Salud Mental durante la Pandemia: Una revisión necesaria

Mental Health During the Pandemic: A Necessary Review

 

Recepción: 25 de septiembre de 2021 / Aceptación: 25 de noviembre de 2021

 

Diego Silva Jiménez1

Paula Méndez Celis2

Romina Lizondo Valencia3

Diego Arancibia Morales4

Javier Silva Silva5

DOI: https://doi.org/10.54255/lim.vol10.num20.551

 

Resumen

La actual pandemia mundial por COVID-19 ha sido un desafío para los sistemas sanitarios debido al alto nivel de contagio y requerimientos de hospitalización asociados a la carga de enfermedad, sin embargo, es igualmente necesario evaluar sus efectos sobre la salud mental de la población. El objetivo fue conocer los efectos provocados por la pandemia en la salud mental de la gente, a través de una revisión narrativa desde las perspectivas de género, del trabajo y las políticas públicas. Como método, se realiza una revisión narrativa de la bibliografía asociada a las perspectivas seleccionadas. Como resultado se obtuvo que las mujeres tuvieron mayor carga laboral en el confinamiento, aumentando su stress; trabajadores de la salud y educación, vieron afectadas sus jornadas laborales, sin recibir la atención necesaria para enfrentar el stress asociado; por último, desde las políticas públicas se actuó rápido a través de medidas de apoyo telefónico y web.

Palabras clave: género, pandemia, políticas públicas, salud mental, trabajadores

 

 

Abstract

The current global COVID-19 pandemic has been a challenge for health systems due to the high level of contagion and hospitalization requirements associated with the disease burden. However, it is equally necessary to evaluate its effects on the population’s mental health. The objective was to know the impacts caused by the pandemic on people’s mental health through a narrative review from the perspectives of gender, work, and public policies. A narrative review of the bibliography associated with the selected views is carried out as a method. As a result, we learned that women had a more significant workload in confinement, increasing their stress; health and education workers saw their working hours affected, without receiving the necessary attention to face the associated stress; finally, in the field of public policies, rapid action was taken through telephone and web support measures.

Keywords: gender, pandemic, public policies, mental health, workers

 

Introduction

COVID-19 turned out to be the most challenging global health crisis to be tackled in recent times. In December 2019, the first outbreak of this virus emerged in Wuhan (China), and it spread throughout the globe, seriously affecting health systems all around the world. Among the most complex aspects of this situation was the general ignorance of its biological, medical, therapeutic, and preventive factors, both for the general population and health personnel (Peiró et al., 2021). This situation gave rise to “universal panic and alarm”, associated with high contagion, the collapse of health systems, and thousands of related deaths (Maguiña Vargas et al., 2020, p.129).

The above-mentioned has generated effects on people’s mental health. Still, people worldwide have presented visible alterations in their physical, mental, social, and emotional health due to the measures taken, such as confinement. (Lizondo et al., 2021). At an individual and collective level, among the consequences on mental health, in the context of health emergency of COVID-19, we can find the “associated psychological disorders, ranging from isolated symptoms to complex disorders with significant deterioration in functionality, such as insomnia, anxiety, depression and post-traumatic stress disorder” (Ramírez-Ortiz et al., 2020, p.1).

People’s mental health was one of the results with the most significant impact associated with COVID-19 because of the isolation, uncertainty, and fear caused by the progress of the pandemic. This increased stress, anxiety disorders, and depression, impacting family life, work, and social relationships. The high number of diagnoses on depression, alcohol, and other substance abuse and the high rates of depressive disorder in adolescents are all indicators of this situation (Mesa Social COVID, 2020, p.3).

Likewise, the cases of family violence increased. Although family violence is part of the Chilean reality, this problem has aggravated with the pandemic. According to mental health specialists, this is related to the fact that in disaster situations such as a pandemic, which causes isolation and confinement, violent alterations in human relationships occur, and this impacts the mental health of families (Ribot et al., 2020).

In this context, Huarcaya-Victoria (2020) explains that the first effect on people’s mental health was increased anxiety due to the large amount of information delivered by the media and specialists in such a short time at the beginning of the outbreak. Another effect was that depression was present in 30.3%, with a higher prevalence in men. In comparison, there was 35% of psychological stress in women, and in general, in 50% of people, there was moderate to severe impact at a psychological level.

