**5. Depression**

Depression is one of the five most incapacitating illnesses, and by 2030, it is expected to be one of the major issues in industrialized countries. It's a common reaction to a rapid deterioration in living conditions, which involves isolation and uncertainty. When people are subjected to unpredictable circumstances, they feel helpless and unmotivated, which can lead to sadness [40]. During past epidemic outbreaks (SARS and Ebola), rates of depression in the general population have been reported with a prevalence approaching even 73.10 percent [41]. Past epidemics were more quickly contained, and infection rates were lower despite greater fatality rates, which might explain why depressive symptoms were less common [42]. Furthermore, during the SARS pandemic in Canada, Hawryluck et al. discovered that the length and unpredictability of the lockdown contributed to greater levels of depression [43]. As a result, the present global lockdown measures might explain the increased incidence of depressive symptoms reported during the COVID-19 epidemic. According to a research that looked at 69 million health data from over 62,000 persons diagnosed with COVID-19, 6% of COVID-19 patients suffered mental health problems including sadness and anxiety within three months of diagnosis, compared to 3.4 percent of non-COVID-19 patients [44]. The addition of a psychological burden to an already devastating physical burden affects the prognosis in a number of ways, with long-term consequences. Furthermore, those who are depressed are less likely to seek treatment for physical or mental problems; as a result, depression, like anxiety, can act as a barrier to reasonable medical and mental health interventions during a pandemic.

#### **5.1 Depression among patient population**

Earlier outbreaks such as SARS and MERS have displayed the presence of depressed mood among those with acute infection [45]. The COVID-19 pandemic is no different. The reported prevalence of depression at 6% in COVID-19 patients is higher to general population [44]. Females are more likely to experience depression than males [46]. According to one study, nearly one-fourth patients had intended to commit suicide or harm oneself [27]. Individuals who were married or underwent a divorce exhibited greater levels of depression than single individuals [27]. This could in part be explained by worries for one's family and grief of separation respectively. Having a family member with confirmed COVID-19, and having two current physical symptoms are independent risk factors for depressive symptoms [28]. Suicide has become a more pressing concern as the pandemic evolved [47]. Those with psychiatric disorders experience worsening symptoms and others are predisposed to develop depression, are all associated with increased suicide risk. Media and other news platforms also affect mental health and psychological behavior [35]. Despite the fact that receiving regular updates on COVID-related health information appears to reduce sadness, it is also claimed that social media exposure is linked to depression and mixed anxiety and depression [48–50]. Unemployment, low social status, a lack of social support, and financial losses are among socioeconomic variables that might contribute to greater incidence of depression [48, 49, 51, 52]. The added impact of quarantine has led to high occurrence of depression and even self-reported suicidal thoughts [29, 53].

#### **5.2 Depression among HCW population**

The COVID-19 pandemic has significant negative impacts on healthcare workers' psychological health, fostering anxiety, depression, and sleep disturbance. Studies conducted during the SARS have reported a prevalence of depression among the front-line HCWs to be 38.5% [54]. The factors in play causing depression are pretty similar to those contributing to anxiety. Increased workload, burnout, inadequate PPE, the risk of contracting the disease, and the challenge of making difficult moral decisions about care priorities during the pandemic have exposed healthcare workers to severe psychological pressures leading to depression. The high infectivity and mortality rates also contribute to depression among healthcare workers around the world. Furthermore, factors such as a high-risk workplace, a lack of clinical experience, young age, and a history of psychological disorders can contribute to depression among healthcare workers. Working on the front lines was found to be an independent risk factor for poor mental health outcomes across all aspects studied, including the prevalence of depression among HCWs. Between doctors and nurses, the latter have been studied to harbor a greater level of depression [55–57]. This may be partially confounded by the fact that nurses are primarily female but could also be attributed to the fact they may face a greater risk of exposure to COVID-19 patients as they spend more time onwards, provide direct care to patients and are responsible for the collection of sputum for virus detection [55]. Emotional exhaustion, depersonalization, being a nurse, 12- or 24-hour shifts or on-call hours, those who live with people who are at risk, and being very concerned about a possible infection of a family member they do not live with are all positively and significantly related to having depression symptoms [58]. Depression is also significantly higher among HCWs who did not know the latest COVID-19-related research/information. Lack of information may precipitate mental health concerns, and prior studies have suggested that updates and knowledge about COVID-19 may have psychosocial impacts, possibly as they represent an active way of coping and dealing with pandemic-related issues [59, 60]. Research also indicates that healthcare workers who take vacation days experience lower levels of depression [26]. Unfortunately, the COVID-19 pandemic crisis witnessed doctors along with other healthcare workers question their choice of profession, in part due to rising infection rates, unavailability of adequate personal protective equipment and other unexpected pandemic related experiences [60].

#### **6. Sequelae**

Long COVID is a term used to describe a condition in COVID-19 patients who have symptoms over an extended period [61]. These patients report prolonged, multisystem involvement and significant disability, which can last for more than six months in 93.2% of patients after the acute phase of illness [62]. Musculoskeletal, cardiovascular, gastrointestinal, pulmonary, and neuropsychiatric symptoms are prevalent in >85% of participants. Fatigue, breathing problems and cognitive dysfunction are among the most debilitating symptoms [62]. Such prolonged physical sequelae are associated with and often are a harbinger of psychological

#### *Mental Impact of COVID-19 – Fear, Stress, Anxiety, Depression and Sequels DOI: http://dx.doi.org/10.5772/intechopen.102754*

sequelae. Multiple studies conducted during previous pandemics also support the development of psychiatric sequelae in survivors. SARS-CoV-1 survivors exhibited posttraumatic stress disorder (PTSD) with an incidence of up to 55%, depression was observed in 39%, pain disorder in 36.4%, panic disorder in 32.5%, and obsessive–compulsive disorder in 15.6% of SARS-CoV-1 survivors [63]. Long term psychiatric complications such as depressed mood, anxiety and insomnia were also reported in 10-20% of patients following SARS and MERS infections [45]. These complications could result from central nervous system involvement of the virus or perhaps a consequence of fear associated with the infection and isolation itself.

Among the psychological sequelae, the most prominent and popular condition is posttraumatic stress disorder [64]. Surviving a critical illness is known to induce PTS symptoms [65]. Data suggests that as many as 43% of COVID-19 patients suffered posttraumatic stress symptoms [66], 'not though true prevalence of PTSD' prevalence. The severity of COVID-19 poses a significant risk factor for PTSD, supported by evidence of higher incidence among ICU patients juxtaposed to non-ICU patients [67, 68]. Even measures of quarantine and isolation, which help to contain the infection from the spread, can have psychological consequences leading to PTSD [2]. Healthcare workers, too, experience significant PTS symptoms. Emotional fatigue, depersonalization, working in a hospital, being highly concerned that someone they live with may become infected, and believing that becoming infected with COVID-19 is very likely are all positively and substantially associated with posttraumatic stress symptoms in the HCW population [56].

Aside from PTSD, COVID-19 infection survivors are more likely to experience depression and anxiety, similar to the acute phase of the disease [64]. The incidence of these disorders is linked to the severity of the disease and the length of hospitalization [69–71]. The baseline systemic inflammation index (SII) is strongly correlated with anxiety and depression [45, 59]. At follow-up, the prevalence of baseline comorbidities, such as mental disorders and female sex, is also linked to depression and anxiety [71, 72]. Although anxiety and depression symptoms generally go away within 1-3 months after infection, their presence increases the risk of developing PTSD later on [61].
