COVID-19-associated psychiatric disorders

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Anahita Deylamsalehi, M.D.[2]

Synonyms and keywords: COVID-19-associated psychiatric disorders

## Overview

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In November 2019, the new coronavirus (COVID-19) was detected in Wuhan in the Hubei state of China for the first time. By April 2020, stay-at-home advisories, or shelter-in-place policies were applied in 42 states of the United States affecting approximately 96% of the US population. Based on multiple studies done in early 2020, the number of internet searches for mental health symptoms have significantly increased and more people requested mental health services. Major depressive disorder, post-traumatic stress disorder, anxiety, ADHD, mood swing, panic disorder, and psychosis were among numerous COVID-19-associated mental disorders that have been reported. The pathophysiology of COVID-19-associated psychiatric disorders can be explained by the body's immunologic response to the virus or due to the psychological stressors such as isolation, loneliness, stigma, concerns about infecting others, and fear of death. COVID-19-associated psychiatric disorders must be differentiated from other diseases that cause sleep disorder, loss of appetite, altered mentation, agitation, and decreased energy. The prevalence of depression has more than doubled during the COVID-19 pandemic and the younger population were more vulnerable to develop psychiatric disorders during the COVID-19 pandemic. Furthermore, studies reported that females are more commonly affected with COVID-19-related mental disorders than males. Ethnic and racial minorities were related to a higher rate of mental health difficulties during the COVID-19 pandemic. Having low income, being single, certain occupations such as medical workers and past medical history of mental or chronic underlying medical illness are some of the reported risk factors of COVID-19-associated psychiatric disorders. The clinical presentations are strongly related to the type of the COVID-19-associated mental disorder. Appropriate treatment of the underlying COVID-19 infection is essential to address the inflammatory process due to the infection and also the fears of the patients. Moreover, standard treatments for each psychiatric disorder must be considered to control the symptoms.

## Historical Perspective

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* In November 2019, the new coronavirus (COVID-19) was detected in Wuhan in the Hubei state of China for the first time.[1]
* By April 2020, stay-at-home advisories, or shelter-in-place policies have been applied in 42 states of the United States affecting no less than 316 million people (close to 96% of the US population).[2]
* Based on multiple studies done in early 2020, the number of internet searches for mental health symptoms had significantly increased. Furthermore, from the start of the pandemic, more people requested mental health services.[3]

## Classification

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The following are COVID-19-associated mental disorders that have been reported:[4][5][6][7][8][9][10][11][12][13][14][15][16]

* Depression
* Post-traumatic stress disorder
* Acute stress disorder
* Anxiety
* Somatization
* Mood swing
* Attention-deficit hyperactivity disorder (ADHD)
* Panic disorder
* Obsessive-compulsive disorder
* Psychosis
* Delirium
* Mania
* Catatonia
* Insomnia

## Pathophysiology

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The pathophysiology of COVID-19-associated psychiatric disorders can be explained by the body's immunologic response to the virus or due to the psychological stressors such as isolation, loneliness, stigma, concerns about infecting others, and fear of death.

### Immunologic Response To the Virus

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* Respiratory viral diseases are associated with psychological disorders, which can be presented both acutely and chronically.[5]
* The coronavirus is a neurotropic virus and can cause mental disorder by affecting the central nervous system or via the immune system response.[7][5][17][12]
* Some data supported the role of inflammatory biomarkers from an infection on development of depression's symptoms such as anhedonia.[18]

### Psychological Trauma

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* Data from previous studies delineated the increased rate of mental disorders following major traumatic events such as natural disasters and pandemics.[8][10]
* The unknown nature of the virus within the first months, the uncertainty of its transmission route, and the high rate of hospitalization and mortality led to serious concern and distress among individuals.[19][20]
* Disruption of the routine day-to-day life due to strict quarantine measures, closing of schools, and cancelling all social events was one of the important determinants.[8]
* The following concerns were associated with a higher rate of psychiatric disorders during the COVID-19 pandemic:[21][22]
* Fear of contracting the infection
* Fear of death due to the infection
* Misinformation regarding COVID-19
* Social distancing
* Economical difficulties
* The role of reduced physical activity, increased screen time, irregular sleep patterns, and lack of interpersonal contacts has been related to mental disorders among children and adolescents who experienced the quarantine.[20]

### Side Effects of COVID-19 Treatment

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Some of the medications used for COVID-19 treatment were known to cause neuropathic and neuropsychiatric side effects.[23][24]

