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Motivation and emotion/Book/2021/COVID-19 and mental health

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COVID-19 and mental health
What is the impact of COVID-19 on mental health?
[ Multimedia presentation (3 min)]

Overview

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Figure 1. Many are advocating for more mental health support worldwide during the COVID-19 pandemic.

COVID-19, also known as the coronavirus pandemic, is an ongoing worldwide pandemic which involves detrimental effects to a person's respiratory system depending on their age, health status, and so on. The pandemic has caused global lockdowns, quarantining for sometimes long periods of time for a large number of people and the breakdown of many nations' economies due to lack of trade and tourism. The virus has been the cause of almost 4.5 million deaths worldwide as of August 2021, making it one of the deadliest viruses in history[factual?]. There have also been many variants of the virus, such as the alpha and delta strains, with increased transmissibility leading to significant increases in case numbers.

There have been many studies that have analysed the effect of COVID-19 on people's overall mental health. Studies have shown that global levels of mental health have steadily declined over the course of the pandemic within the entire worldwide population. The pandemic has had an affect on many aspects of everyday life such as the global economy, socialization, etc. It has been taxing in sociocultural and economic terms and has stretched the limits of healthcare supplies and numbers of staff. The sheer amount of COVID-19 cases around the world shows just how much of an impact it has had on the global population. With the coronavirus on such a huge worldwide scale, it is no wonder people's mental health are being affected dramatically by this event.

Ways the coronavirus has affected the mental health of the population include lockdown restrictions, making people feel like they are stuck, fear about the disease and hopelessness, thinking that things will never get any better[grammar?]. Effects of COVID-19 on preexisting disorders such as OCD and depression are discussed in this chapter, as well as mental health of specific populations such as essential workers, the elderly and children. Theoretical frameworks relevant to mental health during COVID-19 such as Maslow's Hierarchy of Needs will also be discussed in this book chapter.

Effect of COVID-19 on preexisting disorders

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COVID-19 has exacerbated symptoms of preexisting mental health disorders in many people, such as people with depression, OCD and PTSD.

COVID-19 and major depressive disorder

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Numerous findings indicate that levels of Major Depressive Disorder have increased since the beginning of the pandemic[1]. Treatment of clients with MDD has become more difficult during the COVID pandemic, as people are unable to seek psychological help in person. During quarantine and lockdowns, loneliness and negative thoughts have become more prominent in people predisposed to have these thoughts, as people are much less likely to be interacting with others during lockdowns[factual?]. Social interaction and socialization are critical components of normal human functioning, benefiting both physical and mental health[2].

COVID-19 and obsessive compulsive disorder

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Obsessive Compulsive Disorder consists of unwanted intrusive thoughts, and rituals and compulsive behaviors used in order to rid these intrusive thoughts. COVID-19 has been shown to increase suicidal ideation in people with preexisting psychiatric disorders such as Obsessive Compulsive Disorder[3]. Many people with OCD have obsessions about germs and diseases, being worried that they will either catch a sickness themselves or they will pass it on to someone else. With their compulsions including behaviours such as excessive handwashing, showering, avoidance of crowded spaces etc, revised global health guidelines have normalized these compulsive behaviors[4]. This in a way undermines the main method of treating OCD, which is cognitive behavioral therapy. Trauma can be a trigger to OCD, making children and young people vulnerable to germ-related OCD for years after the pandemic[5].

COVID-19 and generalized anxiety disorder

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Anxiety disorders such as Generalized Anxiety Disorder (GAD) have been the most common mental illness in the United States pre-COVID-19. With around 19% of adults experiencing an anxiety disorder in their lifetime, it is worth looking at prevalence rates for this disorder during the pandemic[6]. Children and adolescents are also vulnerable to Generalized anxiety disorder (GAD) especially during the COVID-19 pandemic[7]. People with GAD reported higher levels of stress and loneliness regarding their mental state during the pandemic than those without GAD[8] and individuals with GAD also expressed higher ratings of stress than those without GAD regarding stay-at-home policies such as concern about maintaining income, being isolated for an extended period of time, etc.[9] Considering the pandemic brought stress to those without GAD, the situations that arise due to COVID-19 such as isolation no doubt exacerbate symptoms of those that suffer with GAD.

