma in integrated behavioral health: Barriers and recommendations. Annals of Family Medicine. 2023; doi:10.1370/afm.2924.
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Protecting your mental health during the coronavirus pandemic

Paul Nestadt

Elizabeth Stuart

CALLIOPE HOLINGUE, M. DANIELE FALLIN, LUKE KALB, PAUL NESTADT AND ELIZABETH STUART

The daily counts of COVID-19 cases and deaths tell the public story of the coronavirus outbreak. Privately, the effects of the pandemic aren’t as clear.

The new reality of social distancing and other safety measures is testing everyone, and those living with mental illness may find this time even more challenging if the support system they rely on is not in place.

Experts from the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health put together these tips and resources on how to protect your mental health during these trying times.

As the coronavirus pandemic has unfolded across the U.S., ordinary life has been put on pause.  Lockdowns ,  travel restrictions ,  school closings ,  work closings , and  social distancing  have created a level of social isolation previously unseen across the globe. Fears about  finances  and food  shortages  have placed additional stressors on an already anxious and sensitized population. The practices recommended by the  Centers for Disease Control and Prevention  and  World Health Organization  are necessary and designed to protect the community, particularly the most vulnerable individuals. However, this pandemic and the associated changes, including serious financial implications for many households, can have profound consequences for our mental health.

Traumatic or stressful experiences put individuals at greater risk for not only poor  physical health  but poor mental health outcomes, such as depression, anxiety, and PTSD. You may notice that yourself or others around you are more edgy, irritable, or angry; helpless; nervous or anxious; hopeless, sad, or depressed. Sleep may be disrupted and less refreshing. Practicing social distancing may leave you feeling lonely or isolated. If you are at home with children, you may have less patience than before.

Those who are especially vulnerable to COVID-19—older individuals and people with medical comorbidities or immune-comprised systems—who need to be especially stringent in following guidelines from the health authorities, may be the very people whose mental health may suffer the most. Individuals with a pre-existing mental health condition, such as an  anxiety disorder , are also at heightened risk for poor mental health outcomes as a result of coronavirus.

It is important that as a population, we learn how to protect our mental health during this stressful and ever-changing situation, while also following the guidelines set by health authorities to protect our physical health.  Here are some strategies that can be used during these challenging times to protect your and others’ mental health.

Create structure

• Create a daily schedule for you and your family. Feelings of  uncertainty  can lead to increased mental health symptoms.
• Try to limit the amount of time you spend watching, reading, or listening to the news. Get your information on the coronavirus outbreak from a trusted source, such as the  CDC  or  WHO , once or twice a day.
• Make space for activities and conversations that have nothing to do with the outbreak.

Maintain your physical health

• Protect your sleep. Good quality, sufficient sleep not only helps to support your immune system but also helps you to better manage stress and regulate emotions. Adults should aim for 7–9 hours, while children and teenagers need even more. [See recommendations by the  National Sleep Foundation ].
• Try to eat at regular times and opt for nutritious foods whenever possible. Some people may crave junk food or sugary snacks and be tempted to snack mindlessly when stressed or bored, and others may skip meals altogether.
• Maintain an exercise routine, even if you can’t go to your local gym. Exercise at home using an online workout video, or go for a walk, run, or bike ride in a sparsely populated area.

Support--and create--your community

• Create a virtual support group and check in with those around you. There are many options for connecting, including video conferencing software, such as Google Hangouts and Facetime. During this time of isolation, connecting face-to-face (online) is more important than ever. If you can’t stream, then calling and texting is important. Check out some ideas at  Wirecutter  and  Prokit  for how to be social during the quarantine.
• Crises offer a time for community cohesion and  social solidarity , and volunteering is one way to not only help others, but yourself as well. Science has repeatedly shown that volunteering can improve mental  health . Check out this  article  for a list of organizations to donate to and this article for other ways to help your neighbors and community.
• If you have children, talk to them honestly about what is going on in an age-appropriate manner. Help kids express their feelings in a positive way, whether playing in the backyard, drawing, or journaling. Check out these guides by the  Substance Abuse and Mental Health Services Administration ,  Child Mind Institute , or  National Association of School Psychologists  for tips on how to talk to your kids about coronavirus.

Take care of your spirit

• Find a place of worship that is streaming or recording services. If prayer is an important part of your life, make time for it. Stay connected to your church community through phone calls, emails, and video chats.
• Try  meditation , deep breathing, progressive muscle relaxation, or another mindfulness or  relaxation technique . Check out YouTube or phone apps such as  Calm  or  Headspace  for guided meditation exercises. Consider enlisting friends and family and practicing meditation together at least once a day.  Mindfulness  can help lower blood pressure, reduce stress, support your immune system, and protect brain health.

Continue or seek out mental health treatment

• If you are currently in mental health treatment, continue with your current plan if possible, being mindful of approaches to minimize contact with others. Consider reaching out to a mental health professional even if you haven’t before. Make sure you have ongoing access to any medications you need.
• Ask about video therapy or phone call appointments. Most states have already made emergency exemptions to insurance coverage for telehealth. Regulations have been temporarily relaxed to allow even non-medical software like Skype, Facetime, and Zoom to be used for telehealth. Even if this option wasn't available with your provider previously, it may be now! Contact them to ask about remote services.
• Avoid drugs and alcohol, particularly if you have a pre-existing mental health or substance use disorder. Check out online support groups and meetings, such as  Alcoholics Anonymous ,  Smart Recovery , and  In The Rooms .
• The need for social distancing may make it difficult to see symptoms of depression in others. In "hunker-down" mode, the in-person opportunities that we usually have to notice that friends, family, and colleagues may be struggling with a problem are no longer there. One way to think about it is that child abuse or intimate partner violence is missed more often in winter because long clothes cover bruises. Conduct regular "check ins" with your network and stay attuned to symptoms of  depression , such as persistent feelings of sadness, hopelessness, loss of interest or pleasure in activities, or changes in sleep and weight.

Remember that the emotions you may be experiencing are normal reactions to difficult circumstances. Accept that things are different right now and everyone is adjusting. Prioritize what’s most important and know that it’s okay to let some things go right now.

Be kind to yourself and others. Try to stay positive and use this time to spend more time with your children or spouse, try things you’ve been putting off, such as taking an online class, learning a new skill, or getting in touch with your creative side.

It can be hard to think past what is going on today, let alone in a week or in six months, but give yourself permission to daydream about the future and what is on the horizon. Remember that this is temporary, and things will return to normal.

• The Crisis Text Line
• Suicide Prevention Lifeline
• Veterans Crisis Line
• American Foundation for Suicide Prevention
• World Health Organization
• Centers for Disease Control and Prevention

Calliope Holingue, postdoctoral fellow in the Department of Mental Health and the Department of Neuropsychology at Kennedy Krieger Institute; M. Daniele Fallin, Mental Health chair; and Mental Health faculty Luke Kalb, Paul Nestadt, and Elizabeth Stuart co-authored this piece.

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• Mental Health Support for COVID-19 Health Care Workers
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6 ways to take care of your mental health and well-being this World Mental Health Day

The COVID-19 pandemic has taken a toll on people’s mental health. People from all walks of life have experienced stress throughout the pandemic – from frontline workers who are overwhelmed with work, young people who can’t go to school, family members who are separated from each other, those impacted by COVID-19 infection or loss of loved ones, or people with pre-existing mental health conditions who face difficulties in accessing mental health services during lockdowns.

It is understandable to feel scared, anxious or helpless during this unprecedented time. But whatever situation you are in and wherever you are in the Pacific, you have the power to look after your mental health and well-being. As we celebrate World Mental Health Day this 10 October, here are 6 things you can do to help you cope, not only with the COVID-19 pandemic, but any event that may cause stress.

1. Talk to someone you trust

Talking to someone you trust – whether a friend, a family member, or a colleague – can help. You may feel better if you are able to openly share what you are going through with someone who cares about you. If you live in an area where face-to-face interactions are limited, you can still stay connected with your loved ones through a video call, phone call or messaging app.

2. Look after your physical health

Taking care of your physical health helps improve your mental health and well-being. Be active for at least 30 minutes daily, whether that’s running, walking, yoga, dancing, cycling, or even gardening. Eat a balanced and healthy diet. Make sure to get enough sleep.

3. Do activities that you enjoy

Try to continue doing the activities that you find meaningful and enjoyable, such as cooking for yourself or your loved ones, playing with your pet, walking in the park, reading a book, or watching a film or TV series. Having a regular routine with activities that make you feel happy will help you maintain good mental health.

4. Steer away from harmful substances

Don’t use harmful substances such as drugs, kava, alcohol or tobacco to cope with what you’re feeling. Though these may seem to help you feel better in the short term, they can make you feel worse in the long run. These substances are also dangerous and can put you and those around you at risk of diseases or injuries.

5. Take two minutes to focus on the world around you

Help free yourself of constantly swirling thoughts by reconnecting yourself with where you are at this moment in time. Follow along with the video below or simply take three slow deep breaths, feel your feet grounded on the floor and ask yourself:

• What are five things I can see?
• What are four things I can hear?
• What can I smell?
• What does it feel like to touch my knees or a something else I can reach? How does it feel underneath my fingers?

6. Seek professional help

If you feel like you cannot cope with the stress that you are facing, seek professional help by calling your local mental health helpline or getting in touch with your counsellor or doctor.  Remember you are not alone, and there are things you can do to support your emotional wellbeing.

Further advice is available in Managing Stress: Self-help Tips for People Living in the Pacific Islands

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A wellness expert offers guidance on how to protect your psychological and emotional well-being during the pandemic.

April 6, 2020 10:35 AM

Author | Kate Hagadone, PhD, LP

Editor's note: Information on the COVID-19 crisis is constantly changing. For the latest numbers and updates, keep checking the  CDC's website . For the most up-to-date information from Michigan Medicine, visit the hospital's  Coronavirus (COVID-19) webpage . 

Interested in a COVID-19 clinical trial?  Health research is critical to ending the COVID-19 pandemic. Our researchers are hard at work to find vaccines and other ways to potentially prevent and treat the disease and need your help.  Sign up to be considered for a clinical trial at Michigan Medicine.

This article includes contributions from a similar article written in Michigan Medicine's Headlines publication by Daniel Ellman and Jennifer Williams.

In the midst of managing a situation like the COVID-19 outbreak, it's easy to feel overwhelmed and worried. Focusing on how to slow the spread of the virus is important for our physical health, however, identifying ways to manage our mental health is also crucial.

We may experience increased feelings of anxiety, powerlessness, impatience, irritability or frustration. We might also experience a sense of scarcity, or be concerned about increased stigmatization or xenophobia. We may feel uncertainty about the future or worry about isolation amidst rapidly changing schedules and social plans.

While feeling worried is normal and expected, there are many ways we can increase our resilience during this time:

1. Take breaks from the news.

After a certain point, it can be more upsetting than informational. Make sure the information you do get is from reputable and non-sensationalist sources. And evaluate how much is helpful for you to read in a day, and aim to stick to that limit. It can be upsetting to hear about the crisis and see images repeatedly.

Try to do some other activities you enjoy to return some normalcy back to your life as much as possible. Make time to unwind and remind yourself that these strong feelings will fade.

2. Take care of your body.

Take deep breaths. Stretch. Meditate. Try to eat relatively well balanced meals, move your body regularly, get plenty of sleep and highly limit alcohol and drugs. This will help boost your immunity — and your resilience.

3. Plan for coping with a potentially sudden drop in social contact (e.g., classes & events being cancelled.)

One of the most prominent ways individuals are asked to help mitigate the COVID-19 pandemic is to practice social distancing. That means remaining out of places where people meet or gather, and maintaining distance (approximately six feet or two meters) from others.

In times of crisis, many people seek connection and comfort from others, says Kelcey Stratton, Ph.D., program manager for resilience and well-being services at Michigan Medicine, who is also a clinical psychologist. "It is important to find creative ways to maintain those connections. We might also find some comfort by remembering that we are not alone, and that we are all in this together to protect the health and well-being of our communities."