* Ribavirin
* Interferon alpha
* Chloroquine
* Hydroxychloroquine

## Causes

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In November 2019, the new coronavirus (COVID-19) was detected in Wuhan in the Hubei state of China for the first time.[1] Over the course of a few months, COVID-19 quickly spread globally and turned into a worldwide pandemic. Data on September 1st, 2020 (less than eleven months after the pandemic onset) reported 28 million confirmed cases and over 900,000 deaths globally. The number of confirmed cases and deaths on the same date were 6.4 million and 19,000 in the United States, respectively.[25] The unknown nature of the virus within the first months, the uncertainty of its transmission route, and the high rate of hospitalization and mortality led to more concern and distress among individuals.[19] To control the infection, numerous policies and strict quarantine measures were applied in the United States and other countries; schools were closed, all social events were canceled, people were advised to stay at home and work from home if possible and wear face masks. By April 2020, stay-at-home advisories, or shelter-in-place policies have been applied in 42 states of the United States affecting no less than 316 million people (close to 96% of the US population).[2] As a result of the COVID-19 pandemic a chain of emotional issues developed among individuals, such as guilt, anxiety, loneliness, insomnia, stigma, helplessness, anger, despair, and fear.[26]

## Differentiating COVID-19-Associated Psychiatric Disorders from Other Diseases

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COVID-19-associated psychiatric disorders must be differentiated from other diseases that cause sleep disorder, loss of appetite, altered mentation, agitation and decreased energy, such as the followings:[27][28][29]

* The COVID-19 infection of the central nervous system such as encephalitis
* Substance/medication-induced depressive disorder
* Delirium
* Acute cerebrovascular disease due to COVID-19 infection such as cerebral hemorrhage

## Epidemiology and Demographics

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* Based on a large national study done in the United States, the prevalence of depression has more than doubled during the COVID-19 pandemic.[30]
* The prevalence of depression among adults older than 18 years old in the United States was estimated at 28.6%, only from April to May 2020. During this time, 8.4% of adults reported having suicidal ideation and 18.2% initiated or increased substance usage. Only three months later (September 2020) the rate of depression among American adults older than 18 years old raised to 33%, and the prevalence rate of suicidal ideation increased to 11.9% (Lee & Singh, 2021).[31]
* Based on some evidences, 0.9% to 4% of COVID-19 patients developed psychotic spectrum disorders.[14]

### Age

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* Patients of all age groups may develop mental disorder due to the COVID-19, nevertheless, younger population were more vulnerable to develop psychiatric disorders during the COVID-19 pandemic.[1][8][30][20][22]
* Based on a systematic review, mental disorder due to COVID-19 pandemic was higher in the age group of 21-40 years.[19]
* Another study which was done on 1,653 participants globally, suggested that the high rate of mental disorders among the younger population was related to poor sleep and loneliness of this population.[3]

### Gender

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* Females are more commonly affected with COVID-19-related mental disorders than male.[32][1][8][20][22]
* Supported by a study in Canada, young females are among the populations with a high prevalence of mental disorders during the pandemic.[26]

### Race

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* Ethnic and racial minorities were related to a higher rate of mental health difficulties during the COVID-19 pandemic. Based on a large national study, Hispanics and African Americans had the highest rate of Depression in the United States, compared to other races.[30]

## Risk Factors

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Common risk factors relating to COVID-19-associated psychiatric disorders:[26][1][31][25][8][33][34][6][35][20][36][37][21][38]

* Economic status
* Economic inequalities have been known as a risk factor for mood disorders, such as depression, and the COVID-19 pandemic exacerbated the economic issues of many people in the United States.[39]
* Marital status
* Being single (unmarried, living with parents, widow, or divorcee) is one of the factors associated with a higher rate of mental illnesses, such as depression, during the pandemic.
* Level of education
* Based on some studies, a higher level of education has been related to a higher rate of anxiety due to the COVID-19 pandemic.
* In contrast, other studies in the United States confirmed a significant association between lower education and a higher rate of mental disorders due to the COVID-19 pandemic.
* A systematic review delineated that being a student is a risk factor associated with mental disorders.
* Female gender
* Certain occupations such as medical workers
* Social media exposure
* Based on a study in China, more than two hours of exposure to COVID-19 news via social media was associated with a higher rate of depression.
* History of a chronic underlying medical illness[8]
* History of previous mental disorder[8][30]
* Sever pain during the COVID-19 pandemic
* Poor sleep
* Having a relative with COVID-19
* Prolonged hospitalization

