**4.1 Impacts of COVID-19 on the mental health of psychiatric patients**

Patients with confirmed or suspected COVID-19 may experience fear of the consequences of being infected by a potentially harmful virus, and those in quarantine

might experience boredom, loneliness, and anger [20]. In a Chinese study with 263 participants, the majority (53.3%) of individuals did not feel helpless due to the COVID-19 pandemic. However, 52.1% of the participants felt horrified and apprehensive due to the pandemic. Additionally, most participants (57.8 to 77.9%) received more support from friends and family members, more shared feeling and caring with family [21].

Indeed, a pandemic causes profound changes in social dynamics. One example is supermarkets, which were clear of essential items and faced a rationing procedure at the beginning of the pandemic. Schools and other educational institutions have been affected, with compulsory examinations postponed and most children remaining at home. The financial implications are profound, even though governments have implemented various supportive measures [22]. This situation causes stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear [23].

Moreover, such feelings may especially arise due to fake news and conspiracy theories that circulate as a result of social media "infodemic", particularly in areas with low social capital and public trust [24]. According to Gao et al. [25], the prevalence of depression, anxiety, and a combination of depression and anxiety in 4,872 participants from 31 provinces and autonomous regions in China was 48.3% (95%CI: 46.9–49.7%), 22.6% (95%CI: 21.4–23.8%) and 19.4% (95%CI: 18.3–20.6%), respectively, during COVID-19. More than 80% (95%CI: 80.9–83.1%) of the participants reported frequent exposure to social media.

This impact is more dangerous and worrying in psychiatric patients. Schizophrenia, bipolar, depression and anxiety disorders or autism have an increased risk for infection due to immunogenetic vulnerability. The elderly psychiatric patients are the most vulnerable group, and there is a high exacerbation risk of psychic disorders and an aggravation of existing psychiatric symptoms, cognitive disorders, and loss of autonomy. The elderly may have difficulties adopting "barrier measures" (behavioral measures to protect oneself and others from the virus) and complying with confinement instructions. Severe social isolation, precarious housing, restricted solidarity networks for the informal monitoring of these patients' health condition complicate this population's situation [26].

Furthermore, people with mental disorders can be exposed to more barriers in accessing timely health services due to discrimination associated with patients who have mental illness in health care settings. The elderly could be more substantially influenced by emotional responses brought on by the COVID-19 pandemic, resulting in relapses or worsening of an already existing mental health condition due to high susceptibility to stress compared with the general population. The treatment for mental disease could make that of COVID-19 more challenging [27].

### **4.2 Use of technology as an ally in combating impacts on mental health in the COVID-19 pandemic context**

Health services around the world have been mobilized and reinvented in an attempt to meet the population's mental health demands during the COVID-19 pandemic. The literature states that technology to reduce risk is a way out of proper pandemic management [28].

In France [29], there has been a 90% shift in outpatient activity with the use of telepsychiatry. There is a hotline for psychiatry teleconsultation, and meetings with more than five people became virtual. In addition, psychiatrists alternately present themselves in the department or teleworking. According to Starace and Serrara [30], during phone check-ins, the professional provides information of open hours, changes in access to services, and public health recommendations about limiting social contacts.

In Siena, Italy, more than 90% of the outpatient consultations were transformed into telemedicine consultations, which also made use of cell phones. Hence, health workers may benefit from social contact provided via the Internet, in a group setting, at the end of a working day, from their houses, without wearing the protective garments they wore all day long. They believe that offering a space to talk electronically, to share experiences, and to provide comfort to each other can be helpful, especially for those who live alone [31].

In Croatia, the use of digital technologies in post-traumatic stress disorder (PTSD) mitigation was the main topic of the researches carried out by Cosic et al. [32]. According to the authors, based on their experience, the development of computer tools and methods for emotion elicitation, estimation and regulation, cognitive-behavioral therapy, stress inoculation/resilience training, prevention of stress-related disorders and soldiers' ability strength to cope with highly stressful situations, as well as assessments of individual and group stress resilience features, created the NATO research and development project "Multidisciplinary Metrics for Soldier Resilience Prediction and Training" with researches from Turkey, Croatia, and Austria. It can use these expertise's origin strategies to face the COVID-19 psychology and psychiatric impact.

Increasing the communication with friends, family members and loved ones, even if from a distance, from video-chats or group calls with family members, may help to reduce loneliness and precariousness. In case of insufficient social network, professional helplines are particularly useful, if managed by qualified trained professionals [33].

