Waves of Mental Health Demands During the COVID-19 Pandemic

: This work presents a compilation of data obtained by clinical psychologists during the Covid-19 pandemic in Brazil. Through searches on social media with #Covid19 and #MentalHealth and the exchange of information on networks of professionals, it was possible to compile and group the main psychological symptoms presented during isolation. Information was clustered according to the period it appeared, in order to guide future situations. Moreover, to prepare a group of clinical psychologists to provide online assistance.


Introduction
The declaration of COVID-19 Pandemic by the World Health Organization on March 11, 2020, brought several impacts for all countries on the planet. In addition to economic and political issues, it also brought social, emotional, and behavioral impacts.
As the world prepared itself by closing borders, airports, isolating populations, and all other public health decisions, the waves of mental health demands started progressively. Beginning in China and later spreading to Europe, especially Italy and Spain until it got to the USA, Brazil and other countries in America, we perceived different phases of psychological demands, whether it was to the mental health services by phone or the online modality, adopted by most mental health professionals in the world.
We built this article on a multi-site approach and on multiple time frames 1 . It articulates the perception of psychologists who are working in actions to confront COVID-19, through remote activities in Brazil and experiences shared by coworkers from other countries via social media.
We used the hashtags #Covid19 and #Mental Health to search on social networks. Through them, we created a network of contacts with professionals from other countries who shared articles and reports of interventions. The most recent articles, published or in pre-print were shared among professionals. Through these articles, this one was built as a narrative review. Following the movement of discourses and disconnected actors 2such as the sharing of actions by professionals from countries with different socio-economic and political specificities, in the public responses to coping with COVID-19 -we sough to demonstrate how the demands on the services offered were in Brazil, one of the likely epicenters of the disease in the coming weeks. These connections between experiences with other countries demonstrated how networks are formed, based on the relationships between their elements by bringing together different places and times within a frame of reference, which in this study was called Waves of Mental Health Demands.

Waves of Mental Health Demands
With the pandemic moving in waves around the planet, spreading geographically, it was possible to verify not only its progress from the topographical point of view but also based on the emotional impacts reported. First, China and some Asian countries, such as Thailand, Japan, and South Korea, until it reached the United States and France, still in January 2020. The first major impact, after China, was in Italy 3 , which had their first case on January 30, 2020, but the first death was already in February. With the alarming scenario in Italy, most of the countries began to adopt more drastic measures, such as total isolation (lockdown) and border closure.
We named Waves of Mental Health Demands according to the situation in which each country was, not obeying the chronological order of contagion, since these psychological aspects are directly linked to the public health decisions made by its political leaders. We expect it might help to prevent some consequences of the Covid-19 pandemic 4 .
China reported experiences using online care 5 , and then Italy 6 and France 7 used the same technologies and were followed by other countries. It helped to avoid any unnecessary exposure to the virus 8 .

1st Wave -Pre-Pandemic and the Beginning -Anxiety and Depression
As soon as the population is informed by the local news that the virus has already reached the local cities, first symptoms described by patients and researchers are: -Increase of anxiety levels 9 25 26 , including children 23 24 -Fear of contagion 12 14 19 27 28 -Fear of losing a job 14 27 28 -Social risks and consequences 29 -Fear of death 25 .
-Loneliness / social isolation 12 16 17 18 30 -Increase the use of alcohol and drugs, including relapse 16 31 32 -Insomnia 12 16 33 34 -Easily annoyed or irritable 13 -Fear of going back to work 35 -Lack or excess of information 33 -Fear of shortage resources (treatment, drugs or tests) 33 -Maternity/Pregnancy during Covid-19 Pandemic 36 Fear seems to be the most present feeling in this period 10 19 37 , mainly due to the dissemination of information that has not been scientifically validated. We learned from Italy's experience that it is necessary to concentrate information and pass it on to the public 38 as well as monitoring social media 39 as it can be dangerous spreading fake News or panic 40 , causing what is called infodemic 41 .
Those who already had a mental disorder, such as OCD 42 , may experience an increase in symptoms 14 17 27 33 43 44 . It also includes children and adolescents 45 . Others start to experience the first symptoms and seek help. At this moment, the use of cyberculture resources applied to public health 45 46 was fundamental, especially in teleconsultations and also communications for patients, relatives, and care workers 47 48 .
It is important to note that the concept of "normality" starts to change since it is common during this period to show mood swings, affective lability, irritability. The psychological assistance in this period becomes essential routine guidance, exercises to control anxiety, control the exposure to the media, and tools to deal with new routines 11 49 .
In some countries, many adopted the home office model of working, and the number of marital and family conflicts start to increase. The number of reports of domestic violence 16 rise as aggressive behavior 12 shows as a symptom. The increase in domestic violence is not due to the pandemic itself but to the worsening of marital tensions that already existed before the pandemic context and the distancing of women from their support and protection network, emphasizing the condition of risk 50 .
Some countries anticipated this information through social media reports from various Chinese professionals and newspaper articles and were more attentive in developing possible ways of fighting it. We knew the first wave was coming as the panic had been reported in China 51 52 .
In countries where schools were closed, many parents began to complain about school demands, either due to lack of preparation or lack of skills to deal with the homeschooling model.

