Perspective Chapter: Psychological Effects of COVID-19 Pandemic

*Vasfiye Bayram Değer*

## **Abstract**

COVID-19, the viral pneumonia seen in China towards the end of 2019, was declared a global pandemic in March 2020 since it spread almost all over the world. While such pandemic situations that are concerned with public health cause a sense of insecurity, confusion, loneliness and stigmatization among individuals, it can result in economic losses, closure of workplaces and schools, insufficient resources for medical needs and inadequate satisfaction of needs in societies. The economic crisis, which is one of the most important problems in pandemic periods, and the concomitant uncertainties can also cause suicidal thoughts. As a result, how the society responds psychologically during epidemics has an important role in shaping the spread of the disease, emotional difficulties and social problems during and after the epidemic. It often appears that no resources are allocated to manage, or at least mitigate the effects of epidemics on psychological health and well-being. In the acute phase of the epidemic, health system administrators prioritize testing, preventing contagion and providing patient care, but psychological needs should not be disregarded either.

**Keywords:** psychological impacts, covid 19, pandemic, adults, elderly, trauma

#### **1. Introduction**

COVID-19 global pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus, has precipitated government-mandated quarantines, social distancing, and other measures for the benefit of public health. Forced curfews have changed and disrupted people's daily routines, work, travel and leisure activities abruptly and dramatically in a way that most people living outside of war zones have not experienced. Moreover, this highly contagious virus has transformed situations such as social interaction, touching one's face, attending a concert, shaking someone's hand, and even hugging grandparents into those perceived as potentially dangerous [1].

The Covid-19 pandemic has been deemed as the most prevalent disease of our generation. This pandemic has affected people from almost all nations, continents, races and socioeconomic groups [2]. Mankind has been challenged with many undesirable and unexpected events including natural disasters such as earthquakes, floods, storms, volcanic eruptions, hurricanes, and tornadoes as well as humaninduced conditions such as wars, terrorism, and accidents. These unforeseen and sudden events are considered as a crisis situation [3]. It is argued that the crisis as a term is the main subject and core concept of many scientific fields. In a broader definition, James and Gilliand states that a crisis is an event and situation that an

individual encounters at an unexpected time, has difficulty tolerating and can disrupt their equilibrium [4]. On the other hand, Kaya and Yıldırım suggest that a crisis emanates from life events that occur in some periods of one's lifetime and can lead to pathological consequences unless rational decisions are taken [5].

Given different definitions, it can be argued that the crises affect individuals adversely with their unexpected nature threatening the life, and involve making quick and rational decisions. The crises can influence the individuals physically, socially and psychologically by provoking negative emotions and eliciting different reactions by creating pressure, distress, panic and insecurity on individuals [6] and it is emphasized that the mental balance of individuals is impaired in case of any crisis. All individuals are affected by such crises differently in proportion to their developmental period and may exhibit different reactions. For example, being a child, adolescent, adult or elderly person in the event of a crisis emerges as a different situation [7, 8]. It is contended that infectious diseases are highly associated with mental problems, which is clearly illustrated by the COVID-19 pandemic [9]. The COVID-19 pandemic is a process that needs to be addressed with its social, economic, political and spiritual consequences [10], threatening people's lives and causing traumatic distress [11]. It is widely known that the COVID-19 pandemic especially gives rise to psychological problems [12–14]. It is stated that the solution to overcome this critical process in a healthy way largely depends on the extensive research on the psychological effects of the pandemic [15]. During the pandemic process, people's psychological responses significantly influence the spread of the disease and increase the emotional distress and social dysfunctions that may occur in the next stage [16]. Therefore, the psychological effects of the pandemic must be thoroughly investigated. A recent study conducted by Wang et al. in China has shown that the pandemic process causes moderate and severe psychological effects among the public [14]. Due to the pandemic, people are experiencing psychological problems such as depression, anxiety and distress. Another study conducted by Li et al. has revealed that the COVID-19 pandemic causes a decrease in people's positive emotions and an increase in their negative emotions [17]. After the pandemic, which is inherently a stressful process, people may experience anxiety and discomfort. Stressful situations need to be handled effectively in order to prevent distress and anxiety from turning into more acute state. It is important to understand how people respond to and cope with the threats of the pandemic [15]. It is thought that psychological resilience especially plays a decisive role in coping effectively with this process [18].