Mainstream media, such as television and radio, may play an important role by including content that promotes quality information and safety for the population [15]. They should get ahead and educate people about the importance and existence of not only physical health issues, but also mental health ones during a pandemic, along with medical and mental health professionals in order to sustain scientificand fact-based presentation and suggestions while addressing the importance of COVID-19 control practices [34].

In Singapore, the government have kept the public abreast on the progress of the outbreak with regular broadcasts of news and announcements on social media. These include daily updates, such as the number of new and current infections, patients who are at critical condition or have been discharged, and preventive measures. Social media channels have also been set up by the state to curb the spread of false information and "fake news." Regular dialog with Cabinet Ministers and infectious diseases physicians is aired to clear questions [35].

## **4.3 Mental health promotion measures in the COVID-19 pandemic context for the population**

A significant distress decrease has been associated with the nationwide quarantine, medical supports and resources from all over the country, public education, individual protection strength, medical isolation, population mobility control, reduction of gatherings to stop the virus spread, and social and spiritual support. These are very important elements of community resilience and anti-fragility during COVID-19 crisis periods [3, 36].

During the COVID-19 pandemic, the National Institutes of Health in the USA and other funders must provide administrative supplements and notifications that encourage researchers to go fully remote; assess the mental health impact of COVID-19; prioritize repurposing of psychiatric human and pharmacologic resources for COVID-19 research efforts; and continue working, leveraging the unique clinical research resources in psychiatry to help as many people as possible through the crisis [28].

China created 26 protocols and guidelines regarding mental health promotion between January and February in 2020 [37]. In these protocols, psychological crisis interventions have included three key points: understanding the mental health condition in different populations influenced by the COVID-19 outbreak, identifying people that are at high risk of suicide and aggression, and providing appropriate psychological interventions for those in need [37].

Based on Fiorillo and Gorwood [33] in Italy, some measures to face the mental impacts of the pandemic are: limiting the sources of stress, *i.e*. decrease of access to unofficial channels and uncontrolled sources; breaking isolation, by increasing communication of family and friends via social media; maintaining the usual routine rhythm; focusing on the isolation benefits and asking for professional help when needed. According to Ho, Che and Ho [35], the integration of hospital and community resources, more support for frontline health workers, accurate dissemination of health and related information to the public, identification of high-risk groups, improved screening of psychiatric morbidities, mode and content of psychological intervention encourage the use of a psychodynamic approach as a way to improve the population's adherence to preventive measures [38]. A Chinese study that evaluated 1,304 people showed that cognitive therapy can provide information or evidence to enhance confidence in the doctor's ability to diagnose COVID-19 [39].

Measures for a better health promotion and for combating the COVID-19 include the use of personal protective equipment, mainly of fluid-resistant surgical masks, telemedicine, avoiding crowds/visits, offering individual educational sessions to patients admitted at the unit, providing printed materials, and encouraging hand hygiene [30].

### **4.4 Mental health promotion measures in the COVID-19 pandemic context for health professionals**

As if exposure to the COVID-19 during the global pandemic was not enough, healthcare workers face another risk: burnout due to overstress in an increasingly overloaded healthcare system [10]. Thus, health care professionals have accepted an overwhelming responsibility. They are coping with the psychological distress of losing patients, as well as lack of clarity and unpredictability within their work environments, while trying to protect their own health [22], particularly in countries with limited resources [24]. Health professionals have been dealing with high risk of infection and inadequate protection against contamination, overwork, frustration, discrimination, isolation, patients with negative emotions, lack of family contact, and exhaustion [23].

A study with 1,287 workers in hospitals equipped with fever clinics or wards for patients with COVID-19 in Wuhan and other regions in China reported that health workers have been experiencing psychological burden (depression, anxiety, insomnia, and distress), especially female nurses [40]. After surveying more than 1,200 nurses and physicians in 34 hospitals in the Wuhan region and across mainland China, approximately 14% of the physicians and nearly 16% of the nurses described moderate or severe depressive symptoms. There were also reports of insomnia and anxiety [14].

Some strategies for dealing with COVID-19 impacts include: routine support processes (such as peer support programs) available to the healthcare staff with a briefing on moral injuries, as well as awareness on other causes of mental ill health and what to look out for [10, 41]; training on psychological skills to deal with patients' anxiety, panic and other emotional problems, and, if possible, for mental health staff to be on hand to directly help these patients [42]; formation

of psychological intervention teams and intra hospital support for professionals [43] in public policies that aim to articulate these joint efforts in a centralized and strategic way [11, 13].