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Create new traditions for connecting regularly with friends, family and peers via messaging apps, etc. Check in with your people. Call a family member, friend or coworker. Send a text message, direct message or email. Use FaceTime or other video formats to communicate.

4. Create a new, adapted schedule taking cancellations into account.

Keep things as consistent as possible and focus on what you can control in terms of disease prevention and more broadly.

"Our control resides in taking reasonable precautions and avoiding unnecessary risks. To protect our emotional well-being, we can pay attention to reputable sources of information and adhere to the prevention guidelines of  Michigan Medicine , the CDC and the  World Health Organization ," says Kirk Brower, M.D., chief wellness officer for Michigan Medicine.

5. Do a "worry drop."

Write out all of your fears in a journal until your anxiety has dropped by half.

Make a daily list of what is going well, and remember the things that are going well.  Despite the current situation, maybe you're able spend more time with your kids, or reading a book you've been meaning to get to or learning how to cook.

If you have a pre-existing mental health condition, these recommendations are especially important. If you have appointments with your therapist or doctor, keep them. If you aren't feeling well physically, ask if they have options for video appointments.

Like Podcasts? Add the Michigan Medicine News Break   to your Alexa-enabled device or   subscribe for daily updates on   iTunes ,  Google Play   and   Stitcher .

Explore a variety of health care news & stories by visiting the Health Lab home page for more articles.

Department of Communication at Michigan Medicine

[email protected]

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• Review Article
• Published: 03 October 2022

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

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

Nature Medicine volume  28 ,  pages 2027–2037 ( 2022 ) Cite this article

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• Epidemiology
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• Psychiatric disorders

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

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

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

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

Impact of the COVID-19 pandemic on population mental health

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

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

Self-reported mental health problems

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

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

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

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

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

Mental disorders, self-harm and suicide

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Neuropsychiatric sequelae in individuals with COVID-19

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

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

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

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

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

Neurobiological mechanisms underlying neuropsychiatric sequelae of COVID-19

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

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

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

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

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

Reducing neuropsychiatric sequelae of COVID-19

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

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

Lessons learned, knowledge gaps and future challenges

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

Give mental health equal priority to physical health

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

Communication and trust is crucial for mental health

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

Rapid research should be collaborative and high-quality

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

Do not neglect long-term mental health effects

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

Pay attention to mental health consequences of infectious diseases

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

Prepare mental healthcare infrastructure for pandemic times

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

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

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Acknowledgements

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

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Brenda W. J. H. Penninx & Christiaan H. Vinkers

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Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

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Robyn S. Klein

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Penninx, B.W.J.H., Benros, M.E., Klein, R.S. et al. How COVID-19 shaped mental health: from infection to pandemic effects. Nat Med 28 , 2027–2037 (2022). https://doi.org/10.1038/s41591-022-02028-2

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How to maintain physical and mental health during coronavirus

Assistant Professor of Biology, Center for Infectious Disease Dynamics, Penn State

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Millions are asking for clear, comprehensive information and guidelines regarding the novel coronavirus. Unfortunately, the U.S. public hasn’t received factual information or future direction from the federal government. Instead, the government has underreported cases and local transmission rates due to a lack of testing kits.

But during a crisis, leadership can come from unexpected places.

As he suspended all NBA games, commissioner Adam Silver delivered a powerful message to the public that the outbreak must be taken seriously. With that single announcement, Silver enforced more effective public health policy than the White House has during this pandemic. Shortly thereafter, all other major sports leagues followed his lead; the NBA’s decisive action helped the dominoes fall.

Last January, NFL running back Marshawn Lynch delivered solid advice for his younger colleagues in a post-game interview : take care of your bodies, your mentals, and your chicken (that is, your money). Fortuitously, this is also applicable for everyone during COVID-19.

As an assistant professor of biology at The Pennsylvania State University, I study infectious disease risks and preventative solutions. I know the only way to stop this outbreak and prevent severe cases is to reduce transmission. Without all of us changing our behavior, those who are more likely to experience severe outcomes will have negative health outcomes.

While the elderly and people with respiratory conditions are at highest risk, severe cases have also been reported in young, otherwise healthy people. Without behavioral interventions, so many patients will require hospitalization, they will exceed the capacity of the U.S. health care system. This will cause preventable deaths.

Reducing overall transmission will protect the most vulnerable members of our communities and keep the health care system functioning. You are no longer making decisions for only yourself, you have to constantly consider how your personal behavior is going to impact everyone around you and everyone around them.

You need space, but you also need connection

So far, no pharmaceutical interventions, such as vaccines and antiviral drugs, exist. At the moment, we must rely on basic public health measures: wash your hands frequently, don’t touch your face, use hand sanitizer, and limit your exposure to others. It may sound simplistic, but those things are enormously helpful. Non-pharmaceutical interventions are extremely effective against infectious diseases; all Ebola epidemics prior to 2014 are just one example.

Right now, this means avoiding direct physical contact with others. Avoid crowds, currently groups over 10 , reduce or eliminate non-essential travel, and expand the space between you and others to practice social distancing. Give yourself about 6 feet of space. But if you’re not feeling sick, you don’t have to become sedentary or trapped indoors. Go for a walk, dance around your house, or tune into on-demand fitness or YouTube instructors. If you think you’re getting sick (or if you’re already sick) you need to stay home and keep away from others. Self-quarantine is a good idea anytime you think you have an infectious disease.

Social distancing is actually physical distancing; it does not mean social isolation. During this outbreak, your mental health is critical and vulnerable right now. Social support helps and is also linked to physical health . It’s all connected .

Make deliberate efforts to be in touch with family, friends, or colleagues/classmates who are now telecommuting. Any kind of direct communication will be supportive: email, texts, video chats, even voice calls, if that’s your thing. It’s likely someone you know will end up in quarantine or isolation for 14 days, and it will be psychologically challenging . Help them, but don’t take on all the responsibility.

Create a schedule to have a different friend or relative check in with them. Also note that social media can have negative impacts on mental health. Don’t assume Instagram puppies will keep your quarantined friends fully supported.

Missing travel or events you’ve been excited about will bring disappointment. It’s OK to feel sad about losses that seem trivial right now. The endless stream of news, with rapidly changing information and misinformation, can be overwhelming. The lack of a large-scale management plan from the government might leave you frustrated. Take a moment to acknowledge those feelings of insecurity. Now more than ever, don’t face your anxiety alone.

We’re in this together

Finally, the meaty part of all this: Don’t blow your paycheck stockpiling months of food and supplies. Don’t panic and buy every possible over-the-counter drug. Buy what you need and leave the rest for others.

It is a good idea to check your prescription medications and make sure you’ve got a month’s supply on hand. Assess the shelf-stable foods you have. You may own enough unexpired cans and products to get you through several days. Aim to have two to four weeks of non-perishables around so you don’t have to shop frequently and base your decisions on what you can safely spend and store.

Since this outbreak began, the federal government has fumbled response and preparedness. Conversely, local government officials set precedents to eliminate costs for testing and treatment. New York , Washington and California led the way, announcing free testing early.

On March 12, Rep. Katie Porter pressed the director of the Centers for Disease Control and Prevention to finally deliver a long-overdue “guarantee” of free coronavirus testing for every American. We don’t know how this will roll out operationally, given the shortage of test kits, but the importance of free testing cannot be overstated . People don’t get tested if they’re worried about costs. And that’s a huge problem: Unreported or mild cases lead to transmission that is nearly impossible to stop.

Employers also need to encourage and reward responsible self-quarantining behavior. Paid sick leave would vastly improve compliance with self-quarantine measures. A system where sick days translate to lost wages promotes virus transmission.

This outbreak will continue to change our lives. We will not go back to the way things were in two weeks. We are looking ahead to a new normal. To protect the most vulnerable members of our communities, the less vulnerable must make responsible and unselfish choices. The necessary interventions to manage this outbreak have been unprecedented and sometimes unpopular but necessary. Marshawn Lynch wisely instructed us to protect our bodies, our mentals, and our chicken. Now it’s our responsibility to extend that to protecting each other.

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• Copy URL https://www.pbs.org/newshour/health/watch-live-psychiatrist-takes-your-question-on-coping-during-covid-19

4 ways to take care of your mental health during the coronavirus pandemic

Millions in the U.S. and around the world are under stay-at-home orders as officials hope to slow the spread of the coronavirus. But how do those practices affect individuals’ mental health? What are the unique mental health challenges people are facing during the COVID-19 pandemic, and how do they affect health care workers, those living alone and those returning to work, among others?

Watch the livestream in the player above.

Psychiatrist Dr. Jessi Gold of Washington University School of Medicine in Saint Louis and PBS NewsHour’s Amna Nawaz answered viewer questions on how to take care of our mental health and cope with things like fear and anxiety during the COVID-19 pandemic on May 6.

What are some tips on how to deal with anxiety from uncertainty?

A major cause of anxiety during the coronavirus pandemic is the uncertainty about what the near future will hold, which can be exacerbated by the prevalence of misinformation about the virus, Gold said.

Gold said the reason why we feel anxiety hearkens back to primal instincts to be aware of our surroundings, and to always be prepared to run from predators.

“It’s really, really normal,” she said. “Everyone is dealing with anxiety.”

Gold recommended everyone stay informed through their favorite, trustworthy, news sources to help alleviate some uncertainty, but to also limit that time in an effort to not get overwhelmed.

“I think you have to stay informed to some degree,” she said.

Anxiety can also come from growing daily to-do lists. Even the midst of all the demands, Gold recommends people always be kind to themselves.

READ MORE: The ominous consequences of COVID-19 for American mental health

“You’re going to be less productive right now,” she said, urging people to be patient with themselves.

She suggested breaking down big tasks into smaller, more manageable pieces to make them feel less daunting.

Beyond that, Gold said to explore relaxation methods such as meditation, but also said that method does not work for everyone.

“Don’t beat yourself up if it isn’t for you,” she said.

She also recommended activities like exercising and listing some of your favorite things as a way to get away from anxious thoughts.

How do you know when it’s time to seek professional help?

Living through a global health crisis is a new and trying experience for most, and some who have never experienced serious mental health issues may wonder if, and when, they need to seek help.

Gold assured that “it’s okay to always ask for help,” and that no one is going to turn you away for not having enough symptoms.

She also suggests that everyone becomes familiar with the common signs of mental distress:

• Sleeping too much, or too little
• Eating too much, or too little
• Not interacting as much with friends or family
• A lack of joy in things you used to like

While these aren’t always definite signs, they are indicative of an affected headspace, which may require help from a therapist.

How do we deal with loneliness?

For many people living alone, social distancing has cut off everyday interactions that are critical for mental stability. Gold said she understands this on a personal level since she also lives alone.

“This is the first time it’s been very evident that I live alone,” she said.

Gold recommended everyone should make an effort to reach out to friends or family to maintain social interactions. That could involve just talking, or setting up a game or movie viewing night.

“It actually feels more like work … but it’s worth doing in the end,” she said.

She also suggested that, in this moment of isolation, that we can find the things we truly enjoy doing by ourselves.

PBS NewsHour viewers also weighed in with ways they have been coping and finding joy in things they enjoy, such as bike rides, working out, learning to meditate, knitting and watching new or favorite TV shows.

“Find what coping skills work for you,” she said.

What are some resources available during COVID-19?

As the pandemic continues, many doctors are concerned about the wave of mental health issues caused by extensive social isolation and anxiety about the virus. Gold said it’s important to first break down the distinction between mental and physical health.

“I think we like to separate things, but I don’t know if that necessarily helps us,” she said.

Many physical issues, like a lack of protective gear and helping to treat those with COVID-19, directly affect a person’s mental health. Gold said that means we’re probably already seeing the effects of poor mental health on a portion of the population.

Gold listed a few helpful mental health resources that are available during this pandemic.