## Natural History, Complications and Prognosis

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* The clinical presentations are strongly related to the type of the COVID-19-associated mental disorder.
* As a result of the COVID-19 pandemic the following chain of emotional issues developed among individuals:[26][8]
* Guilt
* Stress
* Loneliness
* Stigma
* Helplessness
* Anger
* Despair
* Fear of infecion
* Behaviors such as substance abuse (such as smoking, overconsumption of alcohol, and drug abuse) has been increased during the COVID-19 pandemic in the United States.[31][21]
* If left untreated, complications such as suicide can occur.[31][21][22][15]
* Presence of some mental disorders such as bipolar disorder, unipolar depression and schizophrenia spectrum disorders was associated with poorer outcomes in COVID-19 patients.[40]

### Diagnostic Criteria

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* Diagnosis can be made if a psychiatric disorder associated to the COVID-19; either in a COVID-19 patient, or in an individual who lived during the COVID-19 pandemic has been observed.

### History and Symptoms

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* Symptoms of the COVID-19-associated psychiatric disorders depends on the type of mental disorder, nevertheless the following are some of the general observed symptoms:[23][41][16]
* Anhedonia
* Sleep difficulty
* Reduced appetite
* Anxiety
* Lethargy
* Irritability
* Inattention

### Physical Examination

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* Patients with COVID-19-associated psychiatric disorders usually appear normal.

### Laboratory Findings

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* There are no specific laboratory findings associated with COVID-19-associated psychiatric disorders.

### Electrocardiogram

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There are no ECG findings associated with COVID-19-associated psychiatric disorders.

### X-ray

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There are no x-ray findings associated with COVID-19-associated psychiatric disorders.

### Echocardiography or Ultrasound

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There are no echocardiography/ultrasound findings associated with COVID-19-associated psychiatric disorders.

### CT scan

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There are no CT scan findings associated with COVID-19-associated psychiatric disorders.

### MRI

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There are no MRI findings associated with COVID-19-associated psychiatric disorders.

### Other Imaging Findings

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There are no other imaging findings associated with COVID-19-associated psychiatric disorders.

### Other Diagnostic Studies

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There are no other diagnostic studies associated with COVID-19-associated psychiatric disorders.

## Treatment

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### Medical Therapy

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* Appropriate treatment of the underlying COVID-19 infection is essential to address the inflammatory process due to the infection and also the fears of the patients.[42]
* Standard treatments for each psychiatric disorder also must be considered to control the symptoms. For instance, in a study on the COVID-19 associated psychosis, initiation of antipsychotics controlled the symptoms successfully.[42]

### Non-Medical Therapy

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#### Telepsychiatry

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* Usage of telepsychiatry to deliver psychiatric care during the COVID-19 pandemic may help the populations who are at risk.[37]
* The talk-based nature of most psychiatric therapies makes utilizing technological means more convenient during the quarantine.[37]
* In addition, this method of psychiatric care can be utilized for group therapy as well.
* A systematic review, reported that video teleconference groups and in-person groups were similar in their treatment outcomes.[43]
* Telepsychiatry is not feasible for certain cohorts of patients. The following may limit the use of telepsychiatry:[37]
* Not having access to internet, smartphone or computer
* Less technologically literate patients
* Old age
* Patients with diminished cognition

### Surgery

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* There is no surgical treatment for COVID-19-associated psychiatric disorders

### Prevention

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* Practiced by some countries, policies and interventions can help individuals to have a better mental health status during the COVID-19 pandemic. For instance Australia developed an initiative called "Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access)" in order to provide psychological therapy sessions for patients suffering from mental disorders.[21]
* Proposing guidelines to provide an overview regarding the COVID-19-associated psychiatric disorders for health care providers to improve their knowledge could also be helpful and has been practiced in some countries such as Singapore, India, China, and Malaysia.[21][44][45]
* Providing accurate and reliable information regarding the COVID-19 and demolishing false information by governments and public health authorities can reduce distress and may prevent the mental disorders related to COVID-19.[19]
* Assuring a proper supply of personal protective equipment, such as masks, and hand sanitizers to address the related concern of individuals during the pandemic.
* Utilizing electronic devices and applications by public health authorities can ensure online access to a medical provider and can secure individuals from the stresses related to the availability of medical help.[46]
* Since financial issues were introduced as one of the most important factors associated with a higher rate of depression during the COVID-19 pandemic, financial supports such as unemployment insurance (UI) may be able to prevent depression among the population at risk.[47]
* Governments and public health authorities can use text messages or computer-based interventions, telehealth services, and mass media campaigns to decrease the risk of mental disorders among the population at risk.[30]
* One of the protective factors for depression during the pandemic was to construct a daily routine, including regular exercises and appropriate sleep, which can be practiced individually.[3]