Psychological resilience refers to the capacity of an individual to adapt to the challenges of life and maintain mental health despite exposure to adversity [19]. The reactions or coping strategies of individual who have been exposed to many adversities, shocking, traumatic and stressful life events throughout their lifetimes may vary. While some individuals react to stressful and traumatic situations in the form of mental problems such as anxiety and depression, others can recover from their negative mood in a short time and continue their normal lives. This phenomenon is termed as psychological resilience in the positive psychology [20]. It is stated that there are optimistic perspectives that most people become stronger by tackling the difficulties they face through resilience [21]. Psychological resilience, which is defined as the capability to adapt flexibly to the changes brought about by stressful events and to recover from negative emotional experiences [22], affects the course of disease and health conditions afterwards [23].

Moreover, it was reported that the psychological effects of the epidemic lasted longer and were more common than that of the physical, and it was very difficult to calculate psychosocial and economic effects in past epidemics [24, 25]. For example, it was stated that the fear experienced during the Ebola epidemic and the resulting

#### *Perspective Chapter: Psychological Effects of COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.101498*

behaviors intensified psychological symptoms, indirectly contributing to the increase in death rates due to reasons other than Ebola [26]. Similarly, easy access to mass media and other technologies along with spread of false and inconsistent information during the COVID-19 process can instigate harmful social reactions such as violent and aggressive behaviors in individuals [27]. During the recent SARS epidemic, both healthcare staff and surviving patients experienced various psychological disorders [28, 29]. A study conducted by Mak et al. has revealed that the most common psychological disorders among the public after the SARS epidemic included as post-traumatic stress and depressive disorders [30]. Similar results were observed after the MERS outbreak [31].

Isolation measures and quarantine practices taken to avoid getting sick or to prevent the spread of the disease arouse a great deal of fear, hopelessness and loneliness among the public [32, 33]. All these negative emotional states increase suicidal thoughts. During the pandemic process, death cases that were directly or indirectly associated with COVID-19 infection were reported in many countries including India, Saudi Arabia, England and Germany [34]. The spread and prolongation of the COVID-19 pandemic imposes deeper impact on financially and socially vulnerable groups. It is predicted that suicide cases will increase in this process, and therefore, necessary precautions should be taken immediately [35]. Following many natural disasters in the world, dramatic changes have been observed in suicide rates due to regional and social structure [36]. In a study investigating the suicide rates in the elderly population after the SARS-CoV-2 epidemic in Hong Kong in 2003, it was observed that suicide rates increased by 30% especially in women compared to 2002 [36]. In a survey conducted in Canada in 2003 on the individuals who were isolated due to SARS-CoV-2, it was found that they had been experiencing boredom, frustration, and anger, and their social life after isolation was adversely affected by this period [37]. In studies conducted among uninfected individuals during the SARS-CoV-2 infection process, it has been observed that there are many psychiatric morbidities that occur with the feeling of guilt at young age [38]. It will be revealed by future studies that the COVID-19 infection may also trigger suicidal thoughts and behaviors in individuals, and underlying factors at the individual and social level.

The major situations that contribute to psychological problems during the pandemic include quarantine and isolation, wearing masks and social distancing, and stigma.

## **2. The psychological effects of quarantine and isolation**

In simple terms, quarantine means separation of people who are exposed to a potentially contagious disease from other individuals to detect whether they are sick and restricting their freedom of movement, thereby reducing the risk of transmission to others [39]. This definition differs from isolation during which people diagnosed with an infectious disease are separated from those who are not sick. However, the two terms are often used interchangeably, particularly in public communication [40]. Quarantine is often an unpleasant experience for those experiencing it. Separation from the beloved ones, loss of freedom, uncertainty about disease, and boredom can sometimes have dramatic effects. Suicide cases have been reported following quarantine practices in previous outbreaks. The potential benefits of mandatory mass quarantine must be carefully assessed against the possible psychological costs [41]. The successful implementation of quarantine as a public health measure requires that we reduce as much as possible the adverse effects associated with it [42]. In another study comparing the psychological states of the quarantined and non-quarantined, it was found that hospital