• To find a therapist, Gold recommended Psychologytoday.com .
• For members of the Trans community, Gold recommended calling or texting the Trans Lifeline .
• For the emergencies, Gold recommended the Crisis Lifeline, or the National Suicide Prevention Lifeline .
• For frontline workers in particular, she recommended Project Parachute or Emotional PPE .

Gold said online services like Teladoc are helpful, but are limiting in many ways, even for the therapist.

“It’s really hard for me, I think I’m really used to the human experience,” she said. “But it’s a lot better than nothing,” particularly during this pandemic, where social distancing has been key to curbing the spread of the virus.

While telemedicine can be cost effective for some, Gold said many people do not have easy access to either the internet or a device in order to use these services.

“This is not something we can just assume people can use,” she said.

Justin Stabley is a digital editor at the PBS NewsHour.

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Supporting Mental Health During the COVID-19 Pandemic

April 3, 2020 • Institute Update

The outbreak of coronavirus disease 2019 (COVID-19) may be stressful—it can be difficult to cope with fear and anxiety, changing daily routines, and a general sense of uncertainty. Although people respond to stressful situations in different ways, taking steps to care for yourself and your family can help you manage stress.

Stress during an infectious disease outbreak can include

• Fear and worry about your own health and the health of your loved ones
• Changes in sleep or eating patterns
• Difficulty sleeping or concentrating
• Worsening of chronic health problems
• Increased use of alcohol, tobacco, or other drugs

Things you can do to support yourself

• Take breaks from the news . Set aside periods of time each day during which you close your news and social media feeds and turn off the TV. Give yourself some time and space to think about and focus on other things.
• Take care of your body . Take deep breaths, stretch, or meditate. Try to eat regular, well-balanced meals; get some physical activity every day; give yourself time to get a full night’s sleep; and avoid alcohol and drugs.
• Make time to unwind . Try to engage in activities and hobbies you enjoy. Engaging in these activities offers an important outlet for pleasure, fun, and creativity.
• Connect with others . Talk with people you trust about your concerns and how you are feeling. Digital tools can help keep you stay connected with friends, family, and neighbors when you aren’t able to see them in person.
• Set goals and priorities .Decide what must get done today and what can wait. Priorities may shift to reflect changes in schedules and routines and that is okay. Recognize what you have accomplished at the end of the day.
• Focus on the facts . Sharing the facts  about COVID-19 and understanding the actual risk to yourself and people you care about can make an outbreak less stressful.

Call your healthcare provider if stress gets in the way of your daily activities for several days in a row.

Resources for Those in Distress

• Call or text 1-800-985-5990 (TTY 1-800-846-8517)
• Visit www.nimh.nih.gov/findhelp

More Information

• NIMH Coping with Traumatic Events
• NIMH Coping with Coronavirus
• Centers for Disease Control (CDC) Managing Stress & Anxiety 

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

Brenda w. j. h. penninx.

1 Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands

2 Amsterdam Public Health, Mental Health Program and Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress Program, Amsterdam, The Netherlands

Michael E. Benros

3 Biological and Precision Psychiatry, Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark

4 Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

Robyn S. Klein

5 Departments of Medicine, Pathology & Immunology and Neuroscience, Center for Neuroimmunology & Neuroinfectious Diseases, Washington University School of Medicine, St. Louis, MO, USA

Christiaan H. Vinkers

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

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

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

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

Impact of the COVID-19 pandemic on population mental health

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

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

Self-reported mental health problems

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

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

Pooled effect sizes from meta-analyses comparing mental health symptoms before versus during the first year of the COVID-19 pandemic in the general population

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

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

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

Mental disorders, self-harm and suicide

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Neuropsychiatric sequelae in individuals with COVID-19

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

Acute and post-acute neuropsychiatric sequelae of COVID-19 disease as described in empirical studies *

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

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

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

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

Neurobiological mechanisms underlying neuropsychiatric sequelae of COVID-19

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

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

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

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

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

Reducing neuropsychiatric sequelae of COVID-19

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

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

Lessons learned, knowledge gaps and future challenges

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

Give mental health equal priority to physical health

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

Communication and trust is crucial for mental health

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

Rapid research should be collaborative and high-quality

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

Do not neglect long-term mental health effects

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

Pay attention to mental health consequences of infectious diseases

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

Prepare mental healthcare infrastructure for pandemic times

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

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

Acknowledgements

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

Competing interests

The authors declare no conflicts of interest.

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How to take care of your mental health during the COVID-19 pandemic

Posted: 1 April 2020 | Victoria Rees (European Pharmaceutical Review) | 3 comments

During the COVID-19 pandemic, when many are in lockdown or self-isolating, mental health could suffer. This article suggests some ways to stay healthy over this period.

The COVID-19  pandemic is creating stress for the global population. Empty store shelves, fear about the disease and quarantine or self-isolation can negatively impact depression and anxiety. The mental health implications of this unprecedented situation will impact everyone differently, leading clinical psychologists to offer a guide on how to support and manage one’s mental health and that of others during these times.

“Global concern about coronavirus means it’s very important to keep the normal routine as much as possible when it comes to sleep, nutrition and exercise, particularly in people with existing mental health problems,” says Daniel Mansson, clinical psychologist and co-founder of Flow Neuroscience , which compiled the guidance. “In the current situation, finding ways to maintain your normal routine is essential to reducing stress and potential depressive thoughts that may appear.”

Filter news and social media

Constant news about the pandemic can feel relentless and may exacerbate existing mental health problems. Be careful about the balance of watching important news and the news that could cause you to feel depressed and disrupt your mental health. Seek trusted information, such as the National Health Service (NHS) website , at specific times to take practical steps to protect yourself and loved ones. Have breaks from social media and mute triggering keywords and accounts.

Talk openly about mental health

Some people might feel that talking about their depression and anxiety requires no additional attention during these times – people should be encouraged to talk about their feelings. Various support helplines are available, including Samaritans , as well as mental health crisis services, details of which can be found via the mental health charity Mind .

Eat an ‘anti-depression diet’

Anxiety is likely to increase during the current crisis, but a well-nourished body is better at handling stress. Traditional Mediterranean food, sometimes referred to as the ‘anti-depression diet’, for its anti-oxidant and anti-inflammatory properties, includes whole grains, vegetables (particularly green leaves), fruit, berries, nuts (including almonds), seeds and olive oil to look after your mental health. 

Get therapeutic sleep

Ninety percent of depressed people struggle with sleep, which is likely to increase with fears over the coronavirus. Good quality sleep is a form of overnight therapy and increases the chance of handling strong emotions effectively. Try to wake up and go to bed at the same time every day. Achieving eight hours of sleep, taking a hot bath, setting the bedroom temperature to 18°C and having no screen time two hours before bedtime will also help.

Exercise as a depression treatment

With months of the coronavirus pandemic ahead, it is important to keep exercising. Clinical studies show that regular exercise produces chemicals, such as dopamine and serotonin, which are as effective as antidepressant medication or psychotherapy for treating milder depression. Most people will not have access to a gym during the crisis, so it is important to create a daily exercise routine at home. Experts recommend between 30-40 minutes of exercise,  three to four times a week to work up a sweat. People with depression often struggle with exercise, so start small with a 10 minute walk, then add a few minutes daily.

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3 responses to “how to take care of your mental health during the covid-19 pandemic”.

Thank you for bringing up such an undoubtedly important topic that plays a big role in modern realities. I never would have thought that being at home in quarantine is so debilitating for mental health in general. As a homebody, I always liked to spend my evenings at home and I did not see this as a big problem before quarantine. Then I understand that when they take away any opportunity to leave the house, it becomes a real torture. Now I understand how difficult it is and I understand that even if I need help after this, I cannot imagine those people who live in unfavorable conditions.

Great content! This is exactly the sort of thing I was looking for. Thanks for your help 🙂

I completely agree with the anti-depression diet. This is an interesting post to read. Thanks for sharing!!

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Open Access

Peer-reviewed

Research Article

Impact of COVID-19 on psychological distress in subsequent stages of the pandemic: The role of received social support

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft

* E-mail: [email protected]

Affiliations Department of Psychology, Indiana University of Pennsylvania, Indiana, PA, United States of America, Institute of Psychology, Polish Academy of Sciences, Warsaw, Poland

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft

Affiliation Academy of Health and Social Studies, NHL Stenden University of Applied Sciences, Leeuwarden, The Netherlands

• Krzysztof Kaniasty, 
• Erik van der Meulen

• Published: September 25, 2024
• https://doi.org/10.1371/journal.pone.0310734
• Reader Comments

This longitudinal study examined a sample of adult Poles (N = 1245), who were interviewed three times from July 2021 to August 2022, during the later stages of the COVID-19 pandemic. The study had two primary objectives. The first was to assess the impact of the pandemic on psychological distress, measured through symptoms of depression and anxiety. The pandemic’s effects were evaluated using three predictors: direct exposure to COVID-19, COVID-19 related stressors, and perceived threats from COVID-19. The second objective was to investigate the role of received social support in coping with the pandemic’s hardships. Receipt of social support was measured by both the quantity of help received and the perceived quality of that support. A Latent Growth Curve Model (LGCM) was employed to analyze psychological distress across three waves, controlling for sociodemographic variables, non-COVID life events, coping self-efficacy, and perceived social support. Findings indicated that COVID-19 stressors and COVID-19 threats were strongly and consistently associated with greater psychological distress throughout the study period. The impact of direct COVID-19 exposure was limited. The quantity of received support predicted higher distress, whereas higher quality of received support was linked to better mental health. Crucially, the relationship between the quantity of support and distress was moderated by the quality of support. Effective social support was associated with the lowest distress levels, regardless of the amount of help received. Conversely, receiving large amounts of low-quality support was detrimental to psychological health. In summary, the ongoing psychosocial challenges of COVID-19 significantly eroded mental health, highlighting the importance of support quality over quantity in coping with significant life adversities.

Citation: Kaniasty K, van der Meulen E (2024) Impact of COVID-19 on psychological distress in subsequent stages of the pandemic: The role of received social support. PLoS ONE 19(9): e0310734. https://doi.org/10.1371/journal.pone.0310734

Editor: Ali B. Mahmoud, St John’s University, UNITED STATES OF AMERICA

Received: December 18, 2023; Accepted: September 5, 2024; Published: September 25, 2024

Copyright: © 2024 Kaniasty, van der Meulen. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are publicly available from the OSF repository ( http://osf.io/xmzw8 ).

Funding: Funding preparation of this paper was supported by Grant OPUS-19 grant No. 2020/37/B/HS6/02957 awarded to Krzysztof Kaniasty from the Polish National Science Centre (Narodowe Centrum Nauki). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

It is reasonable to assert that the COVID-19 pandemic, like no other collective crisis in the world’s history, prompted an unprecedented number of research studies, reviews and meta-analyses attempting to assess its impact on mental health. Many quantitative and qualitative syntheses documented that the heaviest mental health toll on general public, most frequently assessed as symptoms of depression, anxiety, PTSD, or psychological distress, occurred in the early months of the pandemic [ 1 – 4 ]. Similar patterns of findings emerged within different subgroups, such as COVID-19 patients [ 5 ], children and adolescents [ 6 ], college students [ 7 ], elderly [ 8 ] or healthcare workers [ 9 ]. Evidence concerning whether in later months of the first year of the pandemic mental health problems decreased [ 1 , 4 ] or remained stable at moderately elevated levels [ 2 , 3 ] is not yet conclusive.

It is also reasonable to assert that the psychological impact of the SARS-CoV-2 virus would persist through subsequent phases of the pandemic. Few, thus far published, longitudinal investigations with mental health assessments conducted after July 2021 [ 10 – 15 ], evidenced overall improvements in psychological health in various populations since the onset of the pandemic. Nevertheless, mental health issues appear elevated as compared to pre-pandemic times [ 16 ].