Groups with the most significant vulnerability detected in mental health associated with COVID-19 were the elderly, children and adolescents, people with previous illnesses, and those who fought on the front line of COVID-19, such as health personnel (Hernández, 2020). However, it was needed to address other essential works and the perspective of gender roles. In the same way, the Pan American Health Organization and World Health Organization (2020) propose a series of preventive and promotional care, focused on children, the elderly, and health personnel, as they have been identified as the highest risk groups. In addition, the Inter-Agency Standing Committee (2020) adds to the groups mentioned above adults in quarantines, that is to say, most of the population.

Because of the above, it seems necessary to answer the question about the effects of COVID-19 on the population’s mental health and how public policies have addressed it. This article aims to know the impacts caused by the pandemic on the population’s mental health through a narrative review from the perspectives of gender, work, and public policies.

 

Methodology

A narrative review of the existing bibliography in the scientific literature was used as a methodology for the preparation of this article to ensure a comprehensive analysis of the subject of study. The experience of the researchers about the selected topic was also considered to provide the scientific support required for its development. (Salinas, 2020). In addition, it allows answering specific questions through a unique approach due to the authors’ decisions concerning the scope of the review (Aguilera, 2014).

To develop this narrative review, we accessed the SCOPUS, Scielo Latindex, DOAJ, and LILACs databases. We supported the results in government documentation and supra-national institutions specialized in health issues. We used the terms mental health, pandemic, public policies, and gender as search criteria. This search was restricted to the last two years, 2020 and 2021, as they represent the beginning of the pandemic until the present, in addition to some studies applied to humans. The search focused on three categories, which helped deepen what the experts exposed. These are gender perspective, workers’ perspective, and the public policies approached to combat it. All these are analyzed and developed below.

 

Gender and mental health in the covid -19 pandemic

Women spent long hours on paid and unpaid work, more than eight hours compared to men. This situation seems to intensify in Latin America, and it has been established that it could be the region with the most significant differences in the world in this matter. This can also be represented by women with high incomes in contrast to those with lower incomes who would dedicate more time to unpaid work. (Malaver-Fonseca et al, 2021)

These inequalities are not only manifested in the amount of additional work that women must perform, “but these conditions affect their well-being (physical and mental illnesses) and generate negative effects from the social and economic perspective (informal jobs, economic dependence on their spouse and little participation of women in the labor market).” (Malaver-Fonseca et al., 2021, p.154) Furthermore, “the confinement and integration of new tasks into housework exacerbated the deep gender inequalities that have persisted for years” (Power, 2020, p.68).

On the other hand, the pandemic affected the employment situation of families in the short and medium-term while it generated negative impacts on the quality of employment. This situation had the most significant effects on workers under faulty working conditions (Ernst & López-Mourelo, 2020, p.4), conformed primarily by women.

Similarly, another factor contributing to the worsening of mental health in the female population due to COVID-19 has been the work overload on the home and work fronts. On the home front, women have been taking care of their families by maximizing the cleaning and precautionary measures due to their work as health officials, where stress, fatigue, and the fear of infecting their family are added. On the other hand, they feel guilty about the little time they spend with their families. (Ernst & López-Mourelo, 2020; Malaver-Fonseca et al, 2021). In addition to the above, the increase in violence against women in the context of COVID-19 is explained by factors associated with the economic dependence on their partners, unemployment caused by the pandemic, informal jobs, and cultural factors, among others (Borgeaud-Garciandía, 2020).

Because of the measures to restrict individual freedoms caused by COVID-19 due to the establishment of quarantines, the risk of an increase in gender-based violence was on the rise, as support networks could not be used because victims were confined with their perpetrator, which discouraged complaints. (Lorente, 2020) Ariza-Sosa et al., argues that:

During confinement, different forms of manifestation of violence increased (physical, psychological, and sexual). In a second phase, after isolation, after losing the feeling of control, the possibility of a lethal assault on the woman increases. In this context, there was increased gender-based violence against women by their partners during confinement because of COVID-19. This may happen because it became easier for the aggressor to control his partner’s mobility and freedom of action. (2021, p.126).

Also, during the pandemic, both men and women underwent new positive experiences, such as becoming more interested in other people and interpersonal relationships, thinking more about the future, appreciating time spent with family, and even discovering new hobbies and practicing more religious or spiritual activities. (Sandín et al., 2020, p.12).

