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Mental disorders are among the leading causes of the global burden of disease. The 2019 Global Burden of Disease, Injury and Risk Factors (GBD) Study showed that the two most disabling mental disorders were depressive and anxiety disorders, both ranked among the top 25 causes throughout life, for both sexes and in many parts of the world. Another interesting piece of information is that no reduction in prevalence or overall burden has been detected for any of the disorders since 1990, despite compelling evidence of interventions that reduce their impact.
As doctors we are often very good at treating illness, but often not so good at treating the person. The focus of our attention has been on the specific physical condition rather than on the patient as a whole. We have paid less attention to psychological health and how it can contribute to physical health and illness.
However, more and more we see how psychological health can influence not only negatively, but also positively, on the health-disease process.
Few months ago the American Heart Association (AHA) was commissioned to evaluate, synthesize, and summarize for the medical community the knowledge to date on the relationship between psychological health and cardiovascular health and disease.
The World Health Organization (WHO) defines mental health as “a state of well-being in which a person realizes their own potential, can cope with the normal stresses of life, can work productively and fruitfully and contribute to their well-being or that of their community. “
Negative psychological health includes depression, chronic stress, anxiety, anger, pessimism, and dissatisfaction with current life. Positive psychological health is also multifaceted and can be characterized by a sense of optimism, purpose, gratitude, endurance, positive affect (i.e., positive emotion), and happiness.
A little over a year and a half ago, humanity was threatened by the appearance of the COVID-19 pandemic, which exacerbated the negative aspects of psychological health in a context that was already unfavorable for the aforementioned and generates concern about the resulting effects on mental health through its direct psychological effects and its long-term economic and social consequences.
So far no study has looked at the global impact of the COVID-19 pandemic on the prevalence of major depressive disorder and anxiety disorders. Previous work consisted of surveys in specific places for short periods.
Lancet published a systematic review to identify data from population surveys published between January 1, 2020 and January 29, 2021, with the aim of evaluating the global impacts of the pandemic on major depressive disorder and anxiety disorders, quantifying the prevalence and burden of disorders by age, sex, and location in 204 countries and territories in 2020.
Eligible studies reported the prevalence of depressive or anxiety disorders that were representative of the general population and had pre-pandemic baseline information. Using a disease modeling meta-analysis tool, data from eligible studies were used to estimate changes in the prevalence of major depressive disorder and anxiety disorders due to COVID-19 by age, sex, and location.
Estimates of the daily rate of COVID-19 infection and the movement of people were used as indicators of the impact of the pandemic on populations.
The systematic review identified 5,683 data sources, of which 48 met the inclusion criteria. Most of the studies were conducted in high-income Western Europe (22) and North America (14); the remainder in Australasia (5), high-income Asia Pacific (5), East Asia (2), and Central Europe (1).
The meta-analysis showed that increasing the rate of COVID-19 infection and reduced movement of people were associated with a higher prevalence of major depressive disorder and anxiety disorders, suggesting that the countries most affected by the pandemic in 2020 had the largest increases in the prevalence of these disorders.
In the absence of the pandemic, model estimates suggest that there would have been 193 million cases of major depressive disorder (2,471 cases per 100,000 population) worldwide in 2020. However, the analysis shows that there were 246 million cases (3,153 per 100,000), an increase of 28% (53 million additional cases). More than 35 million of the additional cases were in women, compared with about 18 million in men.
With respect to anxiety disorder, model estimates suggest that there would have been 298 million cases of these disorders (3,825 per 100,000 population) globally in 2020 had the pandemic not occurred. The analysis indicates that there were in fact an estimated 374 million cases (4,802 per 100,000) during 2020, an increase of 26% (76 million additional cases). Almost 52 million of the additional cases were in women, compared with about 24 million in men.
Younger people were more affected by major depressive disorder and anxiety disorders than older age groups. The additional prevalence of these disorders peaked among people aged 20-24 years (1,118 additional cases of major depressive disorder per 100,000 and 1,331 additional cases of anxiety disorders per 100,000) and decreased with increasing age.