The COVID-19 experience should be regarded as a disaster or catastrophe that set off a prolonged series of diverse and stressful hardships. The pandemic encompassed all possible classes of stressors [ 17 ]: traumas (e.g., death, injuries), life events (e.g., lockdowns, job interruptions/loss), daily hassles (e.g., social distancing, mask-wearing), macro-system events (e.g., economic downturns, societal protests/disputes), nonevents (e.g., postponements/cancellations of expected life milestones such as graduations and weddings), and chronic stressors (e.g., ongoing life hardships such as caregiving, environmental challenges). Each of these facets of the COVID-19 catastrophe independently impacted psychological and social well-being, capturing different aspects of the comprehensive spectrum of stress processes [ 17 , 18 ].

The present longitudinal study had two major goals. First, it aimed to assess the impact of the pandemic in its later phases (July 2021—August 2022) on psychological distress assessed as combined symptoms of depression and anxiety. The ongoing presence of the pandemic in people’s lives was measured using three predictor variables. COVID-19 direct exposure for individuals and their significant others was evaluated as probable encounters with the virus. This assessment encompassed a range of experiences from simple testing or mild infection to severe illness, including hospitalization or the death of a significant person. Several COVID-19 studies have documented the association between direct exposure to the SARS-CoV-2 virus and psychological health [ 19 , 20 ]. The second measure, COVID-19 stressors, included a series of significant secondary stressors such as occupational disruptions, financial insecurity, and delays or cancellations. These stressors have also been shown to adversely impact mental health [ 21 , 22 ]. Finally, COVID-19 threats, likely the most frequently assessed indicator of the pandemic’s adversities, evaluated people’s concerns and fears for their own health and the health of their families [ 21 , 23 ].

The second goal of the present study was to investigate the role of social support in the ongoing process of coping with COVID-19 adversities. Social support is a multifaceted construct that encompasses social interactions providing actual assistance and embedding individuals in a network of relationships perceived as loving, caring, and readily available in times of need [ 24 ]. The most central distinction between different forms of social support lies between perceived social support and received social support. Perceived social support refers to subjective appraisals of being reliably connected to others, such as believing that "If I needed it, I can easily find someone to talk to about my troubles, worries, or concerns." In contrast, received social support pertains to the actual support received, such as "How often did someone give, loan, or offer you money?"

Perceived social support, regarded as the principal facet of social support, has consistently been shown to be advantageous for better postcrisis outcomes [see 25 , 26 ]. Conversely, studies assessing received social support have produced inconsistent findings. Some investigations have documented a clear benefit of greater received support in reducing distress. However, many other studies have found no effects, or worse, have shown positive associations between received support and increased mental health problems [ 27 , 28 ]. Accordingly, the stress and coping literature consistently highlights the benefits of social support for psychological adjustment, with an emphasis on perceived social support rather than received support. This focus poses challenges for public health professionals and practitioners who provide aid, support, and psychological interventions to communities recovering from disasters. It also presents difficulties for countless individuals worldwide who have been striving to offer actual support to one another during the challenging times of the COVID-19 pandemic.

The reasons why the efficacy of received social support may be undermined during times of coping with stressors are extensive [ 27 , 29 , 30 ]. Providing and receiving help in times of crisis, whether through personal, charitable, or professional relationships, is a complex and challenging process. Good intentions and sincere concerns often mix with confusion, skepticism, and psychological threats. Simply put, while the desire to relieve the suffering of others is commendable, not all forms of social support prove to be helpful.

A number of recommendations can be found in the social support literature that offer ideas for identifying theoretical pathways, along with empirical and practical prerequisites for detecting the genuinely helpful influence of received social support [ 27 , 30 ]. Rini and Dunkel Schetter [ 31 ] proposed a comprehensive theoretical framework for investigating the efficacy of received social support, which they labeled the “ social support effectiveness model ” (SSE). The SSE model delineates the joint influence of the “ quantity ” and “ quality ” of received social support and the extent to which helping provisions meet recipients’ expectations, needs and demands from the stressors they face.

The quantity dimension of support receipt is determined by the match between the recipient’s needs and the amount of help received, ensuring the support is neither too little nor too much. The quality dimension involves more complex practical and psychological dynamics, including: a) “functional fit”—the type of help aligns with what is needed; b) “skillfulness and sensitivity”–support is delivered in ways that minimize the recipient’s feelings of being a burden; c) “ease of access”–help is not difficult to get; and d) “impact on self-concept”–the support received does not reflect poorly on one’s self-esteem, avoiding blame, feelings of incompetence, or a sense of indebtedness.

Rini and her colleagues [ 32 ] provided strong empirical evidence for the SSE model in a sample of hematopoietic stem cell transplant survivors. When examined together, the quantity of support received was predictive of more distress experienced by survivors, whereas favorable appraisals of the effectiveness of support received were associated with better mental health. Most critically, the two operationalizations of received social support statistically interacted with each other producing a disconcerting pattern revealing that when support was judged as being low in quality, receiving greater quantities of it predicted elevated distress. However, recipients of effective support reported the lowest levels of distress, regardless of the amount of help received. The importance of assessing both the amount and quality of postcrisis received social support for psychological functioning was also evidenced among survivors of disasters [ 33 – 35 ]. Altogether, these findings highlight the importance of enhancing the quality of help provided to people coping with life difficulties. Simply providing "more" support is not necessarily better and can potentially be detrimental if offered in substandard ways. This underscores the need for support that is provided in the right amount and type, delivered with skill and sensitivity, easily accessible, and without negative repercussions for the recipient’s self-image.

In addition to reliance on social support, theory and research on coping with stressful life events repeatedly emphasize the importance of self-efficacy as a critical factor influencing adaptation to significant life challenges, threats, and losses [ 36 , 37 ]. Confidence in one’s own coping abilities and social support resources dynamically influence each other. Received social support may enhance self-efficacy (i.e., enabling path), whereas self-efficacy may mobilize (i.e., cultivation path) social networks to action [ 38 ].

The present study examined the role of social support receipt, measured in terms of both quantity and quality, on psychological distress. The analyses accounted for the influence of sociodemographic factors, perceived social support, and beliefs in coping self-efficacy, which are two crucial resources that routinely promote successful coping with stressors. The uniqueness of the COVID-19 catastrophe for studying received social support stems from the fact that everyone has been subjected to its threats, disruptions, and losses. Nearly everyone has needed support at some point, and nearly everyone has provided support at some point.

Sample and procedure

Wave 1 sample was recruited between July 6 and 19, 2021, from an online survey panel (“Ariadna,” a Polish online research panel with over 150,000 registered and verified users) to be representative of Polish adults in terms of gender, age, and size of municipality. It originally consisted of 3074 respondents who met all quality control requirements established for the study based on answers to attention questions, and times of completion of surveys (i.e., participants with completion times faster than 1 SD from the sample mean were eliminated). Wave 2 data were collected in February 2022, and Wave 3 followed six months later in August 2022.

The sample analyzed in this study comprised 1,245 respondents who completed all three waves of data assessments and met subsequent (Wave 2 and 3) quality control requirements. A comparison of these participants with those who dropped out after earlier waves of assessments ( N = 1829, 59.4%) on Wave 1 variables revealed some significant differences. The drop-out participants were younger, less educated, and more likely to live in villages or smaller towns. They were also less likely to be in relationships and had higher scores on the psychological distress measure.

The study was approved by the Institutional Review Board of the Institute of Psychology, Polish Academy of Sciences (Approvals # Wave 1-13/V/2021, Wave 2-01/1/2022, Wave 3-17/VII/2022). All participants provided written consent prior to each wave of assessments.

Outcome variable—psychological distress.

Symptoms of psychological distress were assessed with 8 items from the Patient Health Questionnaire (PHQ-8) [ 39 ], and 7 items from the Generalized Anxiety Disorder scale (GAD-7) [ 40 ]. These self-reports have been frequently used to assess depressive (e.g., “Little interest or pleasure in doing things”) and anxiety symptoms (e.g., “Feeling nervous, anxious or on edge”). In order to keep our measures consistent across all surveys’ administrations with regards to time frames of responding and response opinions, both instruments asked respondents about how often they were bothered by these symptoms in the last 30 days (instead of the typical for these instruments time frames of “the past two weeks”), with the following five answer choices: 0 ( Never ), 1 ( Rarely ), 2 ( Sometimes ), 3 ( Often ), and 4 ( Very often ). These options were recoded to a four-point scale of the standard PHQ-8 and GAD-7’s response sets (range 0 to 3, with answers “rarely” and “sometimes” both coded as 1). Cronbach’s α reliability coefficients of the PHQ-8 and GAD-7 scores computed as sums were high at all assessment times (0.92–0.94).

The PHQ-8 and GAD-7 are often combined into a single measure of general distress [ 41 ], consequently the total score of psychological distress used in the present analyses was a sum of all 15 items. Confirmatory factor analyses using a Diagonally Weighted Least Square Estimator on the present data showed excellent fit for single factor solutions (see S1 Table ). Cronbach’s alphas of the psychological distress total scores at each measurement wave were all high (> 0.95).

Measurement of focal predictors.

COVID-19 direct exposure index was based on a sum of answers to 11 questions that asked about exposure to SARS-CoV-2 in the past 16 (Wave 1) or 6 months (Waves 2 and 3). Questions referred to the participant (e.g., being tested for the virus, if positive how severe was the illness, hospitalization) and to the family and friends (including deaths). Different answer options were used depending on the content of the question, but all responses were recoded as 0 ( No or minimal exposure ) or 1 ( Moderate to severe exposure ).

COVID-19 stressors was derived from the average of items that evaluated the extent to which pandemic-specific events (i.e., decline in household budget, irreversible cancellation of important personal events, postponement of important events, new/additional burdens with care for children, new/additional burdens with care of elderly) negatively influenced respondents’ lives in the past 16 months (Wave 1, 10 items) or 6 months (Waves 2 and 3, 6 items; 0 = Did not happen or not at all , 4 = To a great extent ). One additional item was included that asked whether a participant and/or someone in their household experienced COVID-19 related job loss that had negative consequences.

COVID-19 threats involved 12 questions asking the participants about their fears and concerns regarding current threats associated with the continuing pandemic (e.g., “I am concerned that someone close to me will get sick with COVID-19, even if it would be a subsequent infection,” “I am worried about difficulties with access to medical personnel with issues not related to COVID-19”). Items were answered using a 7-point Likert-type response option format anchored with 1 ( Definitely disagree ) and 7 ( Definitely agree ). Reliability coefficients of the scores were high at each assessment (>.92).

Quantity of received social support was measured by the Inventory of Postdisaster Social Support [ 42 ]. Respondents were asked to estimate how often they received different types of help within the timeframe of the past 16 (Wave 1) and 6 months (Waves 2 and 3). For example, a question at Wave 1 asked: “How often, in the last 16 months (i.e., since the beginning of the pandemic), did family members give, loan or offer you money? Regardless of the reason, did this happen…? (1 = never , 2 = rarely , 3 = sometimes 4 = quite often , 5 = very often ). Another example question, from Wave 3 (August 2022), read: How often, in the past 6 months (i.e., from the beginning of February until today), did friends help you understand the situation you were in?

Three types of received support were assessed: emotional (4 items), informational (4 items), and tangible (8 items) support [ 43 ]. Each of these 16 items was asked two times to gage amounts of support received from two sources: family/relatives and friends/close acquittances. Thus, the total scale score was an average of 32 items. Reliability coefficients of the scores were high at each assessment wave (>. 96).

Quality of received social support was assessed with 12 items modeled on the instrument developed by Rini and Dunkel Schetter [ 31 , 32 ] based on their SSE model. The same six questions, with varying Likert-type five answer options (all coded 1 thru 5), asked respondents for their appraisals of the support received from family/relatives and friends/close acquittances. Respondents judged the help they received along the following dimensions: quantity (“When family members tried to help you, how well did the amount of help you received match the amount of help you wanted?”), functional fit with needs (“How often have you found yourself wishing the help you received had been different—for instance, a different type of help, or offered in a different way or at a different time?), skillfulness of support delivery (“How often did your friends who gave you help provide it skillfully?), ease of getting help (“When you needed help from family members, how often was it difficult to obtain?”; “How often did friends offer you support without you having to ask for it?”), and the overall appraisal of effectiveness of received help (“Broadly speaking, how effective or useful was the help you received from your family?”). Cronbach’s alphas of average scores computed on 12 items were high at each assessment wave (> .85).