In [missing something?] study done in Ireland on people with GAD the study showed that people were more likely to have these disorders if they were of a younger age demographic, had lost income due to COVID-19, had more than one child in their household, had a confirmed case of COVID-19 and if they had been at high risk of contracting COVID-19[10]. These cases of GAD show that COVID-19 has had a massive effect on people with this disorder. The main aims of this study were to analyze what percentage of the Irish population for depression and GAD during the initial phase of the COVID-19 quarantine period and the second aim being to determine if these feelings of depression or anxiety related to the COVID-19 pandemic were higher among those in Ireland who were most at risk of death from COVID-19 (those who were aged 65 or older, and those with underlying health conditions such as heart disease, lung disease, etc).

COVID-19 and post traumatic stress disorder

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The COVID-19 pandemic represents one of the most overall stressful events socially, psychologically and economically in recent times. Risk factors such as being female and coming from a low socioeconomic background contributed to higher levels of SARS-related post traumatic stress symptoms[11]. Professionals who are involved in diagnosing and treating those with COVID-19 (doctors, nurses, etc) are more likely to develop Post Traumatic Stress disorder[12]. Additionally, it has been found that around one third of survivors of the COVID-19 disease who experience the sensation of being unable to breathe develop symptoms of post traumatic stress disorder afterwards[13]. A study was conducted assessing the prevalence of PTSD among nurses working in a COVID-19 hospital. The study found that 40% of nurses who worked in the emergency department during the COVID-19 period received a provisional PTSD diagnosis which required further assessment[14]. The study also found that the activities that caused the most distress in nurses were connected to technical skills that were required for managing ventilation and intubation.

 


Case Study 1

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Ellie is a 20 year old woman, diagnosed with generalised anxiety disorder when she was 14. She studies a nursing degree and is in her final year. The COVID-19 pandemic has just hit, which is causing her GAD to spike. She worries that she will get the virus and pass it on to her older parents, or her friend who has respiratory issues. She also worries about her career choice, anticipating stress on the medical system when she gets a job in a hospital next year.

Mental Health of essential workers

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Healthcare workers

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The mental health of essential workers such as healthcare workers during the pandemic has often been overlooked. With 'essential work' being fields of healthcare, agriculture, public transportation, etc, COVID-19 has affected individuals in these lines of work in many way[grammar?]. Among healthcare workers, frontline workers such as doctors and nurses are the most at risk of developing mental illness symptoms[15]. Essential workers are at greater risk of anxiety and depression compared to those in nonessential work areas, as this was especially the case during the March/April/May 2020 lockdowns all over the world[16]. With healthcare workers especially being under pressure from the amount of COVID patients streaming into hospitals, the mental health of nurses and doctors is under strain as they work long hours with, unable to afford to take breaks. Being exposed almost all the time to the virus, this also creates a sense of danger for healthcare workers, especially those with underlying health conditions. Poor working conditions such as lack of appropriate PPE [explain?] equipment and excessive overtime work during the pandemic leads to greater levels of anxiety and depression in nurses and other frontline healthcare workers[17].

Farmers and agriculture

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Figure 2. Nurses work 12 hour long shifts without a break in what seems like a never-ending war.

Essential workers also include people who work in the farming and agriculture industry. At first, the COVID-19 pandemic didn't seem to have much of an affect on farmers, as farms a lot of the time are secluded and socially distant from the rest of society. However, the economic effects started to show later on, with meat processing beginning to shut down due to COVID outbreaks, difficulty in securing seasonal workforce at critical times, and the overall supply chain slowed down immensely[18]. Even before the pandemic, the overall demographic of farmers have had a history of struggling with mental health and misusing substances such as alcohol[factual?]. Farmers having to destroy crops and dispose of milk because there is no available market access for them has most likely taken a huge toll on their mental health[factual?].

Early childhood workers

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Another essential service includes providing childcare for children of essential workers. Schools all over the world have been shut down on and off, however most of the time early childhood centers have remained open for those who are unable to take care of their children during the day. A survey conducted by Monash University in 2020 indicated that COVID-19 has had a strong impact on early childhood educators in Australia, with them feeling that their work is being devalued compared to school-level teachers over the course of the pandemic[19]. With wellbeing of educators being not just important to the educators themselves, but also the children they care for, early childhood educators, already under stress from their job alone[factual?], have been put under more pressure by the COVID-19 pandemic.

 


Case Study 2

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Richard is a 48 year old farmer in Western New South Wales, Australia. Even before the pandemic, he has had to deal with many unknowns such as weather and market fluctuations, with added uncertainty of pricing for his crops. Since the pandemic, Richard's supply availability has decreased due to pricing uncertainty. Being a farmer in a rural area, Richard's mental health has already been on the vulnerable side, however the uncertainty of everything surrounding the pandemic has made him anxious and has left him feeling suicidal.