staff who may have been in contact with SARS suffered from symptoms of acute stress disorder immediately after the end of the 9-day quarantine period. In the same study, it was found that the quarantined staff had significantly higher levels of fatigue, detachment from others, feeling anxious when dealing with patients with fever, irritability, insomnia, poor concentration and indecisiveness, poor job performance, and reluctance to work or considering to quit their job [43]. In another study [44], the effect of quarantine in hospital staff was found to cause symptoms of post-traumatic stress even after 3 years. Another study comparing the indicators of post-traumatic stress among the quarantined parents and children with those not quarantined, it was found that the post-traumatic stress mean scores of quarantined children were four times higher than those of non-quarantined. In this study, 28% of the quarantined parents and 6% of the non-quarantined parents had sufficient symptoms to be diagnosed with a trauma-related mental health disorder [45]. In other quantitative studies on this subject, psychological distress and disorder symptoms among the quarantined persons were highly prevalent.

Major psychological symptoms with a high prevalence include emotional discomfort [46], depression [47], stress [48], low mood, irritability, insomnia [49], post-traumatic stress [37], anger [50], and emotional burnout [51]. In two studies on the long-term effects of quarantine in healthcare staff, it was found that alcohol use or addiction were positively associated with quarantine 3 years after the SARS epidemic [52]. Therefore, recognizing the stressors in quarantine and taking measures against them is one of the most important points in mitigating the harmful effects of the quarantine process. The duration of quarantine, fears of infection, frustration and boredom, insufficient supplies, missing information are among the major stressors during quarantine while financial concerns are among the postquarantine stressors [42].

#### **2.1 Wearing masks and social distancing**

The interpersonal space (IPS) refers to the area surrounding our own bodies where we comfortably interact with other individuals. Typically, individuals regulate IPS through two basic behavioral patterns: they extend their distance when they feel they are in dangerous and uncomfortable situations (i.e. avoidance behavior) or, conversely, they reduce their distance when they feel they are in friendly and safe situations (i.e. approach behavior). During the COVID-19 outbreak, holding larger-than-normal IPS and wearing a face mask is one of the most effective measures to curb the COVID-19 outbreak which is still highly recommended despite the possibility of vaccination [53].

The members of the society interact with each other. As a result of this interaction, it is known that social values, which are also described as shared values, coexist with human beings. These values are accepted, adopted and influential in people's lives. Love, respect, tolerance, freedom, justice and equality, fraternity, cooperation, honesty, industriousness, hospitality, compassion and mercifulness, and protecting cultural heritage, which are counted as social values, are important values to be handed down to future generations [54]. Being locked down, feeling like a captive, being separated from the beloved ones and close contacts have unexpectedly and radically changed our daily life and traditional values. When encountered with situations such as epidemics with unpredictable effects, it is considered natural for individuals to exhibit panic, fear, hopelessness, avoidance and protective behaviors [55]. When feelings such as anxiety, fear and uneasiness begin to spread among the public, the factors that create fear and anxiety begin to direct people, and with the weakening of traditional solidarity, individuals who are isolated in big cities feel more vulnerable and powerless, thereby promoting the feeling of insecurity. Staying indoors for a long time, being disconnected from social life and work have caused

#### *Perspective Chapter: Psychological Effects of COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.101498*

psychological problems. The social imbalance between those who have the opportunity to work at home and those who have to go to work has been clearly revealed. Consequently, we all experience that the social/physical isolation in our lives with the pandemic affects our interpersonal relations adversely. A study conducted among 145 participants on the subject drew attention to the psychological effects of the virus on themselves and their relationships in most of their responses. Participants reported that, in addition to the fear of contracting the disease, there was a lack of communication between them and their loved ones due to the social/physical distance in the process, that they distanced individuals from each other, and that they were worried about the fact that the traditional ties that bound the generations and the society together would disappear if the process continued like this [56].

