**1. Introduction**

At the end of 2019, a new type of previously unidentified coronavirus appeared in the Chinese city of Wuhan, then known as the novel coronavirus 2019, which was renamed SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. The disease it causes is officially named Coronavirus Disease-2019 (COVID-19). The first cases of infection with this virus spread from animals to humans, presumably at the seafood market in the Chinese city of Wuhan, causing a terrible epidemic in many cities in China [1, 2]. Due to the growing rate of reporting cases in Chinese and international locations, on January 30, 2020, the WHO Emergency Committee declared a global health emergency [2].

To slow the spread of COVID-19 and prevent health systems from becoming overloaded, many countries around the world have implemented restrictions on population movement and complete or partial lockdowns, police-enforced curfew, strict travel bans and shutted borders [3]. All of this has affected the established way of human life and caused a major psychological impact on people around the world, posing a serious threat to mental health [3].

The severity of the COVID-19 pandemic poses a new challenge to mental health. The World Health Organization defines mental health as a state of well-being in which an individual achieves his potential, can cope with normal life stress, can work productively and is able to contribute to the community. The definition of mental health leads to the conclusion that it is more than just the absence of mental illness, ie that good functioning within one's own family, good relationships with other people and expressing life satisfaction are qualities of a person who is mentally healthy [4]. People with good mental health are often sad, sick, angry or unhappy, and that is part of a fully lived life for a human being. Nevertheless, mental health is often conceptualized as a purely positive impact, marked by a sense of happiness and a sense of having control over one's environment [4].

With the outbreak of COVID-19, people faced a series of situations that changed their lives, but also the lives of their loved ones. Closing in houses, distancing oneself from other people, death of close people and general uncertainty are situations to which people were not used until then [3, 5]. The continuing stress associated with a pandemic can have serious consequences for their mental health. Stress involves physiological and psychological reactions to stressors that come from the environment, and people very often have no control over these causes of stress [6].

Depression, anxiety, and stress have been identified as basic negative indicators of mental health and some of the major health problems, and research interest has focused on understanding their nature, causes, and treatments [7]. An individual's depression is characterized by experiences of dysphoria, hopelessness, devaluation of oneself and life as a whole, impoverishment of social life and anhedonia. Anxiety is a mental state characterized by a subjective experience of anxiety, a feeling of helplessness and a high level of arousal of the organism. Negative stress is a state of high arousal of the organism that occurs as a result of one or more threatening events, with strong negative emotions on the mental level [7]. People who are generally prone to anxiety, as a rule, often express symptoms of depression, and vice versa. Stress is also associated with depression and anxiety [7].

Studies assessing stress, anxiety and depression during quarantine caused by the spread of SARS-CoV-2 have revealed the presence of severe psychological distress and psychopathological factors and have shown that the COVID-19 pandemic is associated with very significant levels of stress, which in many cases could reach the threshold of clinical importance [8].

Further in the text of this book chapter, a more detailed review of the existing literature on mental health and associated factors during the COVID-19 pandemic will be reported, ie the prevalence of symptoms of depression, anxiety and other forms of psychological distress. After that, the roles of preventive factors related to mental health will be identified, with a focus on resilience and capacity for mentalizing.

## **2. COVID-19 pandemic and mental health disorders**

The outbreak of the COVID-19 pandemic caused an increase in the prevalence of mental disorders by a massive 25%. The most common and important of these

*Perspective Chapter: The Impact of COVID-19 on Mental Health – The Protective Role… DOI: http://dx.doi.org/10.5772/intechopen.106161*

disorders are depression, anxiety and various types of psychological distress, which are described in more detail in this book chapter. In addition to the COVID-19 pandemic, multiple factors also caused a "pandemic of mental disorders", ie a massive increase in mental health problems.

One of the main explanations for the increase in mental health problems is the unprecedented multiple stress caused by the social isolation resulting from the pandemic. Related to this were limitations in people's ability to work, seek support from loved ones and engage in their communities, loneliness, fear of infection, suffering and death for themselves and loved ones, grief after bereavement, and financial worries. These are all stressors that lead to the fundamental mental problems of anxiety and depression. Among healthcare workers, who belong to a group particularly vulnerable to the COVID-19 pandemic, exhaustion and burnout syndrome have been main triggers for suicidal thoughts [3, 5].