Measurement of additional predictors.

Normative life events index was a sum of answers (0 = No , 1 = Yes ) to questions asking whether, in the past 16 (Wave 1) and past 6 months (Waves 2 and 3), respondents experienced any of 19 major life events (e.g., change in marital status, birth of a child/grandchild, other than COVID-19 illness of self or family, not COVID-19 bereavements). The count of non-COVID events was recoded to range from 0 to 9.

Coping self-efficacy was measured with six items modeled on the Trauma Self-Efficacy scale [ 44 ]. At Wave 1 and 2 the items referred to participants’ perceived capability to cope with challenges and uncertainties of the COVID-19 pandemic (e.g., “Today, how capable are you to successfully deal with your emotions [ anxiety , sadness , disaffection , anger ] related to the pandemic?”; 1 = Not capable , 7 = Very capable ). At Wave 3, the same items were asked about participants’ appraisals of their capability to cope with serious negative life events that might happen to them in the future (e.g., “In the future, when faced with a difficult life circumstance, how capable will you be to successfully deal with emotions [ anxiety , sadness , disaffection , anger ] that you might experience at that time?”). Confirmatory factor analyses with scale items showed acceptable fit for single factor solutions [ 45 ]. Internal reliability coefficients of average scores of this scale were high at each wave (> .93).

Perceived social support was assessed with 12 items from the Interpersonal Support Evaluation List [ 46 ] and 3 items from the Social Provision Scale [ 47 ] that asked about an overall perceived availability of emotional (5 items), informational (4 items) and tangible (6 items) social support (e.g., “If I were sick and needed someone to take me to the doctor, I would have no trouble finding that person;” “I have close relationships that provide me with a sense of emotional security and well-being;”1 = definitely false ; 4 = definitely true ). Cronbach’s alphas of average scores of this 15-item instrument were high at each wave (> .92).

Sense of danger due to the war was also assessed because during the course of this longitudinal research Russia attacked Ukraine (February 24, 2022), a country bordering with Poland. To account for this additional life stressor, participants were asked at Wave 3 (August 2022) to what extent, in the past 30 days, they were afraid, worried, and/or concerned about their own, their family, and the entire country’s safety and welfare due to the ongoing armed conflict (e.g., “To what extent have you felt that life of your family members and relatives were in danger because of the war in Ukraine?”; 1 = Not at all , 5 = To a very great extent; α = .85) [ 48 ].

Sociodemographic variables.

Five sociodemographic factors were also included in all analyses. Participants’ gender and their marital status were scored as dichotomous variables. Age was scored in years, respondents’ educational attainment was classified into four levels and size of municipality was grouped into five categories.

Statistical analysis

The lavaan package (version 0.6–9) [ 49 ] for R was used to conduct latent growth curve modelling (LGCM) with psychological distress at three waves as an outcome. The latent growth was modelled to be a linear process. Distress was normally distributed (skewness < 0.630 and kurtosis < 0.720 at all three measurement waves) making it feasible to use maximum likelihood estimation for our models.

Three models with increasing complexity were fitted. First, a model with only the psychological distress latent intercept and slope without any predictors was tested. In the next model, the time-invariant predictors of age, gender, educational level, marital status and municipality size were added as predictors of the psychological distress latent intercept and slopes.

The final model of interest in was a model with a latent intercept and slope (using psychological distress measured at three waves), and included time-invariant predictors of the latent intercept and slope (gender, age, educational level, marital status, and municipality size), and time-varying predictors that were measured at all three waves predicting trajectory deviations either only concurrently (COVID-19 exposure, COVID-19 stressors, COVID-19 threat, Non-COVID events), and both concurrently and prospectively (coping self-efficacy, perceived social support, received support-quantity, and received support-quality). Fig 1 gives a full overview of the study model.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0310734.g001

A stepwise approach was used to successively fitting models leading up to more complex models, running from a growth curve model only to the addition of both time-invariant and time-varying predictors. First, we fitted a model with only the growth curve, which included a latent intercept and slope. Next, we enhanced the model by adding the time-invariant predictor. Finally, we further refined the model by incorporating the time-varying predictors. All variables were mean-centered before being entered into the conditional models. The following model fit statistics were used: χ 2 (and its significance), RMSEA (and its confidence interval), CFI, NFI and SRMR. Using Hu and Bentler’s [ 50 ] criteria, a CFI and NFI close to .95, an SRMR close to .06 and an RMSEA close to 0.08 were indications of adequate fit.

Post-hoc analyses on the interaction effects were conducted by categorizing the quality of received support into three levels (< - 1 SD , -1 SD to + 1 SD , > + 1 SD ). Subsequently, a simple regression of predicted distress scores (retrieved from the most complex LGCM) on the quantity of received support for each category were conducted.

Table 1 provides an overview of descriptive statistics and S2 Table provides correlations for all variables ( N = 1047; participants who reported receiving no support at any of three measurement times were excluded).

https://doi.org/10.1371/journal.pone.0310734.t001

In total three models were tested (unconditional model, conditional model with only time-invariant predictors and conditional model with time-invariant and time-varying covariates). Before we modelled our intended model, we assessed: 1) potential multicollinearity among predictors and 2) potential overfit of the model (given the number of predictors). Multicollinearity was assessed by examining correlations among the predictor variables. Of the 528 correlations possible among all predictors, 24 were larger than 0.5 or smaller than -0.5 (4.5%).

These stronger correlations existed among the same variables measured at different times and between COVID-19 coping self-efficacy and psychological distress. To determine whether these correlations raised multicollinearity issues in the LGCM, three multiple regression models were run with the predicted distress scores at each wave as dependent variables and the LGCM-corresponding time-varying covariates as independent variables. Independent variable’s variance inflation factors (VIFs) of these models never exceeded values of 2.871 which was well under the threshold of 5 and, thus, signaling no obvious multicollinearity problems.

Overfit of the model was assessed by changes in the Akaike’s Information Criterion (AIC) of the predictors in relation to a model without predictors—a decrease of the AIC was indicative of an enhanced model fit when the particular predictor was added to the model. We examined both the bivariate decreases in AIC for each predictor (i.e. differences in AIC between every predictor separately to a model without any predictors) and hierarchical decreases in AIC (i.e. successively adding predictors and determining the decrease in AIC after each addition). Some variables appeared to add little to the model and caused a slight increase in the AIC. However, these decreases were relatively small and their negative impact on model fit, thereby, was rather minor. For reasons of completeness, these variables were kept in the model, nonetheless. S3 Table gives a full overview of overfit assessment. An additional consideration for overfit is the adequacy of the sample size in relation to model complexity. This can be captured by the ratio of estimated parameters to the number of respondents [ 51 , 52 ]; a minimum is 1 to 5 (i.e. 5 respondents for every estimated parameter), for the current study this was 1 to 18.70 highlighting an exceedingly sufficient sample size. Therefore, our modelling approaches were deemed valid.

Latent growth

All models, one unconditional and two conditional models, yielded significant latent intercepts and non-significant latent slopes. The first rows of Table 2 indicate the latent growth factors (intercept and slope) for each model. The non-significant slopes in all three models reflect a general absence of change over time. Only in the unconditional model, the latent intercept and slope were associated; individuals with higher initial starting values showed a higher decline over time ( cov = .177). In both conditional models, the latent intercept and slope were unrelated ( cov = .113 and .001, respectively).

https://doi.org/10.1371/journal.pone.0310734.t002

Time-invariant predictors.

In the model with only time-invariant predictors (Model 2; see Table 2 ), the latent intercept was associated with gender and age; women and younger respondents were more distressed initially. None of the time-invariant predictors were predictive of the latent slope.

Time-varying predictors: COVID-19 variables, non-COVID life events, and sense of danger due to the war.

The last column of Table 2 (Model 3) conveys the outcomes of time-varying predictors. The COVID-19 experiences variables (COVID-19 exposure, stressors and threats) and the experience of non-COVID events were assessed as concurrent predictors (i.e. i th wave to i th wave) of distress at each wave. Of these variables, the COVID-19 stressors and COVID-19 threats, and non-COVID events were significantly associated with distress at each wave. Higher levels of stressors, threats and other life events were associated with more symptoms of distress. COVID-19 exposure was only significantly positively associated with distress at Wave 2; i.e., more virus exposure was predictive of with more distress. Sense of danger due to the Russian-Ukrainian war significantly predicted higher levels of symptom at Wave 3.

Time-varying predictors: Coping self-efficacy, perceived social support, quantity and quality of received social support.

Coping self-efficacy ratings were strongly both concurrently and prospectively (i.e. i th wave to i+1 th wave) associated with lower distress scores at all waves. Perceived social support was concurrently associated with lower levels of distress symptoms, but never prospectively.

Quantity and quality of received support were concurrently associated with distress at all three measurement moments. Prospectively, both Wave 1 quantity and quality of received support were predictive of later distress only at Wave 2. Received support quantity was positively associated with psychological distress, such that greater amounts of support were associated with more distress. However, appraisals of the quality of received support were negatively associated with distress, such that greater quality of received support was associated with lower levels of distress symptoms.

The interaction between Wave 1 quantity of received support by Wave 1 quality of received support was statistically significant predicting Wave 1 distress. Fig 2 presents the plots of this interaction associated with observed (left panel) and predicted distress scores (right panel). Persons who judged support received as low in quality reported the highest levels of distress, and greater amounts of received help were strongly associated with higher levels of distress (post-hoc slope analyses, B = 1.810, p = .030). The slope for the average quality of received support group was also statistically significant ( B = 0.737, p = .020) but the adverse effect of the amount of received support was less pronounced. Most importantly, however, persons who received most efficacious support reported lowest levels of symptoms compared to the other two groups, and the amount of help they actually received did not influence of their experience of distress (B = 0.607, p = .207). No other quantity by quality interactions were statistically significant.

Interaction Effect of Received Support Quantity with Quality on Observed (left pane) and Predicted Distress Scores (right pane). Predicted scores were retrieved from the Latent Growth Curve Model including all time-invariant and time-varying predictors.

https://doi.org/10.1371/journal.pone.0310734.g002

Fundamentally, the experience of COVID-19 could be considered a total catastrophic event because the pandemic spurred all possible classes of stressors [ 17 ]. It has been a traumatic and/or major life changing event, it created daily hassles, it caused macro-system turbulences, generated a surplus of disappointing nonevents, and many of its repercussions have evolved into identifiable chronic stressors. All these facets of the COVID-19 pandemic represent separate parts of the overall universe of stress processes, each potentially adversely influencing mental health.

The present study examined psychological distress trajectories a sample of adult Poles who were interviewed three times from July 2021 to August 2022, thus during later stages of the pandemic. A Latent Growth Curve Model (LGCM) revealed that respondents differed in their level of psychological distress, although changes in these trajectories were generally absent. In other words, individual growth trajectories only differed in the level of distress, but all trajectories were horizontal. Relative stability of the pandemic-related symptomatology was also documented in the meta-analysis of prevalences of depression reported by studies conducted during the first year of the pandemic [ 2 ]. Similarly to prior COVID-19 studies, the levels of mental health were dependent on gender and age with women and younger respondents exhibiting more symptoms [ 2 , 3 , 6 , 7 , 9 ].

COVID-19 stressors and COVID-19 threats were both strongly and consistently associated with greater distress throughout the study. The influence of COVID-19 direct exposure was limited to one assessment period. Notwithstanding the overall traumatic and grave consequences of the SARS-CoV-2 virus, it can be said that the pandemic’s psychosocial challenges and disturbances have most forcefully eroded mental health [ 21 , 22 ]. Continuing effect of COVID-19 pandemic on distress in the present sample was observed controlling for harmful influences of other normative life events and sense of danger associated with Russia’s invasion of Ukraine [ 48 , 53 ].