In men, the effects observed in this pandemic were the following: “physically inactive, a reduction of the number of steps from 6,203 to 1,394 steps per day for three weeks.” (Celis-Morales et al., 2020, p.885). Despite this, men maintained their work routines without significant alterations during the pandemic, which led them to increase their workload at home by a tiny percentage. (Castillo et al., 2021)

Therefore, many men were confined to their homes due to the COVID-19 quarantine, either because they did not have a job, because they decided to work from home, or because of the temporary closure of their source of employment. This turned out to be an opportunity to witness the daily routines at home, opting to spend more time with their family (Alon et al., 2020). “Men who have spent more time in their homes have had a positive but radical change, which implied the most profound modifications of family relationships in addition to putting aside activities that they used to carry out periodically, such as being the provider of the house.” (Márquez Doren et al, 2021.p54).

The bibliography on the effects of the LGBTIQ + community was reviewed, but there is a lack of knowledge regarding the subject; the same happens with sexual dissidents. There are no studies that show the real effects in this community.

 

The mental health of workers during the pandemic

COVID-19 substantially impacted the mental health of all workers, producing real urgency to adapt the methodologies and physical spaces of work in many and diverse fields. This adaptive period has undoubtedly been accompanied by higher rates of psychiatric pathology on a generalized scale in the world of work, evidenced by a decrease in the rate of psychological well-being and an increase in the indicators of depression and anxiety (Vindegaard & Benros, 2020). However, we must recognize that different areas may have been more impacted than others, either by their physical proximity and exposure to the disease in the case of health workers, as well as the new challenges of social interaction in the case of teachers, or the inability to abandon or adapt ways of working to reduce eventual exposure to the virus on the part of independent workers or essential service workers, such as janitors and garbage collectors.

The most significant amount of evidence and the most outstanding research efforts on the impact on the mental health of a group of workers is undoubtedly concentrated in health professionals, mainly conditioned by greater exposure to contagion by the virus and therefore eventual worse consequences at the mental health level. This assumption has been supported by empirical evidence since a systematic review examined the prevalence rates of anxiety, depression, and stress in different health workers. The lowest reported rates were 24% for anxiety, 12% for depression, and 30% for stress, while the highest rates were 68%, 56%, and 62%, respectively. They are all higher rates in comparison to those of the general population. The nursing staff reported the worst mental health indicators among the different health professions. In addition, front-line staff, younger staff, and staff working in areas with higher rates of contagion also had higher psychological symptoms than the rest of the area’s workers (Vizheh et al., 2020). This information is consistent with the reality of Chile. An investigation carried out in a cohort of health professionals in the country through online questionnaires, which sought to assess the presence of some psychological symptoms through different scales and indexes for depressive, anxiety, insomnia, and stress symptoms showed that this work area presents worse mental health conditions than that of other types of work. The research reports that 65% of the professionals surveyed have depressive symptoms, 74% anxiety, 65% insomnia, and 57% stress. These rates are much higher than those reported in the general national population. Among them, the nursing staff presented the highest reported rates of these symptoms, and the medical staff the lowest. In addition, those professionals who treated cases of respiratory infections reported worse indicators of mental health than those who did not treat such patients (Urzúa et al., 2020). This way, all health professionals, especially nurses, have had to face something that was not visualized for a long time, they have been faced with work overload and the anguish of not having access to elements of personal protection, supplies, and devices to be able to provide adequate care to each patient, which has generated high levels of stress and helplessness. (Oliva Yarlaqué & Chávarry Ysla, 2021). This, according to Peiró et al. (2021), causes greater physical and, most of all, emotional pressure on nurses, as they are aware of the fact that they are risking their own life.

Another area of work that may present a meaningful impact on mental health is pedagogy.

From this point of view, Beames et al. (2021) suggest that teachers mental health has been neglected at the research level and because they were not provided with the necessary tools to manage this pandemic scenario. Teachers have had to apply various changes in the teaching-learning strategies, and both teachers and students have had to adapt to such changes required (Ribeiro et al., 2020). However, it is estimated that the pandemic has substantially deteriorated the field of education, mainly due to the need to adapt to new remote education techniques, plus the challenge of motivating students virtually. In addition, it was found that anxiety, depression, stress, post-traumatic stress symptoms, burnout, exhaustion, and sleep are problematic for teachers. In times of emergency, those education professionals with pre-existing mental health conditions perform worse than those without them, and these ideas are supported by evidence. According to a Spanish study, education professionals would have high psychological symptoms due to the coronavirus pandemic. This study reported that 51% of the teachers suffered from stress, with 5% reporting highly severe symptoms and 14% severe symptoms. On the other hand, 32% of them suffered from depression, of which 3% reported highly severe symptoms and 4% severe symptoms. Of this group, the oldest people had higher rates of stress and anxiety, while the youngest had higher levels of stress than the average analyzed. Additionally, the shorter the remaining contract, the higher depression, anxiety, and stress levels were reported. Primary and secondary education teachers showed higher anxiety levels than university teachers (Ozamiz-Etxebarria et al., 2021). It should be noted that the educational sphere does not only cause the teachers’ psychological wear and tear, since the online workload, hasty adaptation, acquiring knowledge of technology, having to communicate with other teachers and their students through a camera, and everything that the pandemic itself entails, significantly affect the mental health of teachers (Reynosa et al., 2020)