#### **2.1 COVID-19 pandemic and mental health status in the general population**

Numerous studies on the mental health status of people around the world have been published during the COVID-19 pandemic, reporting on different rates of mental health problems. Some differences can be attributed to methodological issues such as different instruments for measuring mental health indicators such as depression, anxiety and distress, and the range of outcomes used, while other differences probably stemmed from cultural factors about discovering mental health problems [9].

A review of research literature from China, India, Nepal, Iran, Iraq, Japan, Nigeria, the United Kingdom, Italy and Spain showed that the average prevalence of depression in 14 studies with a sample size of 44,531 people was 33.7%, the prevalence of anxiety in 17 studies with a sample size of 63,439 was 31.9%, while stress rates in 5 studies with a total sample size of 9074 individuals were 29.6% [10].

When it comes to the results of research conducted in Europe, similar findings have been obtained. The first study in Serbia examining the mental health status of the general adult population found that of the 1057 participants in the study, 28.9% reported moderate to severe depression, 36.9% moderate to severe anxiety, and 38.1% moderate to severe symptoms of stress. Fear about COVID-19 news, feelings of helplessness, the likelihood of impending death, and the presence of COVID-19 symptoms were associated with higher levels of depression, anxiety, and stress. Current smoking status was associated with a higher risk of depression and stress. Higher socioeconomic status was significantly associated with lower levels of depression, anxiety and stress, while students had significantly higher levels of depression and stress [3].

Isolation, reduced social contacts, the duration of quarantine and restrictions, and significant changes in access to higher education in response to the global COVID-19 pandemic have played an important role in increasing negative emotional symptoms and stress in students. A study conducted on a sample of 338 students in Serbia during the state of emergency due to the COVID-19 pandemic examined the relationship between depression, anxiety, stress and procrastination [11]. The results showed that the average values of depression, anxiety and stress among students were significantly higher compared to the findings of research conducted on a sample of university students before the pandemic in Serbia, but also in other European countries [11].

The psychological impact of COVID-19 on the university community has also been demonstrated in research conducted in Spain, Greece and France. According to research conducted in Spain during the first weeks of the introduction of curfew due to the pandemic, students showed higher scores on the scales of depression, anxiety and stress, compared to the situation before the COVID-19 pandemic [12]. The authors, who conducted research in Greece during the state of emergency due to the COVID-19 pandemic, pointed to an increase in anxiety, depression and psychological distress in students compared to the time before the pandemic [13]. A cross-sectional study aimed at assessing the prevalence of anxiety and identifying anxiety-related factors among French students during the outbreak of COVID-19 found that of the 3936 students, 15.2% experienced moderate anxiety. Female gender and having relatives or acquaintances who were hospitalized for COVID-19 were major risk factors for anxiety [14].

Systematic review of three electronic databases (Google Scholar, PubMed and Medline), with 13 studies from different European countries that published data on the prevalence of anxiety, depression and stress in students, showed that the overall combined prevalence rate was 55% for anxiety, 63% for depression and 62% for stress [15]. A significant increase in anxiety, depression and stress has been identified among university students across Europe, but the long-term effect of this will need to be monitored. Governments, universities and other higher education service providers should take into account students' mental health and provide strategies to support their mental well-being [15].

A study examining mental health during the COVID-19 pandemic and key risk factors in the adult population in Croatia, on a nationally representative sample of 1201 participants, shows that 9.8% of respondents were at risk of adjustment disorders, 7.7% were at risk of developing depressive disorder, and 7.8% were at risk for anxiety disorder. In addition, 7.2% experienced high levels of stress. Key risk factors for specific negative mental health outcomes varied, but common predictive factors for some of the mental health problems included younger age, current health status, previous diagnosis of mental disorder, having an below-average income, and over-following COVID-19 news. Together, the key risk factors identified in this study indicate the need for public health interventions that address the mental health of the general population, but also for specific risk groups [16].