There are many psychological and social resources that empower humans to show resilience and recover successfully from adversity. Chief among them are survivors’ sense of trust in their own ability to face demands/losses posed by the stressor [see 36 , 37 , 54 ] and perceptions of being supported [see 55 , 56 ]. In accord with other investigations of the pandemic, results of the present study showed that higher levels of coping self-efficacy [ 57 – 59 ] and perceived social support [ 60 – 63 ] were consistently associated with lower levels of distress symptomatology.

The main interest of this research was focused on mental health influence of the amount of received social support and appraisals of its quality. The few available COVID-19 studies that investigated the quantity of actual receipt of help have produced mixed findings, yielding very limited beneficial effects [ 64 , 65 ], or no effects at all [ 59 , 66 ]. Contradictory evidence was also reported suggesting that the amount of received support was associated with lower distress [ 67 , 68 ], or with greater distress [ 69 ]. On the one hand, the results of the present analyses showing adverse psychological effects of receiving greater levels of support could just add to this confusion. However, more favorable appraisals of effectiveness of received support showed a protective function and, with equal consistency, were associated with lower levels of psychological distress. The pattern of the received support quantity by its quality interaction offers a reasonable and theory-based (SSE model) [ 31 ] interpretation of this apparent inconsistency. Persons who received effective social support exhibited the lowest levels of distress symptoms, irrespective of the amount of help. On the other hand, receiving large amounts of ineffective social support appeared to be detrimental to mental health. These results replicated an interaction pattern reported by Rini et al.’s [ 32 ] and should warn potential social support providers that if they cannot help smart , they should not attempt to help that hard . In other words, as long as it is delivered in an efficacious manner, received social support protects mental health in the context of stressful circumstances [ 33 – 35 ].

Strengths and limitations

The use of LGCM allowed to model psychological distress trajectories and predicting distress trajectory deviations from factors that were both stable and changed over time. In other words, the model depicted individuals’ typical distress trajectories and identified why and when individual’s had a-typical distress levels influenced by a comprehensive set of (possible) experiences along the trajectory, most notably: COVID-19 experiences and received support. Conservative analyses included, as control factors, relevant sociodemographic variables, potentially stressful life events not related to the pandemic, and participants’ concerns about the ongoing war in neighboring Ukraine. The study’s sample was large and randomly selected from a nationally representative internet panel. However, across the study’s three assessments, close to 60% of the initial sample was not retained due to attrition and strict data quality control procedures. In addition, all typical disadvantages associated with longitudinal online surveys apply. Finally, although the quantity by quality of received support interaction was consistent with theoretical underpinnings of the study it reached statistical reliability only one time. Thus, this interactive effect should be viewed with prudence as it requires additional examinations.

Although the rates of severe illness and deaths due to infections with variants of the coronavirus SARS-CoV-2 have gradually decreased and vaccination campaigns continue to reach more and more people, it is not unreasonable to assert that adverse mental health impact of the COVID-19 pandemic will persist. Results of the present study suggest that the ongoing presence of COVID-19 concerns, disturbances and losses have become chronic stressors. Citizens of the world may have to “domesticate” these challenges along with mastering personal and collective strategies to prevent and mitigate harmful psychological consequences of the pandemic. Clearly, beliefs in coping self-efficacy and sense of being reliably connected to others serve as robust contributors to successful coping and adaptation. The conditions under which actually receiving social support are less straightforward, particularly in the context of community-wide emergencies that routinely call for considerable amounts of help and assistance. What appears decisive when aiding people in times of coping with a variety of stressors is the quality, not necessarily quantity, of support provided. In our private as well as professional roles as helpers, it is worth remembering that the benefits of support provided to others may be achieved more readily if we attempt to help smarter rather than harder .

Supporting information

S1 table. confirmatory analysis of single factor distress scale composed of gad-7 and phq-8..

https://doi.org/10.1371/journal.pone.0310734.s001

S2 Table. Correlations among study variables (n = 1047).

https://doi.org/10.1371/journal.pone.0310734.s002

S3 Table. Assessment of model overfit and incremental value of predictors.

https://doi.org/10.1371/journal.pone.0310734.s003

Acknowledgments

The authors would like to thank the members of our research team: Maria Baran, Marta Boczkowska, Katarzyna Hamer, and Beata Urbańska.

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Coping with COVID-19: a prospective cohort study on young Australians' anxiety and depression symptoms from 2020–2021

• Ana Orozco 1 , 2 ,
• Alexander Thomas 1 ,
• Michelle Raggatt 1 , 2 ,
• Nick Scott 1 ,
• Sarah Eddy 1 ,
• Caitlin Douglass 1 , 3 ,
• Cassandra J. C. Wright 1 , 4 , 5 ,
• Tim Spelman 1 &
• Megan S. C. Lim 1 , 2 , 3  

Archives of Public Health volume  82 , Article number:  166 ( 2024 ) Cite this article

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Metrics details

Studies have shown that the coronavirus (COVID-19) pandemic negatively impacted the mental health of young Australians. However, there is limited longitudinal research exploring how individual factors and COVID-19 related public-health restrictions influenced mental health in young people over the acute phase of the COVID-19 pandemic. This study aimed to identify risk and protective factors associated with changes in individual symptoms of anxiety and depression among young Australians during the COVID-19 pandemic.

This prospective cohort study collected data on anxiety and depression symptoms of young Australians aged 15–29 years old using the Depression, Anxiety and Stress Scale short form (DASS-21). We delivered four online questionnaires from April 2020 to August 2021 at intervals of 3, 6, and 12 months after the initial survey. We implemented linear mixed-effects regression models to determine the association among demographic, socioeconomic, lifestyle and COVID–19 public health restrictions related factors and the severity of anxiety and depression symptoms over time.

Analyses included 1936 young Australians eligible at baseline. There was a slight increase in DASS-21 anxiety mean scores from timepoint 3 to timepoint 4. DASS-21 depression scores showed slight fluctuations across timepoints with the highest mean score observed in timepoint 2. Factors associated with increases in anxiety and depression severity symptoms included LGBTQIA + identity, financial insecurity both before and during the pandemic, higher levels of loneliness, withdrawal or deferral of studies, spending more time on social media, and difficulties to sleep. Risk factors for only depression symptoms include unemployment during COVID-19 pandemic and being in lockdown. Living with someone was a protective factor for both anxiety and depression symptoms, pre-COVID-19 unemployment for depression symptoms, and older age and unemployment during the pandemic for anxiety symptoms.

These findings indicate that during the first year of the pandemic in Australia, there were significant changes in young people’s mental health which were associated with multiple demographic, socioeconomic, lifestyle, and lockdown factors. Hence, in future public health crises, we suggest more inclusive guidelines that involve young people in their development and implementation ensuring that their unique perspectives and needs are adequately considered.

Peer Review reports

Introduction

Globally, the experience of the coronavirus (COVID-19) pandemic and related public health restrictions has been associated with adverse mental health outcomes [ 1 , 2 , 3 , 4 , 5 , 6 , 7 ]. In Australia, mental health was already a leading concern for young people prior to the pandemic [ 8 ]. National data show that young Australians were disproportionately impacted by COVID-19 stressors including disruptions to employment and education [ 9 , 10 ]. These stressors were further compounded by reduced social support [ 10 ].

Multiple systematic reviews of global cross-sectional and longitudinal studies [ 7 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ] have reported either high prevalence or significant increases in anxiety and depression symptoms in adolescents and young adults during the pandemic [ 22 , 23 , 24 , 25 , 26 ], with younger people more affected than older generations [ 27 ]. Some studies have found that this relationship varies based on demographic, behavioural, and social factors. Cross-sectional studies have found that young people, especially females [ 13 , 20 , 22 , 28 , 29 ], nonbinary people [ 5 , 21 ], and LGBTQIA + people [ 30 , 31 ], experienced higher anxiety, and depression symptoms. Additional risk factors contributing to these symptoms included living alone or with parents [ 13 , 16 ] [ 30 ], unemployment [ 32 ], financial insecurity [ 13 ], disruptions in education [ 19 ], lower education [ 22 , 30 , 33 ], extensive screen or internet use [ 7 , 17 ], levels of loneliness [ 16 ], sleep disturbances [ 19 , 29 ], and COVID-19-related factors like perceived risk [ 11 ], diagnosis or suspected infection [ 17 ], and mandatory quarantine [ 7 , 11 ]. Equally, protective factors identified among youth and adult samples included higher level of education, financial security, being in a relationship [ 34 ], physical activity [ 35 ], and routine [ 24 ].

Some longitudinal and repeated cross-sectional research has also been conducted in adolescent and adult populations to identify correlates of changes in anxiety and depression. Female gender [ 25 ], disruptions in education [ 36 ] increased social media use or consumption of COVID-19 media [ 24 ] and stricter lockdown mandates [ 37 ] were identified as increasing risk, while feeling socially connected was identified as protective. Despite substantial research on longitudinal factors associated with depression and anxiety during the pandemic, inconsistencies have been reported across studies [ 26 ]. Additionally, few studies to date have specifically focused on both adolescents and young adults. This age group represents a key population of interest, considering the substantial disruptions to psychosocial development during the pandemic [ 38 ].

Australia’s experience of the COVID-19 pandemic contrasted from many other countries, with strong public health restrictions translating to low case numbers in 2020 [ 39 ]. Moreover, the severity of restrictions and number of COVID-19 cases differed substantially between Australian states in 2020 and 2021. For instance, Victoria (VIC) and New South Wales (NSW) experienced multiple prolonged lockdowns in 2020 and 2021 compared to the other states that did not experience major disruptions to daily life [ 40 ]. While Meyer et al. (2023) [ 41 ] reported no significant difference in mental health (as measured by the DASS-21) between young people aged 16–24 living in Victoria and Queensland (QLD) during mid-2021, other global studies have emphasised greater negative mental health impacts of stricter lockdowns [ 37 , 42 ]. Considering these mixed findings, further comparison of mental health impacts between jurisdictions throughout the pandemic is warranted.

Research in Australia identified notably elevated levels of anxiety and depression symptoms during the COVID-19 pandemic. Comparison with pre-pandemic Australian national mental health data is limited, as the last version available before the pandemic was published in 2007, and the most recent data is from during the pandemic (2020–2022) [ 43 ]. However, compared to other international community-based samples of adults studied before 2020 [ 44 , 45 ], anxiety and depression levels in Australia were significantly high, particularly on younger people [ 5 , 44 , 46 ]. An online survey in June 2020 with a sample of 760 Australian adolescents (aged 12–18 years) showed that 48% presented psychological distress scores above the threshold indicative of mental illness [ 46 ]. A longitudinal cohort study with young Australian adults (mean age 22 years) reported a significant increase in young people’s anxiety and depression mean scores from August 2019 (pre-pandemic) to May–June 2020 (during the pandemic) [ 15 ]. Mean scores provide an idea of the average impact on the population’s anxiety and depression symptoms. However, by using measurements that acknowledge individual effects, additional and more precise insights can be learned about the impact within individuals. This will allow for further exploration of individual-level factors associated with changes in anxiety and depression symptoms during the pandemic, as supported by Witteveen et al. (2023) [ 26 ].

This prospective cohort study aimed to investigate risk and protective factors associated with changes in the severity of anxiety and depression symptoms in young people in Australia during the COVID-19 pandemic (April 2020 to August 2021).

Study design and participants

This quantitative prospective cohort study recruited 2006 Australian residents aged 15–29 years to complete a baseline and three follow-up surveys over a 12-month period (see Fig.  1 ). This study used quota sampling to ensure minimum representation of gender, age groups and state and territories proportional to population size [ 47 ]. Quotas for states and territories were determined by the target population's demographics. Age and gender quotas allocated around 300 positions for each age-gender group along with an additional 200 slots for participants in any other category in case a group exceeds its quota, or participants identified as nonbinary gender or other genders.