## References

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1. ↑ 1.0 1.1 1.2 1.3 1.4 Ustun G (2021). "Determining depression and related factors in a society affected by COVID-19 pandemic". Int J Soc Psychiatry. 67 (1): 54–63. doi:10.1177/0020764020938807. PMC 7331110 Check `|pmc=` value (help). PMID 32605422 Check `|pmid=` value (help).
2. ↑ 2.0 2.1 Ettman CK, Abdalla SM, Cohen GH, Sampson L, Vivier PM, Galea S (2020). "Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic". JAMA Netw Open. 3 (9): e2019686. doi:10.1001/jamanetworkopen.2020.19686. PMC 7489837 Check `|pmc=` value (help). PMID 32876685 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 3.2 Varma P, Junge M, Meaklim H, Jackson ML (2021). "Younger people are more vulnerable to stress, anxiety and depression during COVID-19 pandemic: A global cross-sectional survey". Prog Neuropsychopharmacol Biol Psychiatry. 109: 110236. doi:10.1016/j.pnpbp.2020.110236. PMC 7834119 Check `|pmc=` value (help). PMID 33373680 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
4. ↑ Halaris AE, Belendiuk KT, Freedman DX (1975). "Antidepressant drugs affect dopamine uptake". Biochem Pharmacol. 24 (20): 1896–7. doi:10.1016/0006-2952(75)90412-8. PMID psychiatric disorders COVID-19-associated psychiatric disorders Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
5. ↑ 5.0 5.1 5.2 Mazza MG, De Lorenzo R, Conte C, Poletti S, Vai B, Bollettini I; et al. (2020). "Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors". Brain Behav Immun. 89: 594–600. doi:10.1016/j.bbi.2020.07.037. PMC 7390748 Check `|pmc=` value (help). PMID 32738287 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
6. ↑ 6.0 6.1 de Sousa Moreira JL, Barbosa SMB, Vieira JG, Chaves NCB, Felix EBG, Feitosa PWG; et al. (2021). "The psychiatric and neuropsychiatric repercussions associated with severe infections of COVID-19 and other coronaviruses". Prog Neuropsychopharmacol Biol Psychiatry. 106: 110159. doi:10.1016/j.pnpbp.2020.110159. PMC 7605739 Check `|pmc=` value (help). PMID 33147504 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
7. ↑ 7.0 7.1 Steardo L, Steardo L, Verkhratsky A (2020). "Psychiatric face of COVID-19". Transl Psychiatry. 10 (1): 261. doi:10.1038/s41398-020-00949-5. PMC 7391235 Check `|pmc=` value (help). PMID 32732883 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L; et al. (2020). "Epidemiology of mental health problems in COVID-19: a review". F1000Res. 9: 636. doi:10.12688/f1000research.24457.1. PMC 7549174 Check `|pmc=` value (help). PMID 33093946 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
9. ↑ Smith CM, Komisar JR, Mourad A, Kincaid BR (2020). "COVID-19-associated brief psychotic disorder". BMJ Case Rep. 13 (8). doi:10.1136/bcr-2020-236940. PMC 7418683 Check `|pmc=` value (help). PMID 32784244 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
10. ↑ 10.0 10.1 Raudenská J, Steinerová V, Javůrková A, Urits I, Kaye AD, Viswanath O; et al. (2020). "Occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel coronavirus disease 2019 (COVID-19) pandemic". Best Pract Res Clin Anaesthesiol. 34 (3): 553–560. doi:10.1016/j.bpa.2020.07.008. PMC 7367798 Check `|pmc=` value (help). PMID 33004166 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
11. ↑ Horn M, Wathelet M, Fovet T, Amad A, Vuotto F, Faure K; et al. (2020). "Is COVID-19 Associated With Posttraumatic Stress Disorder?". J Clin Psychiatry. 82 (1). doi:10.4088/JCP.20m13641. PMID 33296149 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
12. ↑ 12.0 12.1 Uvais NA (2021). "COVID-19-Associated Panic Disorder". Prim Care Companion CNS Disord. 23 (1). doi:10.4088/PCC.20l02826. PMID 34000140 Check `|pmid=` value (help).