#### **2.2 Stigma**

Public health strategies to deal with emerging outbreaks require a delicate balance between maintaining public health and initiating exclusionary practices and treatments that can lead to fear, stigma and discrimination against certain communities. Due to their evolving nature and inherent scientific ambiguity, emerging epidemics of infectious disease may be associated with fear in a significant way in the general population or in certain communities, particularly where the disease and death are significant. Reducing fear and discrimination against the infected and the affected by a contagious disease can be vitally important in controlling the transmission. Those people who are feared and stigmatized may delay seeking care, remaining unnoticed within the society [57]. Fear of being socially marginalized and stigmatized on account of a disease outbreak may contribute to individuals' denial of early clinical symptoms and failure to seek medical care on time [57]. Such fears can aggravate stigma when cases are detected at a later time. The stigma associated with discrimination often has social and economic consequences that exacerbate internalized stigma and feelings of fear [57].

Among those affected by the 2003 SARS epidemic, the stigma associated with the disease was found to be somewhat evident even years later, and resuming the usual rituals of daily life was very difficult for many [50, 57, 58]. Similarly, the COVID-19 pandemic, with all its social and economic consequences, can lead to stigmatizing factors such as fear of isolation, racism, discrimination and marginalization [58]. A stigmatized community tends to seek medical care late and conceal their important medical history related to travel in particular. In addition to the potential psychological problems caused by the Covid 19 pandemic, the stigma, discrimination and social rejection of the quarantined group, suspicion and avoidance by the neighbor, distrust of property, prejudice at workplace and withdrawal from sociocultural events even after the epidemic is under control are among other crucial issues [42]. Health care providers (HCPs), especially general practitioners, have been found to be more prone to stigma of those caring for patients affected by SARS [59]. Since health care staff are quarantined and constantly more psychologically affected, they are more subject to stigma than the general public.

During the period after the onset of the COVID-19 epidemic in China, the 'social media panic', characterized by an endless flux of false and manipulated information and misinformation, evolved into a metastatic condition more rapidly than the coronavirus itself [60, 61]. WHO defined it as "coronavirus infodemic" that fueled fear and panic by unleashing uncontrolled mind-blowing rumors, bombastic news propaganda, and sensationalism [62] From the onset of the COVID-19 pandemic, social media has played an integral role in generating anti-Chinese sentiments and opinions around the World [60]. Conspiracy theory, derogatory headlines about eating habits, biased comments on Chinese socio-cultural norms posted on social


*Perspective Chapter: Psychological Effects of COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.101498*


#### **Table 1.**

*Psychosocial impact o Covid 19 on different strata of society and suggested interventions.*

media, and news have paved the way for situations that could lead to discrimination, isolation of an entire nation, and a rise of racism [63].

Stigma and blaming targeted at the affected communities can hamper international trade, finance and relations, provoking further unrest. Due care should be taken to eliminate the stigma associated with disease, racism, religious propaganda and psychosocial impact. Furthermore, it should be implemented through regular evaluation with trained and specialized health staff by establishing a directly health-related task force and executive teams [64].

To avoid discrimination and stigma in the context of COVID-19, governmental institutions, political leaders and health officials must undertake an integral role in maintaining interracial harmony during and after the pandemic [65]. In addition to the aforementioned issues, the Covid 19 pandemic has effects on different segments of the society. Special attention should be paid to more vulnerable groups such as quarantined people, healthcare staff, children, the elderly, marginalized communities (including daily bookies, migrant workers, slum dwellers, inmates and homeless populations) and patients with pre-existing psychiatric conditions (**Table 1**) [64].

The **Figure 1** below illustrates the relevant psychosocial consequences and impact of COVID-19 in various segments of modern society [65].

Bearing in mind that psychopathology may differ across developmental stages, it is essential to address the psychological effects of the pandemic primarily on adults, children, adolescents and the elderly.

#### **Figure 1.**

*Intricate psychosocial relationship between the disease, health care providers, government and population. Source: Dubey et al. [65].*