As for essential service workers who have not been able to suspend their work despite the pandemic, such as janitors and garbage collectors, there is a fundamental deficit in research or reflection regarding how recent events have affected their mental health, at least in formal literature. However, it is safe to formulate some a priori hypotheses about the situation in the case of garbage collectors. According to Abou-ElWafa et al. (2019), garbage collectors would have one of the highest rates of work-related respiratory illnesses, a consequence of constant exposure to dust, microorganisms, toxins, and contamination by fuels. Although it does not necessarily imply higher infection rates by Sars-Cov 2, they would most definitely have a more fragile respiratory system and, therefore, a possible worse course of coronavirus disease. On the other hand, garbage collectors report symptoms of stress related to exposure to high or low temperatures, night shifts, low educational levels, and insufficient income (Nguyen et al., 2021). Faced with a greater risk of suffering severe disease courses, added to high rates of multifactorial stress, we would be led to suppose that there is a poorer quality of mental health due to the pandemic in this workgroup than the general population. In the case of janitors, there is little evidence regarding the pandemic’s effects on their mental health now or how they were before the pandemic started.

Another important group of workers, not often visible, is informal workers, who receive income from their own work but whose conditions are not regulated by a legal framework (Palacios, 2011). As in the previous case, there is little evidence regarding how the mental health of these workers has been affected but taking into consideration that they are a vulnerable group, since they do not have legal guarantees to protect their economic stability, we can assume that stress or distress rates could be higher in comparison to the general population.

These workers are essential activities workers (caregivers for the elderly, people working on sales, security, cleaning, and distribution) who had to continue operating normally, living with people who may have been infected, thus expanding the virus to their own family. (Ruiz-Frutos and Gómez-Salgado, 2020).

 

Public mental health policies during the pandemic

According to Roth Deubel, public policies are the response of a government that has the administration of the State “to a state of things perceived as problematic” (Tassara, 2014, p. 19) to which it can generally assist through its health care network and through how this is organized to respond to the various pathologies of society. However, in a pandemic, the situation becomes so critical that governments must convene other non-state actors to contribute to the generation of responses to face the pandemic. In this context, the opinion and recommendations of medical societies regarding mental health care and guidelines for attending health care centers emerge and become essential. Under a governance perspective, the Spanish Society of Psychiatry developed a series of documents focused on prevention and response to mental health in the context of COVID-19, which highlights the guide for intervention in mental health during the epidemic outbreak of COVID-19 (Spanish Society of Psychiatry, 2020).

In consequence of the above, regarding the visibility of mental health as a pathology that turned into a priority in the context of a pandemic, non-state actors such as the Inter-American Psychological Society must be highlighted. They constituted a Psycho-Covid Committee to support the articulation of institutional and professional responses that allow responding to the mental health demands arising in the context of a pandemic. This resulted in the preparation of a guide of recommendations on the action on different segments of the population, be these children, young people, adults, the elderly, people with disabilities, people living on the street, migrants, sexual diversity, health professionals, among others (Gallegos et al., 2020).

It is relevant to mention that many of the public policies adopted by the governments of Latin America responded to the guidelines and recommendations of the Pan American Health Organization (PAHO) in different areas of action, such as surveillance and research (Arancibia et al., 2021), and around the action of the population to consider psychosocial and mental health factors during the COVID-19 outbreak (PAHO, 2020). In this respect, the pandemic revealed that governments did not have public policies to face a pandemic. The pandemic became a strength test for the authorities, managers, and health teams that had to use the tools and capacities they had to face COVID-19. Likewise, it seems necessary to reiterate the role that non-state actors, such as foundations, unions, and scientific societies, have played in discussing, advising, and delivering guidance to governments as a way of suggesting lines of action, facilitating decision-making processes, and contributing to the strengthening of health governance.