Mental health of the elderly during COVID-19

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With elderly individuals being more at risk to having more adverse and life threatening symptoms of COVID-19, this sense of danger could potentially put elderly mental health under strain. In March of 2020, over 80% of deaths from COVID-19 were aged 65 and older, indicating a higher vulnerability to the virus[20]. Additionally, with older people in nursing homes and receiving at-home care, visitors would rarely be allowed during lockdown such as family and friends. Despite these risk factors, it has been found overall that older adults are less likely to acquire depressive symptoms and anxiety symptoms than younger people during the COVID-19 lockdowns[21]. Early data suggests that older individuals are more resilient to the anxiety and depression related mental health disorders that has been shown among younger people. In August of 2020, the Centers for Disease Control and Prevention found in a survey across the United States that participants aged 65 and over reported a much lower level on the anxiety and depression scale during the lockdown periods. Older people may seem to have a higher emotional resilience when it comes to the pandemic, however this doesn't mean elderly people weren't affected by it at all. A study conducted in the general public of China indicated that 37.1% of the elderly had experienced depressive and anxiety symptoms[22] due to the pandemic.

Mental health of children during COVID-19

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The COVID-19 pandemic has altered the lives on[spelling?] many children around the world, taking away their routine and continuity. Schools have been shut and children have been directed to online learning, meaning they get no interaction with their peers and teachers. Without these interactions, children are susceptible to growing up with altered life skills, such as socialisation. Mothers of young children have also been found to have a higher risk factor of depression even when disregarding the pandemic, in which the mental health of the mother heavily affects the child's development[23]. With routine being important to everyone's wellbeing, and especially so for children, COVID has affected most people's daily and nightly routines. Without a home routine, children are susceptible to poor mental health during the lockdowns[24]. Children's routines such as weekend or weekday after-school sport, weekly attendance of school, and for some children psychologist/psychiatrist appointments provide a sense of stability and security for the child. With this sense of stability being threatened, including activities of interaction and learning, it is possible that a child's development will be retarded or deficient, especially for younger children.

Treatment of mental health during COVID-19

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Due to COVID-19, most psychological sessions for people with preexisting mental health conditions are now via telehealth or e-health. Mental health professionals such as psychologists and psychiatrists are utilizing online services such as Zoom and WeChat in order to communicate with their clients and patients. Telehealth reduces COVID-19 transmission by preventing any physical contact between the patient and the health professional, making it an effective alternate solution to face-to-face treatment during a pandemic. Videoconferences have shown to be more effective than phone calls, but obviously there is no online option for those that need help with serious mental situations or suicide attempts[25]. For some patients, telehealth could potentially be an even more anxiety provoking way of seeking treatment than in-person sessions, especially for those whose internet is either non-existent or slow (such as people in rural areas). For those with already existing anxiety, the issues that they could have with their internet could amount to a source of stress. For people with much more specific mental health disorders, such as OCD, relying on computers could also be the subject of anxiety depending on the illness.

Despite these potential negative effects telehealth could have on people with preexisting disorders, the pandemic has been helpful for the development of telehealth and online mental health services. The provision of health services is improved by telehealth, especially during the pandemic. For people with preexisting disorders who prefer the methods of telehealth and e-health, the pandemic has been useful for the development of this service and helps these people, maybe making mental health treatment much easier than before.[factual?]

Theoretical frameworks

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[Provide more detail]

The Motivational Urge (Action Tendency) Associated with Emotions

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This [which?] theory describes three levels of emotion categories, being basic, self conscious and cognitive. Reeve (2018) has put the emotions under these categories into a table, showing next to them the motivational urges that are paired with the emotions[26]. Fear and sadness and joy, falling under the 'basic' category of emotion, are 'ubiquitous experiences', and are relevant emotions that occur during the COVID pandemic. For fear, Reeve states that the motivational urge for this emotion is the urge to 'protect oneself'. In this case, protecting oneself would be socially isolating from the rest of the world, especially those with phobias of infectious diseases such as the coronavirus. Sadness is also relevant to this pandemic, as many people feel as though they have lost a significant part of their lives, spending most of it in isolation. With Reeve stating the motivational urge for sadness as 'the repair of a loss or a failure', many people feel as though they need to make up for the time lost during the pandemic. For those who have lost loved ones to the virus, this urge is even more relevant. In terms of joy, in which this emotion's motivation is to goal strive and engage in social interaction, many people's sources of joy have been taken away during the pandemic, such as goals and interactions with others. This may lead to an individual's motivation associated with this emotion being lessened or taken away completely.[factual?]