13. ↑ Richter K, Kellner S (2021). "["Coronasomnia"-promoting resilience through insomnia treatment]". Somnologie (Berl): 1–5. doi:10.1007/s11818-021-00322-8. PMC 8381348 Check `|pmc=` value (help). PMID 34456621 Check `|pmid=` value (help).
14. ↑ 14.0 14.1 Borovina T, Mastelić T, Glavina G, Glavina T (2021). "COVID-19 Associated Psychotic Disorder with Suicidal Behaviour - Case Report". Psychiatr Danub. 33 (3): 421–424. doi:10.24869/psyd.2021.421. PMID 34795193 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
15. ↑ 15.0 15.1 Ferrando SJ, Klepacz L, Lynch S, Shahar S, Dornbush R, Smiley A; et al. (2021). "Psychiatric emergencies during the height of the COVID-19 pandemic in the suburban New York City area". J Psychiatr Res. 136: 552–559. doi:10.1016/j.jpsychires.2020.10.029. PMC 7992036 Check `|pmc=` value (help). PMID 33158555 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
16. ↑ 16.0 16.1 Zhang WR, Wang K, Yin L, Zhao WF, Xue Q, Peng M; et al. (2020). "Mental Health and Psychosocial Problems of Medical Health Workers during the COVID-19 Epidemic in China". Psychother Psychosom. 89 (4): 242–250. doi:10.1159/000507639. PMC 7206349 Check `|pmc=` value (help). PMID 32272480 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
17. ↑ Wu Y, Xu X, Chen Z, Duan J, Hashimoto K, Yang L; et al. (2020). "Nervous system involvement after infection with COVID-19 and other coronaviruses". Brain Behav Immun. 87: 18–22. doi:10.1016/j.bbi.2020.03.031. PMC 7146689 Check `|pmc=` value (help). PMID 32240762 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
18. ↑ Miller AH, Raison CL (2016). "The role of inflammation in depression: from evolutionary imperative to modern treatment target". Nat Rev Immunol. 16 (1): 22–34. doi:10.1038/nri.2015.5. PMC 5542678. PMID 26711676.
19. ↑ 19.0 19.1 19.2 19.3 Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M; et al. (2020). "Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis". Global Health. 16 (1): 57. doi:10.1186/s12992-020-00589-w. PMC 7338126 Check `|pmc=` value (help). PMID 32631403 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
20. ↑ 20.0 20.1 20.2 20.3 20.4 Gilsbach S, Herpertz-Dahlmann B, Konrad K (2021). "Psychological Impact of the COVID-19 Pandemic on Children and Adolescents With and Without Mental Disorders". Front Public Health. 9: 679041. doi:10.3389/fpubh.2021.679041. PMC 8602182 Check `|pmc=` value (help). PMID 34805060 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
21. ↑ 21.0 21.1 21.2 21.3 21.4 21.5 Samy AL, Awang Bono S, Tan SL, Low WY (2021). "Mental Health and COVID-19: Policies, Guidelines, and Initiatives from the Asia-Pacific Region". Asia Pac J Public Health. 33 (8): 839–846. doi:10.1177/10105395211025901. PMID 34308673 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
22. ↑ 22.0 22.1 22.2 22.3 Rodríguez-Hidalgo AJ, Pantaleón Y, Dios I, Falla D (2020). "Fear of COVID-19, Stress, and Anxiety in University Undergraduate Students: A Predictive Model for Depression". Front Psychol. 11: 591797. doi:10.3389/fpsyg.2020.591797. PMC 7674167 Check `|pmc=` value (help). PMID 33224080 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
23. ↑ 23.0 23.1 Soltani S, Tabibzadeh A, Zakeri A, Zakeri AM, Latifi T, Shabani M; et al. (2021). "COVID-19 associated central nervous system manifestations, mental and neurological symptoms: a systematic review and meta-analysis". Rev Neurosci. 32 (3): 351–361. doi:10.1515/revneuro-2020-0108. PMID 33618441 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
24. ↑ Russo MW, Fried MW (2003). "Side effects of therapy for chronic hepatitis C." Gastroenterology. 124 (6): 1711–9. doi:10.1016/s0016-5085(03)00394-9. PMID 12761728.