2nd Wave -During the Pandemic
During the pandemic, when the deaths begin, the symptoms of the first wave are accentuated. The demands are still related to the early symptoms, but with indications of emotional fatigue, given the prolongation of isolation. It does not matter if it was vertical, social, or total isolation (lockdown). Some new complaints are: -Financial loss 17 33 -Domestic violence 16 17 53 -Marital problems -Emotional isolation 33 -Boredom 16 33 -Stigma 16 18 33 54 55 -Difficulties dealing with homeschooling 24 The different generations that co-habit today have not had experiences with isolation 30 , except for countries that have been involved in international or internal wars. The habit of staying at home, isolated, was something not experienced by millions of people worldwide. Parallel to the feelings of the first wave, the symptoms of fear of contagion 27 28 , fear of death, and considerations about the uncertain future begin to accentuate since many lost their jobs 27 .
Not all countries have implemented social and financial benefit policies to support this period. And even those who have implemented it, the uncertainty of the future, the labor market and the economic situation begins to take over the population.
Another critical point is also the care for the health professionals 20 56 , many of whom are emotionally exhausted 14 17 , and started to use the mental health services provided and describe other symptoms: -Burnout syndrome or high level of stress 16 18 22 57 58 59 60 -Suffering from the absence and separation from their family members, and many of whom are afraid of dying 61 -Fear the contamination. 12 16 19 58 61 62 -Loss of colleagues 62 -Substance abuse 34 -Sleeping problems 63 People undergoing home treatment for Covid-19 start to seek help to deal with their fear of death and isolation 29 , since they need to be totally separated from their loved ones, even in the same house. Those admitted to hospitals, with lighter conditions, also seek emotional refuge on social networks and online forms of care. It is common to find messages in social media from hospitalized people seeking to satisfy their affection and social demands 64 . We should pay attention to those, providing psychological support 12 13 16 .
Parents begin to report domestic difficulties, due to the anxiety or irritability of minors. Parents of teenagers and young adults might face consequences of the excessive use of videogames. 6 65 As the pandemic advances and the number of deaths increases, the number of people seeking psychological help to deal with the grief 6 16 rise too. The deads are no longer numbers and statistics, but they have a first and last name, as well as an affective bond. It is no longer 100 deaths per day, but a brother, a cousin, or even a husband, father, or mother. The professionals then begin to deal with the demands of elaborating mourning, since the ritual of watching over the body and burial is restricted by health rules, modified in several countries. People suffer at home mourning the impossibility of providing the proper ceremonies. The same happened during the 1918 influenza pandemic 47 .

Important note:
Between the first and the second wave, the number of suicides 12 16 27 26 40 among the general population increases and also suicide ideation 14 26 66 . Either by the fear of the unknown in the first phase, or by the losses and suffering faced in the second. This phenomenon is present since the middle of the first wave and extends throughout the process 67 68 69 . It was already reported cases among health workers 62 . Patients who had Covid-19 also should be monitored. 70

3rd Wave -After the Pandemic
It is still quite recent, and without much data from experience reports, this third wave has a very theoretical emphasis. It starts once life returns to normal, with some adjustment. China entered this period, with the relaxation of social isolation and the return to normal activities. Some European countries and American States also gradually started to relax their quarantines, and life tends to return to normal (the new normal). We will only know the real impacts when all countries leave the period of isolation, and we will have a real scenario 71 .
It is worth noting that there is an expectation that the standards of normality will be reformulated in-depth in the post-pandemic context. Social scientists believe that the pandemic experience forced people to return to fatality, which weakens individual promises for the future and strengthens attitudes of shared care. Despite the suffering arising from the fragmentation of personal fantasies, such a scenario can favor the recognition of social inequalities and the promotion of citizenship and rights 72 .
What we can take from previous experiences, which are related to wars and another pandemic period, there will be an increase in the number of cases of anxiety disorder, especially post-traumatic stress disorder(PTSD) 18 20 35 33 54 . Children and adolescents may also experience mixed anxiety and depression 23 . The health workers 10 61 73 , due to the higher demand, will suffer from depression, anxiety and burnout syndrome. They will require special attention.
We can use as an example the experience of Sierra Leone 74 that after the Ebola pandemic needed to create strategies for mental health 75 or other experiences from natural disasters 76 77 . Always having in mind the SARS-CoV in 2002 was referred as "mental health catastrophe" 12 and we must be prepared for what is coming.

Final Considerations
Based on individual experiences from these periods, traumas will arise and will demand much attention from mental health professionals. It will be necessary to review all classical techniques to resolve conflicts of this type.
More and more mental health professionals will be demanded. While politicians and economists will be concerned about reorganizing countries' economies, mental health professionals will have to increase their workload and demand because, in exceptional situations like this, it is tough for someone to come out unscathed.
We know that these are not, by far, all the symptoms that appear in this period, and much more will be added to this scenario.
However, paradoxically, the scenario of evidence of human finitude can potentiate the construction of meanings of valuing life. The torpor caused by the anguish of the possibility of death (re) invents mental health needs that, at its core, denote desires to live.

Author Roles
EJSH and SML developed key article concepts. EJSH led the writing of the manuscript. ALMN, MTCMP, GCM, and VSLM assisted with writing areas of the manuscript related to their expertise and revised the manuscript for intellectual content. All authors reviewed the final manuscript before submitting it for publication.

Financial disclosures
None.

Declaration of Competing Interest
None of the authors report any conflict of interest.