Australian lockdown dates by state and recruitment period for young people at data collection timepoints 1–4. Note: Australian states and territories: Victoria (VIC), New South Wales (NSW), Queensland (QLD), South Australia (SA), West Australia (WA), Tasmania (TAS), Northern Territory (NT) and Australian Capital Territory (ACT). Timepoint 1 refers to baseline survey when participants were recruited, and timepoint 2,3,4 to follow up surveys

Recruitment and follow up

Participants were recruited via a market research panel Pure Profile [ 48 ] and paid social media advertising including Facebook, Instagram, Reddit, and Twitter. People recruited via social media entered a draw to receive one of five $50 vouchers per completed survey starting from the first survey. Pure Profile participants were reimbursed $3.80 for their first survey. For subsequent surveys, Pure Profile participants were entered in the draw to win $50. Participants aged 15–17 years were required to complete a mature minor comprehension form to confirm capacity to provide informed consent. Refer to Fig.  1 for recruitment periods alongside Australian lockdown dates per state.

Data collection and questionnaire

The online survey included demographic (gender, age, sexual identity, Aboriginal or Torres Strait Islander status, relationship status), socioeconomic (living in a bushfire affected postcode, residential status, living situation, education level, employment and student status, financial security), lifestyle (social media usage, sleeping problems), and mental health (anxiety, depression, loneliness) questions. The survey was hosted on REDCap [ 49 ].

Outcome variables

The primary outcomes of this study were the severity of anxiety symptoms and depression symptoms over the observed period. Severity of symptoms was measured using the validated and reliable short form of the Depression, Anxiety, and Stress Scale (DASS-21). [ 50 ]. The DASS-21 scores measure the continuum of severity of the core symptoms of depression, anxiety and stress; it is not intended as an anxiety and depression diagnostic tool [ 51 ]. The DASS-21 has three subscales with 21 items in total. Each item is rated on a 4-point scale from 0 "Did not apply to me at all" to 3 "Applied to me very much, or most of the time". Item scores were summed to produce subtotal scores for each subscale (7 items per subscale) and multiplied by 2, ranging from 0 to 42 points. Higher scores indicate more severe mental health symptoms.

This study focuses on the depression and anxiety subscales of the DASS-21 (i.e., 14 out of 21 items), due to their strong validity and reliability in adults [ 50 ]. The DASS-21 stress scale was excluded due to concerns about its inconsistent performance and validity, particularly in adolescent populations and in longitudinal studies [ 51 , 52 , 53 ]. In accordance with DASS guidelines [ 51 ] and Laranjeira et al. (2023) [ 54 ], participants at each time point with up to one missing item per subscale ( n  = 70) had the missing item replaced with the calculated mean score from the 6 remaining subscale items. Participants with more than one missing item per subscale were excluded from analysis ( n  = 33, 1.7%) (37).

Independent variables – potential risk and protective factors

Relevant variables were classified as either static or time-varying variables. Static variables included variables at baseline such as gender (female, male, non-binary), age group (15–19, 20–24, and 25–29 years), bushfire affected postcode (no, yes), LGBTQIA + (no, yes, missing), residential status in Australia (citizen, permanent resident, other temporary visa), Aboriginal or Torres Strait Islander (no, yes), highest completed or enrolled level of education (high school, tertiary education, missing or I don’t know), work status before the pandemic (full-time, part-time, casual, unemployed, other), financial security before the pandemic (financially secure, financially insecure), recruitment approach (research market panel, social media), and loneliness (mild loneliness or lower, moderate loneliness or higher, missing data). Time-varying variables were updated at each data collection point, including baseline and follow-up surveys, such as hours spent on social media per day, living situation (alone, parents, partner, friends/roommates, other), in a relationship (no, yes, prefer not to say), student status (not a current student, going to school/university/class in person, studying, by distance/online, deferred/withdrawn/dropped studies), current work status (full-time, part-time, casual, unemployed, other), financial security when taking the survey (financially secure, financially insecure), in lockdown (no, yes), days per week having trouble to sleep (zero to two days per week, over two days per week, missing).

A “lockdown” variable was generated to reflect stay-at-home orders for each Australian State between 2020 and 2021, see specific dates in Fig.  1 . Participants were coded as being in lockdown if their corresponding state was under stay-at-home orders when the participant completed each survey. Dates were collected from the state premier media announcements [ 40 ], confirmed against online news and compared against the Oxford Covid-19 Government Response Tracker (OxCGRT) database [ 55 ]. Loneliness was measured with the UCLA loneliness scale short form (ULS -6) [ 56 ]. This scale contains six questions with a score range from 6 to 24 points, where higher scores are indicative of higher levels of loneliness. We created a "bushfire" variable by identifying Australian postcodes impacted during the severe and uncontrolled bushfire season that Australia endured from September 2019 to March 2020, see specific dates in Additional file 1 [ 57 ].

Statistical analysis

To describe and summarise the data collected we used frequencies, percentages, and mean values. We used boxplots to compare DASS- 21 anxiety and depression scores over the observation period for those not in lockdown and in lockdown, showing distribution differences.

To investigate risk and protective factors associated with changes in mental health symptoms, and account for the repeated measures within participants, we analysed DASS-21 anxiety and depression scores using mixed-effects models (Estimation method: Maximum likelihood, Fixed effects: predictors in Table  1 , Random effect: Participant ID).We used two linear mixed-effects regression models fitted separately for 1) anxiety and 2) depression scores. Assumptions for both mixed-effects models were met including linearity, homoscedasticity, and normality of residuals. Random effects were checked for normality and independence, with no violations detected. Covariates were selected for inclusion in each model by applying backwards stepwise selection where only those with a p -value less than 0.20 were selected in the final model. Participant ID was included as the random effect to account for within-subject variability and to control for the repeated measures structure of the data. This random effect served as a proxy for time, capturing the underlying temporal structure associated with each participant's repeated measures. Each model allowed estimate the associations among changes in individuals’ anxiety and depression scores and both static and time-varying variables over the observation period. Mixed-effects models allow the inclusion of both static and time-varying predictors; uneven assessment intervals and differing number of time points across participants [ 58 ].

For all analyses, p  < 0.05 was considered significant. All analyses were undertaken using Stata Statistical Software version 15 by StataCorp USA, Texas [ 59 ].

Sensitivity analysis

Because of differential loss to follow-up between recruitment methods (market research panel, social media), sensitivity analyses were used to investigate whether the recruitment type influenced DASS-21 anxiety and depression outcomes. Linear mixed-effects regression models similar to the primary models were used, separated by the two recruitment methods (see Additional file 2 ) and by states Victoria vs other states (see Additional file 3 ). Characteristics of participants who were more likely to remain in the study were analysed using a Chi-squared test. Additionally, we used two logistic regressions to investigate if baseline mental health scores ( n  = 1936) influenced participants continuation in the study, using continuation (yes/no) as the outcome variable and anxiety and depression as predictors in their respective models (See Additional file 4 ).

Ethics approval

Ethical approval for the project number 190/20 was granted by the Alfred Health Ethics Committee on 08 April 2020.

Participant characteristics

A total of 2006 participants completed the baseline survey. Of these, 1936 were eligible to be included in the baseline analysis (e.g., met age criteria and completed at least 6 items of each DASS-21 anxiety and depression subscales). A total of 518 (27%) completed timepoint 2, 470 (24%) completed timepoint 3, and 397 (21%) completed timepoint 4. In total, 219 participants (11%) completed all four surveys.

At baseline, most participants were recruited from the market research panel (58%). The attrition rate from timepoints 1 to 4, was 62% for social media and 92% for panel participants. Chi-squared tests showed that participants more likely to remain in the study were female (71% vs 58% at baseline, p  < 0.01), aged 15 to 19 years (33% vs 27% at baseline, p  < 0.001), living in Victoria (48% vs 36% at baseline, p  < 0.001), recruited through social media (75% vs 42% at baseline, p  < 0.001), living with parents (51% vs 46% at baseline, p  < 0.001), and had completed tertiary education (65% vs 69% at baseline, p  < 0.001).

Table 1 summarises the cohort’s main demographic, socioeconomic and lifestyle characteristics at baseline. Table 2 summarises the time-varying characteristics of the cohort including changes from timepoint 1 to timepoint 4.

Changes in time-varying variables from the start of April 2020

Almost half of the sample (48%, n  = 931) changed their employment status at least once during the observation period. There was an observed decrease in proportions of unemployment and an increase in full-time and casual work from timepoint 1 to timepoint 4. Part-time employment remained relatively stable over the observation period while ‘other’ employment categories declined (See Additional file 5 ).

Table 2 shows a 0.3 increase in DASS-21 anxiety mean scores from timepoint 3 (October 2020 – March 2021) to timepoint 4 (April 2021 – August 2021). Meanwhile, DASS-21 depression scores showed slight fluctuations across timepoints with the highest mean score observed in July to December 2020 (timepoint 2). This timepoint coincides with the longest lockdown in 2020 in Victoria as well as shorter lockdowns in South Australia and New South Wales (as shown in Fig.  1 ). By timepoint 3, rather than longer lockdowns, multiple short lockdowns were in place across multiple states, including Victoria, New South Wales, Queensland, South Australia, and Western Australia.

Anxiety and depression symptoms by lockdown from April 2020 –August 2021

Figure  2 shows slight changes with high variability in anxiety and depression scores over the observation period. A slight increase in both scores is observed for those in lockdown between October 2020 and March 2021 (Timepoint 3).

Young people’s DASS-21 anxiety and depression scores by lockdown status at each timepoint in Australia

Static and time-varying factors associated with changes in the severity of anxiety and depression symptoms

Table 3 shows static and time-varying factors associated with changes in anxiety and depression scores identified in the linear mixed-effects regression models.

Static factors

Identifying as non-binary gender, LGBTQIA + or Aboriginal or Torres Strait Islander, experiencing financial insecurity before the pandemic, and experiencing moderate to severe feelings of loneliness at baseline were associated with increased anxiety scores. Being aged 25–29 years compared to 15–19 and 20–24 was associated with a decrease in anxiety scores from timepoint 1 to 4.

Time-varying factors

Experiencing financial insecurity, spending more time on social media per day, being in a relationship, studying in person, having deferred, withdrawn, or dropped studies, and having sleeping problems two or more days per week were factors associated with increased anxiety scores. Transitioning between full-time employment and unemployment, and changes in living circumstances, including living with parents, a partner, friends, or roommates compared to living alone, contributed to lower anxiety scores.

Identifying as LGBTQIA + , experiencing financial insecurity before the pandemic, and experiencing moderate to severe feelings of loneliness at baseline were associated with increased depression scores. Being unemployed before the pandemic was associated with a decrease in depression scores when compared to being full-time employed before the pandemic.

Experiencing financial insecurity, spending more time on social media per day, having deferred, withdrawn, or dropped studies, transitioning between full-time employment and unemployment or holding an alternative job type, being in lockdown, and reporting sleeping problems over two days per week were factors associated with increased depression scores. Compared to living alone, transitioning to living with parents or a partner was associated to a decrease in depression scores over time.

The mixed-effect regression models adjusting for recruitment type (See Additional file 2 ), yielded similar results to primary analysis, with some slight differences. In the Pure Profile sample, a significant increase in anxiety scores was observed only among those aged 20–24 and who were under lockdown, while student status and employment status were no longer significant compared to primary analysis. In the social media cohort, residency status became significant, with permanent residents showing increased anxiety scores. Additionally, changes in depression scores differed in the social media cohort, with females and those with higher education showing significant effects, whereas living alone was no longer significant. After adjusting for states (VIC vs. others), many results shifted to non-significance. This may be because 70% of those in lockdown were from Victoria, explaining the non-significant lockdown effect in other states. Additionally, bushfire effects became significant in the VIC model, though only 3 participants from Victoria were affected compared to 127 in NSW. Additionally, the two logistic regressions assessing whether dropout rates were associated with DASS-21 baseline scores showed no significant differences in mental health between those who dropped out of the study and those who continued (see Additional file 4 ).