Maslow's Hierarchy of Needs

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Figure 3. Maslow's Hierarchy of Needs highlights basic human desires that we need in order to live a 'happy' life.

Maslow's Hierarchy of Needs is a motivational framework that consists of five tiers of human needs, including physiological, safety, love, esteem and self-actualization. With safety being the second level, this including security of employment, health, resources, etc, the COVID-19 pandemic has threatened the stability of people's 'Safety'. With unemployment rates in the United States soaring to 14.8% in April of 2020[27], security in terms of employment dropped to an all time low. Additionally, with health of the individual and their family being threatened by the huge spread of the virus, this also affects the safety aspect of Maslow's hierarchy of needs.

Love and belonging, being the third tier of the hierarchy, is also another factor that has been affected by the pandemic. Friendship and intimacy is affected by constant lockdowns and quarantine periods, as well as working from home. Isolation from friends, family and intimate partners has been a common occurrence during the pandemic, essentially affecting the mental health of those who rely more on human contact and interaction.

Conclusion

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The purpose of this chapter was to answer the question, 'What is the impact of COVID-19 on mental health?'. Summarizing the results of the external references and case studies, it seems that the impact of COVID-19 on the general population's mental health is significant, making individuals deteriorate in terms of their already existing mental illnesses, and people develop new ones due to the situational contexts of the pandemic. Over the course of the COVID-19 pandemic, governments have slowly paid more attention to citizens' mental health, such as allowing people to go outside and exercise for an hour or more a day in order to sustain good mental health. Governments, such as the Australian government, are also providing disaster payments to those citizens who have lost income due to the pandemic. These payments, in a way, give people incentive to do the right thing and follow the public health advice, as they soften the blow of the loss. Although overall mental health has been damaged by the COVID pandemic, one positive impact that the pandemic could have on the general population is that they will potentially come out of this period with a much more resilient mindset, maybe improving their reactions and responses to other crises in the future. In terms of practical messages, governments need to continue to follow the advice of psychiatrists and mental health experts during the course of this pandemic in order to nurture the mental health of their citizens during large scale disasters like the COVID-19 pandemic.