25. ↑ 25.0 25.1 Firew T, Sano ED, Lee JW, Flores S, Lang K, Salman K; et al. (2020). "Protecting the front line: a cross-sectional survey analysis of the occupational factors contributing to healthcare workers' infection and psychological distress during the COVID-19 pandemic in the USA". BMJ Open. 10 (10): e042752. doi:10.1136/bmjopen-2020-042752. PMC 7580061 Check `|pmc=` value (help). PMID 33087382 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
26. ↑ 26.0 26.1 26.2 26.3 McQuaid RJ, Cox SML, Ogunlana A, Jaworska N (2021). "The burden of loneliness: Implications of the social determinants of health during COVID-19". Psychiatry Res. 296: 113648. doi:10.1016/j.psychres.2020.113648. PMID 33348199 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
27. ↑ Yang H, Chi Y, Chen Z, Fan Y, Wu H, Hu X; et al. (2020). "Differential Diagnosis and Hospital Emergency Management for Fastlane Treatment of Central Nervous System Infection Under the COVID-19 Epidemic in Changsha, China". Front Neurol. 11: 555202. doi:10.3389/fneur.2020.555202. PMC 7606862 Check `|pmc=` value (help). PMID 33192989 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
28. ↑ Panariello A, Bassetti R, Radice A, Rossotti R, Puoti M, Corradin M; et al. (2020). "Anti-NMDA receptor encephalitis in a psychiatric Covid-19 patient: A case report". Brain Behav Immun. 87: 179–181. doi:10.1016/j.bbi.2020.05.054. PMC 7255176 Check `|pmc=` value (help). PMID 32454137 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
29. ↑ Li J, Long X, Zhang Q, Fang X, Fang F, Lv X; et al. (2021). "Emerging Evidence for Neuropsycho-Consequences of COVID-19". Curr Neuropharmacol. 19 (1): 92–96. doi:10.2174/1570159X18666200507085335. PMC 7903490 Check `|pmc=` value (help). PMID 32379592 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
30. ↑ 30.0 30.1 30.2 30.3 30.4 Khubchandani J, Sharma S, Webb FJ, Wiblishauser MJ, Bowman SL (2021). "Post-lockdown depression and anxiety in the USA during the COVID-19 pandemic". J Public Health (Oxf). 43 (2): 246–253. doi:10.1093/pubmed/fdaa250. PMC 7928742 Check `|pmc=` value (help). PMID 33426559 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
31. ↑ 31.0 31.1 31.2 31.3 Lee H, Singh GK (2021). "Monthly trends in self-reported health status and depression by race/ethnicity and socioeconomic status during the COVID-19 Pandemic, United States, April 2020 - May 2021". Ann Epidemiol. 63: 52–62. doi:10.1016/j.annepidem.2021.07.014. PMC 8435379 Check `|pmc=` value (help). PMID 34358622 Check `|pmid=` value (help).
32. ↑ Moghanibashi-Mansourieh A (2020). "Assessing the anxiety level of Iranian general population during COVID-19 outbreak". Asian J Psychiatr. 51: 102076. doi:10.1016/j.ajp.2020.102076. PMC 7165107 Check `|pmc=` value (help). PMID 32334409 Check `|pmid=` value (help).
33. ↑ Kämpfen F, Kohler IV, Ciancio A, Bruine de Bruin W, Maurer J, Kohler HP (2020). "Predictors of mental health during the Covid-19 pandemic in the US: Role of economic concerns, health worries and social distancing". PLoS One. 15 (11): e0241895. doi:10.1371/journal.pone.0241895. PMC 7657497 Check `|pmc=` value (help). PMID 33175894 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
34. ↑ Ni MY, Yang L, Leung CMC, Li N, Yao XI, Wang Y; et al. (2020). "Mental Health, Risk Factors, and Social Media Use During the COVID-19 Epidemic and Cordon Sanitaire Among the Community and Health Professionals in Wuhan, China: Cross-Sectional Survey". JMIR Ment Health. 7 (5): e19009. doi:10.2196/19009. PMC 7219721 Check `|pmc=` value (help). PMID 32365044 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
35. ↑ Vindegaard N, Benros ME (2020). "COVID-19 pandemic and mental health consequences: Systematic review of the current evidence". Brain Behav Immun. 89: 531–542. doi:10.1016/j.bbi.2020.05.048. PMC 7260522 Check `|pmc=` value (help). PMID 32485289 Check `|pmid=` value (help).