We conducted longitudinal analyses to investigate factors associated with changes in the severity of anxiety and depression symptoms among young people living in Australia amidst the COVID-19 pandemic from April 2020 to August 2021.Compared to a study conducted with young Australians aged 18–24 during April 2020, DASS-21 anxiety and depression mean scores were similar to those without a mental health diagnosis and were lower than those with an existing mental health diagnosis [ 34 ]. Our findings showed significant variability in anxiety and depression severity symptoms between participants.

Longitudinal analyses identified several key risk factors associated with increases in anxiety and depression symptoms including LGBTQIA + identity, financial insecurity both before and during the pandemic, higher levels of loneliness, withdrawal or deferral of studies, spending more time on social media, and difficulties to sleep. Risk factors for only depression symptoms include unemployment during COVID-19 pandemic and being in lockdown. The study also identified several protective factors including pre-COVID-19 unemployment associated with a decrease in depression symptoms, while older age, unemployment during the pandemic, and living with someone were all associated with reduced anxiety symptoms. Some of these factors are common risk factors for higher levels of mental health symptoms identified before COVID-19 [ 2 , 60 ]. However, these findings suggest that these factors may also impact the longitudinal course of symptoms, contributing to either their improvement or exacerbation over time. These findings suggest the need for interventions to support the mental health of young Australians during the recovery from the COVID-19 pandemic and in preparation for future pandemics.

This research reveals significant changes in anxiety and depression symptom severity among young Australians at the individual level, even though the mean scores remained relatively stable across four distinct time points. This divergence in individual experiences underscores the significant role of longitudinal data in identifying factors linked to shifts in DASS-21 anxiety and depression scores.

Our results are consistent with other longitudinal studies conducted globally and in Australia that indicated a rise in anxiety and/or depression symptoms in young people during the COVID-19 pandemic [ 15 , 17 , 20 , 21 ]. However, our research also highlights the critical role of individual differences and factors in shaping young people’s psychological response to the pandemic and related disruptions.

This study’s findings align with literature indicating that various factors were associated with higher levels of anxiety and/or depression among young people, including being aged 18–24 years [ 17 , 25 , 34 ], identifying as LGBTQIA + [ 30 , 31 ], identifying as nonbinary [ 5 , 21 ] increased social media use [ 24 ] and having sleep problems [ 15 ]. We did not find any evidence to support an association between the primary outcomes and living in an area recently affected by bushfires [ 44 ]. Our results contribute to existing research by highlighting longitudinal factors influencing the mental health of young people aged 15 to 29 in Australia during the COVID-19 pandemic.

This study found that Aboriginal and Torres Strait Islander youth were more likely than other young people to experience a significant increase in the severity of anxiety symptoms over time. This is not surprising, given that prior to the COVID-19 pandemic, Aboriginal and Torres Strait Islander adolescents reported significantly higher rates of psychological distress and depression when compared to non-Indigenous adolescents [ 61 ]. We recognise that past and present personal, family and community experiences of trauma (driven by the effects of colonisation) underpin these statistics [ 61 ] and that during the COVID-19 pandemic limited access to culturally sensitive and safe mental health services to meet their needs is likely to have contributed to this increase [ 62 ]. Additionally to this Aboriginal and Torres strait Islander young people anxiety symptomology may not be measured accurately by the DASS-21, given that anxiety sits within a holistic experience of wellbeing for many Aboriginal and Torres Strait Islander youth [ 63 ]. To appropriately interpret these results, we recommend a self-determined response that is developed and led by Aboriginal and Torres Strait Islander communities with participation from Aboriginal and Torres Strait Islander young people to understand the adequacy and what underpins these statistics.

Demographic correlates

Our study conflicts with previous literature [ 13 , 20 , 28 , 29 ] that identified being female as a significant risk factor for anxiety and depression symptoms worsening. We found that being female was not a significant predictor of the impact of the COVID-19 pandemic on the mental health of young adults in our sample. These results indicate that, irrespective of their initial mental health status, males and females encountered comparable levels of mental health changes during the pandemic. However, non-binary people were more prone to experience worsening anxiety symptoms over the observation period, in line with existing literature [ 5 , 21 ].

Additionally, our research found that participants who transitioned between full-time employment and unemployment, self-employment, caregiving roles, or gig work during the observation period, were more likely to experience worsening depression symptoms over time. This may be due to increased financial burden or loss of some benefits of employment such as identity and purposeful used of time [ 64 ]. Conversely, participants who experienced changes in employment status, such as transitioning between full-time employment and unemployment, were less likely to experience worsening anxiety symptoms. This may be attributable to Australian government financial support programs mitigating some of the stress associated with unemployment. Nonetheless, financial insecurity was identified as a risk factor for worsening anxiety and depression symptoms among young people in our sample despite the extension of government financial support programs [ 65 ]. This may be due to not all young people meeting the criteria for accessing government financial support.

Lockdown correlates

Our study findings indicate that young people who were in lockdown during the observation period experienced an increase in the severity of depression symptoms. This aligns with the findings of a systematic review in which depressive symptoms but not anxiety symptoms were higher during periods of social restrictions [ 1 , 26 ]. Our findings support previous research, which showed that young Australians (18–24 years old) living with their parents or partners were less likely to experience severe psychological distress than those living alone [ 13 , 16 ]. Lockdown restrictions may not have impacted on anxiety in the same way. Considering the different facets of anxiety, a reduction in socialisation may have led to a decrease in social anxiety, while social distancing may have reduced fear about the risk of COVID-19 infection [ 37 ]. The high levels of loneliness reported in our study are concerning as loneliness is a risk factor for anxiety and depression disorders and suicidal ideation [ 66 ]. To address this issue, we recommend implementing more inclusive public health restrictions. The restrictions in 2020–2021 often catered to normative family and relationship structures, neglecting the needs of individuals who live alone or do not conform to these structures. We suggest consulting with those living alone or in non-heteronormative relationships to generate ideas on how to make more inclusive public health guidelines.

Limitations

This study had some limitations. The use of a non-probability sampling method and a high attrition rate may constrain the generalisability of the findings. While sensitivity analyses suggest that findings remain comprehensive across different recruitment methods (e.g., social media and research market panels), future studies should attempt to recruit a more representative sample and investigate ways to improve retention. The high attrition rate among panel participants may have been influenced by the change in reimbursement methods for Pure Profile participants following survey 1, potentially impacting their motivation to continue participating [ 67 ]. If resourced sufficiently, researchers could consider contacting participants via phone or text message to keep them informed of the project’s progress and provide an alternative method to complete the survey such as a phone interview [ 68 ]. This approach could potentially enhance participant retention rates and improve the study's overall representativeness. This said, there are considerable logistical challenges in implementing a longitudinal study when a pandemic begins, including securing funding that allow for more intensive contact. Further, it is understandable that retention is constrained during times of widespread hardship and uncertainty.

This study was unable to assess some potential risk factors for anxiety and depression symptoms such as history of mental illness or perceived risk of COVID-19 infection or actual infection. Previous research has shown, young individuals diagnosed or suspected of being infected with COVID-19 and people with pre-existing mental illness have reported higher anxiety and depression scores [ 17 , 21 , 34 ].

Because it was implemented in response to the pandemic, this study lacked pre-pandemic baseline measures. All study data related to pre-pandemic experiences is based on participants’ recall. Furthermore, the most recent publicly accessible national mental health data concerning Australian youth, prior to the 2020 pandemic, dates back to 2007 [ 69 ]. As such, data may not capture all relevant factors or situations. Another limitation is not performing imputation for missing data as part of the sensitivity analysis, considering the exploratory nature of the study and the risk of introducing additional assumptions and potential bias. As a result, the findings should be interpreted with caution. Additionally, it is worth considering that the reliability of the DASS-21 scale for people under 17 is ambiguous [ 70 , 71 , 72 ], indicating the need for a different scale with higher reliability for young people in this age group such as DASS-Y developed in 2022 [ 73 ].

Moreover, this study did not disaggregate the direction of the associations found between various factors and anxiety and depression symptoms nor reported their temporal and causal structure. For instance, the association between change in employment and change in anxiety scores could be due to a combination of factors, such as people who become employed reporting decreased anxiety scores and people who become unemployed reporting increased anxiety scores. While specifying these correlations would provide more detailed information, it could also spread the data more sparsely, limiting statistical power and potentially reducing the study's ability to draw meaningful conclusions. Therefore, future studies could benefit from exploring the direction and causal structure of associations more thoroughly, while also considering the potential impact on statistical power. Lastly, to clearly differentiate between short-term fluctuations from more stable changes in symptom severity, further investigation is warranted. One alternative could be to incorporate daily or weekly tracking of symptoms.

This study benefited from a unique opportunity to explore the effects of prolonged lockdowns on anxiety and depression symptoms among young Australians. This was possible because participants' lockdown status after the first Australian national lockdown on March 30 varied by state, allowing for a natural experiment. This study also provides an understanding of what could exacerbate or mitigate young people’s mental health issues during public health emergencies. This dual focus could guide interventions to enhance protective factors and mitigate risks. Taken together, these findings advance our understanding of the complex interplay between the pandemic, public health policies, and mental health outcomes.

Implications for policy and practice

Public health strategies to protect mental health should target groups most vulnerable to the pandemic's impact to reduce anxiety and depression symptoms during the COVID-19 pandemic recovery. Additionally, it is crucial to attain a deeper understanding of the factors associated with improved mental health symptoms during such crises to inform prevention and support initiatives.

Our study reinforced the importance of employment and education as a protective factor for young people’s mental health [ 74 ], including during pandemics. In the ongoing response and recovery efforts during the COVID-19 pandemic, it remains imperative to prioritise providing young people with more accessible training to cultivate transferable skills, creating stable employment opportunities, and upholding existing jobs. To mitigate mental health risks among young people, it is also vital to target financial support programs at those facing financial hardship, regardless of their employment status. Expanding eligibility criteria to encompass financially vulnerable young individuals can furnish essential support to this demographic, potentially fostering positive impacts on their mental well-being.

Adding to existing work, our cohort study reveals significant shifts in the mental health of young Australians during the COVID-19 pandemic from 2020 to 2021. We found young people who are younger, LGBTQIA + , non-binary gender, experiencing financial insecurity, facing lockdowns, dealing with unstable employment, enduring loneliness, spending more time on social media, and living alone tended to experience worsened mental health. This highlights the necessity for targeted interventions and ongoing support for these subgroups. To enhance future pandemic and public health crises responses, we suggest more inclusive guidelines that involve young people in their development and implementation ensuring that their unique perspectives and needs are adequately considered. Finally, future longitudinal studies should implement strategies to decrease attrition among young people. Such studies would help identify the critical time periods when young people are most at risk and provide deeper insights into their evolving health needs during public health crises and their recovery.

Availability of data and materials

The data that support this study will be shared upon reasonable request to the corresponding author.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Research Electronic Data Capture

Lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual

Coronavirus disease 2019

United States of America

New South Wales

West Australia

South Australia

Northern Territory

Australian Capital Territory

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Acknowledgements

The authors thank all the young Australians who participated in the surveys. Authors would also like to thank Dr Shelley Walker for her advice.

This study was funded by the Victorian Health Promotion Foundation, Melbourne.

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Ana Orozco, Alexander Thomas, Michelle Raggatt, Nick Scott, Sarah Eddy, Caitlin Douglass, Cassandra J. C. Wright, Tim Spelman & Megan S. C. Lim

Monash School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

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Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia

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All authors have contributed to the manuscript. ML, MR, CD, AT, and CW designed and delivered the study. SE and AO prepared, cleaned and managed the data. AO, AT, NS and TS conducted analyses. AO drafted the manuscript and prepared all figures and tables. All authors read, reviewed, and approved the final manuscript.

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Orozco, A., Thomas, A., Raggatt, M. et al. Coping with COVID-19: a prospective cohort study on young Australians' anxiety and depression symptoms from 2020–2021. Arch Public Health 82 , 166 (2024). https://doi.org/10.1186/s13690-024-01397-z

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