See also

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References

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  1. ↑ Wu. J, Wu. Y, Yu. T (2021), Temporal associations among loneliness, anxiety, and depression during the COVID-19 pandemic period. Accessed at: https://doi-org.ezproxy.canberra.edu.au/10.1002/smi.3076
  2. ↑ Publisher, Author removed at request of original (2016-04-08). 4.1 The Importance of Socialization (in en). https://open.lib.umn.edu/sociology/chapter/4-1-the-importance-of-socialization/. 
  3. ↑ Khosravani, Vahid; Samimi Ardestani, Seyed Mehdi; Sharifi Bastan, Farangis; McKay, Dean; Asmundson, Gordon J. G. (2021-04-21). "The associations of obsessive-compulsive symptom dimensions and general severity with suicidal ideation in patients with obsessive-compulsive disorder: The role of specific stress responses to COVID-19". Clinical Psychology & Psychotherapy. doi:10.1002/cpp.2602. ISSN 1099-0879. PMID 33881790. PMC 8250844. https://pubmed.ncbi.nlm.nih.gov/33881790/. 
  4. ↑ Toh, Wei Lin; Neill, Erica; Phillipou, Andrea; Tan, Eric J.; Rheenen, Tamsyn E. Van; Meyer, Denny; Rossell, Susan L. (2021). "Obsessive–compulsive disorder and related symptoms amidst the COVID-19 outbreak: Results from the COLLATE project". Psychiatry and Clinical Neurosciences 75 (4): 146–148. doi:10.1111/pcn.13202. ISSN 1440-1819. PMID 33470504. PMC PMC8013877. https://onlinelibrary.wiley.com/doi/abs/10.1111/pcn.13202. 
  5. ↑ Nissen, J. B.; Højgaard, D.R.M.A.; Thomsen, P. H. (2020-10-20). "The immediate effect of COVID-19 pandemic on children and adolescents with obsessive compulsive disorder". BMC Psychiatry 20 (1): 511. doi:10.1186/s12888-020-02905-5. ISSN 1471-244X. PMID 33081741. PMC PMC7573524. https://doi.org/10.1186/s12888-020-02905-5. 
  6. ↑ Cordaro, Millie; Grigsby, Timothy J.; Howard, Jeffrey T.; Deason, Rebecca G.; Haskard-Zolnierek, Kelly; Howard, Krista (2021-08). "Pandemic-Specific Factors Related to Generalized Anxiety Disorder during the Initial COVID-19 Protocols in the United States". Issues in Mental Health Nursing 42 (8): 747–757. doi:10.1080/01612840.2020.1867675. ISSN 1096-4673. PMID 33480832. https://pubmed.ncbi.nlm.nih.gov/33480832/. 
  7. ↑ Li, Yumei; Duan, Wenjie; Chen, Zheng (2020-9). "Latent profiles of the comorbidity of the symptoms for posttraumatic stress disorder and generalized anxiety disorder among children and adolescents who are susceptible to COVID-19". Children and Youth Services Review 116: 105235. doi:10.1016/j.childyouth.2020.105235. ISSN 0190-7409. PMID 32834272. PMC 7342099. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342099/. 
  8. ↑ Cordaro, Millie; Grigsby, Timothy J.; Howard, Jeffrey T.; Deason, Rebecca G.; Haskard-Zolnierek, Kelly; Howard, Krista (2021-08). "Pandemic-Specific Factors Related to Generalized Anxiety Disorder during the Initial COVID-19 Protocols in the United States". Issues in Mental Health Nursing 42 (8): 747–757. doi:10.1080/01612840.2020.1867675. ISSN 1096-4673. PMID 33480832. https://pubmed.ncbi.nlm.nih.gov/33480832/. 
  9. ↑ Cordaro, Millie; Grigsby, Timothy J.; Howard, Jeffrey T.; Deason, Rebecca G.; Haskard-Zolnierek, Kelly; Howard, Krista (2021-08). "Pandemic-Specific Factors Related to Generalized Anxiety Disorder during the Initial COVID-19 Protocols in the United States". Issues in Mental Health Nursing 42 (8): 747–757. doi:10.1080/01612840.2020.1867675. ISSN 1096-4673. PMID 33480832. https://pubmed.ncbi.nlm.nih.gov/33480832/. 
  10. ↑ Hyland, P.; Shevlin, M.; McBride, O.; Murphy, J.; Karatzias, T.; Bentall, R. P.; Martinez, A.; Vallières, F. (2020-09). "Anxiety and depression in the Republic of Ireland during the COVID-19 pandemic". Acta Psychiatrica Scandinavica 142 (3): 249–256. doi:10.1111/acps.13219. ISSN 1600-0447. PMID 32716520. https://pubmed.ncbi.nlm.nih.gov/32716520/. 
  11. ↑ Bonichini, Sabrina; Tremolada, Marta (2021-04-20). "Quality of Life and Symptoms of PTSD during the COVID-19 Lockdown in Italy". International Journal of Environmental Research and Public Health 18 (8). doi:10.3390/ijerph18084385. ISSN 1661-7827. PMID 33924236. PMC 8074764. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8074764/. 
  12. ↑ Marcomini, Ilaria; Agus, Cristina; Milani, Laura; Sfogliarini, Roberto; Bona, Annamaria; Castagna, Marco (2021-06-15). "COVID-19 and post-traumatic stress disorder among nurses: a descriptive cross-sectional study in a COVID hospital". La Medicina Del Lavoro 112 (3): 241–249. doi:10.23749/mdl.v112i3.11129. ISSN 0025-7818. PMID 34142675. PMC 8223933. https://pubmed.ncbi.nlm.nih.gov/34142675/. 