36. ↑ Zhou SJ, Zhang LG, Wang LL, Guo ZC, Wang JQ, Chen JC; et al. (2020). "Prevalence and socio-demographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19". Eur Child Adolesc Psychiatry. 29 (6): 749–758. doi:10.1007/s00787-020-01541-4. PMC 7196181 Check `|pmc=` value (help). PMID 32363492 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
37. ↑ 37.0 37.1 37.2 37.3 O'Brien M, McNicholas F (2020). "The use of telepsychiatry during COVID-19 and beyond". Ir J Psychol Med. 37 (4): 250–255. doi:10.1017/ipm.2020.54. PMC 7411439 Check `|pmc=` value (help). PMID 32434596 Check `|pmid=` value (help).
38. ↑ Zhang C, Yang L, Liu S, Ma S, Wang Y, Cai Z; et al. (2020). "Survey of Insomnia and Related Social Psychological Factors Among Medical Staff Involved in the 2019 Novel Coronavirus Disease Outbreak". Front Psychiatry. 11: 306. doi:10.3389/fpsyt.2020.00306. PMC 7171048 Check `|pmc=` value (help). PMID 32346373 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
39. ↑ Kujawa A, Green H, Compas BE, Dickey L, Pegg S (2020). "Exposure to COVID-19 pandemic stress: Associations with depression and anxiety in emerging adults in the United States". Depress Anxiety. 37 (12): 1280–1288. doi:10.1002/da.23109. PMID 33169481 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
40. ↑ Barcella CA, Polcwiartek C, Mohr GH, Hodges G, Søndergaard K, Niels Bang C; et al. (2021). "Severe mental illness is associated with increased mortality and severe course of COVID-19". Acta Psychiatr Scand. 144 (1): 82–91. doi:10.1111/acps.13309. PMC 8250986 Check `|pmc=` value (help). PMID 33894064 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
41. ↑ Jiao WY, Wang LN, Liu J, Fang SF, Jiao FY, Pettoello-Mantovani M; et al. (2020). "Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic". J Pediatr. 221: 264–266.e1. doi:10.1016/j.jpeds.2020.03.013. PMC 7127630 Check `|pmc=` value (help). PMID 32248989 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
42. ↑ 42.0 42.1 Ferrando SJ, Klepacz L, Lynch S, Tavakkoli M, Dornbush R, Baharani R; et al. (2020). "COVID-19 Psychosis: A Potential New Neuropsychiatric Condition Triggered by Novel Coronavirus Infection and the Inflammatory Response?". Psychosomatics. 61 (5): 551–555. doi:10.1016/j.psym.2020.05.012. PMC 7236749 Check `|pmc=` value (help). PMID 32593479 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
43. ↑ Gentry MT, Lapid MI, Clark MM, Rummans TA (2019). "Evidence for telehealth group-based treatment: A systematic review". J Telemed Telecare. 25 (6): 327–342. doi:10.1177/1357633X18775855. PMID 29788807.CS1 maint: Multiple names: authors list (link)
44. ↑ Dandona R, Sagar R (2021). "COVID-19 offers an opportunity to reform mental health in India". Lancet Psychiatry. 8 (1): 9–11. doi:10.1016/S2215-0366(20)30493-4. PMID 33341174 Check `|pmid=` value (help).
45. ↑ Lim WP, Seet XY, Rahman H (2020). "Designing a psychological preparedness toolkit for healthcare workers in the wake of COVID-19: A Singapore perspective". Asian J Psychiatr. 53: 102204. doi:10.1016/j.ajp.2020.102204. PMC 7286254 Check `|pmc=` value (help). PMID 32544820 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
46. ↑ Wang Y, Di Y, Ye J, Wei W (2021). "Study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (COVID-19) in some regions of China". Psychol Health Med. 26 (1): 13–22. doi:10.1080/13548506.2020.1746817. PMID 32223317 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
47. ↑ Berkowitz SA, Basu S (2021). "Unemployment Insurance, Health-Related Social Needs, Health Care Access, and Mental Health During the COVID-19 Pandemic". JAMA Intern Med. 181 (5): 699–702. doi:10.1001/jamainternmed.2020.7048. PMC 8094006 Check `|pmc=` value (help). PMID 33252615 Check `|pmid=` value (help).

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