The pandemic has exacerbated many existing inequalities and social determinants of mental health, and women have been the hardest hit.
School closures and broader restrictions that limited young people’s ability to learn and interact with their peers, along with the increased risk of unemployment, also meant higher numbers of major depressive disorder and anxiety during the pandemic in this group.
With regard to cardiovascular health and risk, there is evidence from observational studies and large administrative databases showing that psychological stress, trauma, anger, hostility, and mental health disorders, as well as positive psychological attributes , influence cardiovascular health.[3,4]
Due to the methodology of these analyzes, there is potential misclassification and confounding bias, which presents challenges in establishing causal associations. However, many studies have used a methodology that includes carefully adjudicated events and objective measures of cardiovascular disease and adjustments for a wide variety of potential confounders.[5,6]
During the pandemic, it could be easy to explain the reduction in scheduled procedures in cardiovascular disease, due to the suspension measures taken by the authorities. But the explanation of why cardiovascular emergency visits decreased is more complex. Possible explanations would be:
There was a real decrease related to isolation at home, not attending work, modification of eating habits and use of leisure time. This implies, on the one hand, a lower exposure to contagions of other viral diseases that play a role known as a triggering factor in heart failure and acute coronary syndromes, as well as less work stress.
There was no such decrease and on the contrary there was an increase, because global mortality includes violent deaths, which decreased in that period, being able to be replaced by deaths of cardiovascular origin due to triggers such as stress due to the loss of a job source, fear to get sick, lack of social interaction, in addition to bad eating habits in the most vulnerable sectors, lack of physical activity and fear of consulting in hospitals due to the risk of infection.
At the moment it is difficult to estimate the impact of inattention on cardiovascular disease. Only time will allow us to understand it and it is interesting to ask whether part of the cardiovascular disease of COVID-19 has a component related to the psychological stress experienced.
Returning to the systematic review published in The Lancet, the authors acknowledge that their study was limited by the lack of high-quality data on the effects of the COVID-19 pandemic on mental health in many parts of the world, particularly in low- and middle-income countries.
For this reason, estimates extrapolated for other countries where data are lacking should be done with caution. Most of the available data was based on self-reported symptom scales that only estimate probable cases of major depressive disorder and anxiety disorders. More data from representative mental health diagnostic surveys of the general population, of which only three covered the study period, will improve understanding of the effects of the pandemic on mental health.
The prevalence of other mental disorders, such as eating disorders, could also have been affected by the COVID-19 pandemic and the authors believe these should be assessed as new mental health surveys are conducted.
The available information, beyond the methodological limitations mentioned, is very relevant and imposes a call to action to strengthen mental health systems and urgently encourage more research in order to determine the most complete geographic distribution of depression and depression. anxiety, the prevalence of depressive and anxiety disorders, and the underlying mechanisms for improving mental health in the context of the global COVID-19 pandemic.
Depressive and anxiety disorders increased during 2020 due to the COVID-19 pandemic.
Even before this, depressive and anxiety disorders were the main causes of disease burden worldwide, despite the existence of intervention strategies that can reduce their effects.
Meeting the additional demand for mental health services due to COVID-19 will be difficult, but not impossible. Mitigation strategies should promote mental well-being and target the determinants of poor mental health exacerbated by the pandemic, as well as interventions to treat those who develop a mental disorder.
On the other hand, it is essential that doctors in general take note of the following:
Psychological health is an important component of the well-being of patients.
There is a substantial set of good quality data showing clear associations between psychological health and physical health.
There is growing evidence that psychological health may be causally related to biological processes and behaviors that contribute to and cause disease.
The preponderance of data suggests that interventions to improve psychological health may have a beneficial impact on overall health. Doctors should use simple screening measures to assess the state of psychological health.
Diseases should not be treated as an isolated entity, but as a part of an integrated system, that is to say: “the person as a whole”.
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