  13. ↑ "PTSD From COVID-19? What You Should Know". Cedars-Sinai. Retrieved 2021-10-05.
  14. ↑ Marcomini, Ilaria; Agus, Cristina; Milani, Laura; Sfogliarini, Roberto; Bona, Annamaria; Castagna, Marco (2021-06-15). "COVID-19 and post-traumatic stress disorder among nurses: a descriptive cross-sectional study in a COVID hospital". La Medicina Del Lavoro 112 (3): 241–249. doi:10.23749/mdl.v112i3.11129. ISSN 0025-7818. PMID 34142675. PMC 8223933. https://pubmed.ncbi.nlm.nih.gov/34142675/. 
  15. ↑ Maroufi, Khashayar; Razavi, Rashin (2021). "Nurses’ mental health and COVID-19 pandemic: Is there any approach?". Nursing Open 8 (5): 2004–2006. doi:10.1002/nop2.930. ISSN 2054-1058. PMID 33979027. PMC PMC8242563. https://onlinelibrary.wiley.com/doi/abs/10.1002/nop2.930. 
  16. ↑ Bell, Caroline; Williman, Jonathan; Beaglehole, Ben; Stanley, James; Jenkins, Matthew; Gendall, Philip; Rapsey, Charlene; Every-Palmer, Susanna (2021-07-01). "Challenges facing essential workers: a cross-sectional survey of the subjective mental health and well-being of New Zealand healthcare and ‘other’ essential workers during the COVID-19 lockdown". BMJ Open 11 (7): e048107. doi:10.1136/bmjopen-2020-048107. ISSN 2044-6055. PMID 34281926. https://bmjopen.bmj.com/content/11/7/e048107. 
  17. ↑ Sampaio, Francisco; Sequeira, Carlos; Teixeira, Laetitia (2020-10). "Nurses’ Mental Health During the Covid-19 Outbreak: A Cross-Sectional Study". Journal of Occupational and Environmental Medicine 62 (10): 783–787. doi:10.1097/JOM.0000000000001987. ISSN 1076-2752. https://journals.lww.com/joem/fulltext/2020/10000/nurses__mental_health_during_the_covid_19.2.aspx. 
  18. ↑ www.apa.org https://www.apa.org/topics/covid-19/farming-communities-stress. Retrieved 2021-09-28. {{cite web}}: Missing or empty |title= (help)
  19. ↑ "Childcare educators are feeling the strain in the COVID crisis". Monash Lens. 2020-08-05. Retrieved 2021-09-28.
  20. ↑ Lee, Kunho; Jeong, Goo-Churl; Yim, JongEun (2020-11). "Consideration of the Psychological and Mental Health of the Elderly during COVID-19: A Theoretical Review". International Journal of Environmental Research and Public Health 17 (21): 8098. doi:10.3390/ijerph17218098. ISSN 1661-7827. PMID 33153074. PMC 7663449. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7663449/. 
  21. ↑ Vahia, Ipsit V.; Jeste, Dilip V.; Reynolds, Charles F., III (2020-12-08). "Older Adults and the Mental Health Effects of COVID-19". JAMA 324 (22): 2253–2254. doi:10.1001/jama.2020.21753. ISSN 0098-7484. https://doi.org/10.1001/jama.2020.21753. 
  22. ↑ Lee, Kunho; Jeong, Goo-Churl; Yim, JongEun (2020-11). "Consideration of the Psychological and Mental Health of the Elderly during COVID-19: A Theoretical Review". International Journal of Environmental Research and Public Health 17 (21): 8098. doi:10.3390/ijerph17218098. ISSN 1661-7827. PMID 33153074. PMC 7663449. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7663449/. 
  23. ↑ Cameron, Emily E.; Joyce, Kayla M.; Delaquis, Chantal P.; Reynolds, Kristin; Protudjer, Jennifer L. P.; Roos, Leslie E. (2020-11-01). "Maternal psychological distress & mental health service use during the COVID-19 pandemic". Journal of Affective Disorders 276: 765–774. doi:10.1016/j.jad.2020.07.081. ISSN 0165-0327. https://www.sciencedirect.com/science/article/pii/S016503272032526X. 
  24. ↑ Roy, Adrija; Singh, Arvind Kumar; Mishra, Shree; Chinnadurai, Aravinda; Mitra, Arun; Bakshi, Ojaswini (2021-08-01). "Mental health implications of COVID-19 pandemic and its response in India". International Journal of Social Psychiatry 67 (5): 587–600. doi:10.1177/0020764020950769. ISSN 0020-7640. PMID 32873106. PMC PMC7468668. https://doi.org/10.1177/0020764020950769. 
  25. ↑ de Siqueira Rotenberg, Luisa; Nascimento, Camila; Cohab Khafif, Tatiana; Silva Dias, Rodrigo; Lafer, Beny (2020-09). "Psychological therapies and psychoeducational recommendations for bipolar disorder treatment during COVID-19 pandemic". Bipolar Disorders 22 (6): 644–646. doi:10.1111/bdi.12981. ISSN 1399-5618. PMID 32780503. PMC 7436460. https://pubmed.ncbi.nlm.nih.gov/32780503/. 
  26. ↑ Reeve. J (2018), Understanding Motivation and Emotion, 7th Edition. Korea University. p.340.
  27. ↑ Falk. G, Romero. P (2021). "Unemployment Rates during the COVID-19 Pandemic". Congressional Research Service. Accessed at: https://sgp.fas.org/crs/misc/R46554.pdf
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