Beyond the recommendations of the non-state actors mentioned, the leading measures of adaptation or refocus of public policies took place in the organization of the healthcare network for a better supply of clinical beds, both in Intensive Care Units (ICU) and beds in Critical Patient Units (CPU). Similarly, guidelines and recommendations were delivered to health teams in primary care for efficient and effective management, both in care and referral to other more complex hospital centers, such as the cases of Chile and Cuba (Ministry of Health, 2020; Ribot et al., 2020).

The communication component in delivering preventive messages to the population must also be highlighted. This was possible through the installation of web platforms for the delivery of preventive recommendations and information regarding where to go in case of being affected by a specific situation, collecting all the actions of the public policies of the State to face the pandemic. The Healthy Mind program of the State of Chile stands out in this regard. It is based on several recommendations of the Inter-American Psychological Society; its actions are segmented into the general population; boys, girls, and adolescents; older adults; moms, dads, and caregivers; educational community; women, people with COVID-19; people with disabilities and health personnel (Government of Chile, 2020). This web platform allows online access to a group of professionals who provide help and information to people, including self-care advice and support from specialists. Within this line of action, similar to the Chilean case, we find Mexico. Mexico also has a web page with advice and telephone numbers to ask for professional help in different areas, based explicitly on various emotional states (Government of Mexico, SF). In Peru, it was possible to find telephone platforms answered by specialists to address mental health issues (Government of Peru, n.d.). On the other hand, in Argentina and Ecuador, it was only possible to access normative documents such as guides and action protocols in various situations under a COVID-19 context.

Finally, it was difficult to find publications that address the construction of mental health public policies in the context of COVID-19 since not all countries have developed research on the subject. Therefore, there is an opportunity to increase studies and research in this area. In fact, in terms of mental health in a pandemic, the literature review concludes that the academy has not made enough analysis of public policy on mental health based on COVID-19. The measures adopted, in general, were rapid responses with a preventive approach when the pandemic was already unleashed. These measures followed mainly the guidelines provided by international organizations that stand out in global health governance, and which in their role of providing global public services, came out strengthened. They legitimized their actions and validated themselves as reference agencies for all governments worldwide.

 

Conclusion

The COVID-19 pandemic affected the entire population in different ways. It affected directly with infections and deaths, and indirectly due to the consequences of the measures that had to be taken to face it, such as quarantines and individual and social freedoms restrictions. Confinements affected mental health the most, but this was, at the same time, the least visible of the effects. In this context, children, and adolescents, the elderly, the sick, and health personnel who fought the virus on the front line were the risk groups identified as more likely to be affected by the virus in both ways. Still, the effect that it could have on other workers, women, men, and sexual dissidents was left aside.

From a gender perspective, the pandemic has affected women and men differently. Women experienced job insecurity and had to work more on the house chores, which jeopardized their mental health in the face of this overwhelming burden. On the other hand, men experienced certain tranquility in the workplace; confinement affected their physical health and consequently their mental health, causing an increase in the domestic violence exerted by them. However, at this point, emphasis should be placed on the processes of returning to normalcy, as leaving home to go to the office can become a significant stressor due to the possibility of bringing the virus home, where children under six years of age have not been vaccinated. Also, this triples the workload for women by adding the trip to and from work and having to prepare the family in the morning. Baring this in mind, mothers and fathers should be given time flexibility.

From the workers’ point of view, we must highlight the health personnel who exposed their lives, families, and mental health to combat the pandemic. But they were not the only ones; another sector played a fundamental role in developing “virtual” education: teachers. They had to quickly adapt their teaching techniques to continue with their work in a “normal” way amid the pandemic, causing an increase in stress by 51%, often without feedback from their workplaces and working extra hours. Another workgroup that was affected and exposed were essential services workers, who were not investigated for these pathologies the same way as health workers. Essential services workers also exposed their lives since they could not stay at home teleworking; this is the case of janitors, garbage collectors, security personnel, cleaners, and caretakers. Extraordinary measures should be taken for these workers, who carried out superhuman work during the pandemic. They must be rewarded with vacation days and monetary incentives; they are heroes.

Regarding the public policies adopted by the different governments to face mental health during COVID-19, we found more actions than directed policies per se. There was no greater increase in psychological or psychiatric consultation hours to support citizens in general. Still, there was an increase in channels of help for citizens through telephone lines, web pages, and normative guides. These actions were deployed quickly and consistently under the parameters of international organizations. However, now is the time to take profound action to address the population’s mental health. We are in the process of returning to “normalcy,” and we are thinking about the post-pandemic stage. However, in this gray area, measures must be taken to support the improvement, maintenance, and recovery of people’s mental health who have gone through a tremendous collective crisis such as this pandemic.

 

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