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• The pandemic by covid-19 will bring psychic consequences that will last beyond the period of transmission of the disease.

• Frontline health professionals are susceptible to a number of mental health-threatening disorders.

• Situations such as: fear of contagion; illness of family, friends and team members; scarcity of personal protective materials and fake news about treatment can increase stress levels.

• Health and institutions services should be attentive to the health of professionals who are part of the frontline, in the treatment of patients with COVID-19, performing actions to prevent and promote physical and mental health.

During the pandemics it is common for health professionals, scientists and managers to focus predominantly on the pathogen and its biological risk, in an effort to understand the pathophysiology, as well as the mechanisms involved, and thus propose measures to prevent contain and treat the disease. In such situations, the psychological and psychiatric implications secondary to the pandemic context, both at the individual and collective levels, tend to be underestimated and neglected, generating gaps in coping strategies and impact on the psychological health of health professionals (Morens, 2013).

Although the occurrence of infectious diseases was reported thousands of years ago, globalization has currently facilitated the spread of pathological agents, and epidemics and eventually the occurrence of uncommon diseases are not uncommon. This adds greater complexity in containing infections, as they generate an important political, economic and psychosocial impact, leading to urgent public health challenges (Morens & Folkers, 2008). Human-acquired immunodeficiency virus (HIV), Ebola and H1N1, among other diseases, is recent examples (Morens, 2013).

Coronavirus (SARS-CoV-2), identified in China at the end of 2019, has a high potential for contagion, leading to the increase of its incidence exponentially. Its high contagion rate has been leading the World Health Organization (WHO) to recognize COVID-19 as a pandemic on March 11, 2020. False information about factors related to the transmission of the virus, the incubation period, its geographic reach, number of infected and the actual mortality rate led to insecurity and fear in the population. The situation worsened due to lack of knowledge of the pathophysiology of the new coronavirus, forms of contagion, control measures and scarce and ineffective therapeutic mechanisms (Malta & Rimoin, 2020; Neil et al., 2020).

These uncertainties had consequences in several sectors, with direct implications in the daily life of the population and mental health.  Based on these observations, a number of questions were raised: is there a concomitant fear/stress arising from the pandemic by COVID-19? How can we evaluate this phenomenon?

To understand the psychological and psychiatric repercussions of a pandemic, the emotions involved, such as: fear; loneliness; anxiety; uncertainty and stress, should be considered and observed. Fear is an adaptive defense mechanism critical to survival and involves several biological processes of preparing for a response to potentially threatening events. However, when it is chronic or disproportionate, it becomes harmful and can be a key component in the development of various psychiatric disorders (Shin, 2019).

In a pandemic, fear increases anxiety and stress levels in healthy individuals and intensifies the symptoms of those with pre-existing psychiatric disorders. The number of people whose mental health is affected tends to be higher than the number of people affected by the infection (S.R. Ebola’s mental-health wounds linger in Africa, 2015).

Past epidemics have shown that the implications on mental health can last longer and have a higher prevalence than the epidemic itself and that psychosocial and economic impacts can be incalculable if we consider its resonance in different contexts (Shultz & Cooper, 2016).

Since the economic costs associated with mental disorders are high, mental health treatment strategies can lead to gains in both physical health and the economic sector.

In addition to the concrete fear of death, the pandemic by COVID-19 has implications in other spheres: family organization, closure of schools, businesses and public places, changes in work routines and economic insecurity. All these implications arising from social isolation could generate important social repercussions.

During the Ebola outbreak, for example, fear-related behaviors had an epidemiological impact during all phases of the event, increasing the population's rates of suffering and psychiatric symptoms, which contributed to the increase in indirect mortality (S.R. Ebola’s mental-health wounds linger in Africa, 2015).

Currently, ease of access to communication technologies and the transmission of inaccurate or false information can increase harmful social reactions, such as anger and aggressive behavior.

The COVID-19 outbreak has become a clinical threat to the population, especially to health professionals, who are on the frontline worldwide (Lai et al., 2020).

One study demonstrated that people with suspected cases and/or confirmed by COVID-19 may experience intense emotional and behavioral reactions, such as fear, boredom, loneliness, anxiety, insomnia or anger (Wang et al., 2020). Such conditions can progress to disorders, whether depressive, anxiety (including panic attacks and post-traumatic stress disorder), psychotic or paranoid, and may lead to suicide. These conditions may be especially prevalent in quarantined individuals, whose psychological distress tends to be greater (Brooks et al., 2020; Xiang et al., 2020).

In addition to the conditions mentioned above, we add to the uncertainty of professionals about the risk of infection and death or the possibility of infecting family and friends. All of this can potentiate dysphoric mental states. Long working hours, scarcity of resources and personal protective equipment (PPE), in addition to illness and losses of health team members, can also contribute to the increase of stress and emotional exhaustion of these professionals (Figure 1).

Figure 1: Relationship between different situations, such as: afraid; work overload; high levels of stress and emotional exhaustion, which can lead to a vicious cyclical state, enabling the development of numerous mental disorders.

The following are sensitive points, which are necessary for a better understanding of some psychic demands.

The pandemic by COVID-19 is an international public health problem that transcends the health problem itself, since it has become a very serious social crisis, having alarming implications for both individual and collective health and emotional and social stability (Pfefferbaum et al., 2020).

The lack of specific treatment and immunization in the face of the virus and, mainly, its high ease of propagation have characterized the emergence of the public health problem in almost all countries of the world.

One of the main consequences will be the increase in psychic demands among health professionals, which will certainly cause future repercussions on the increased incidence of occupational diseases (Lai et al., 2020).

As of September 9, 2020, more than 27 million confirmed cases and almost 900,000 deaths worldwide had been counted, spread across 216 countries (Sohrabi et al., 2020).

Maslach et al. states that physical and emotional exhaustion is not a problem of people, but from social environment in which they work. The author considers that physical and emotional exhaustion is expressed in a unique way by people, but the basic contents are the same: an exhaustion of commitment to work and emotions (a problem of adequacy between the individual and work). It is important to draw attention to the term exhaustion, which refers to a meaning of the order of a gradual process of loss, during which the imbalance between the needs of the individual and the demands of work becomes increasingly accentuated (Maslach & Schaufeli, 2001).

These professionals experience, in their routine, a constant expectation of crisis situations, mainly due to the high concentration of severe patients, subject to prolonged hospitalizations, isolation and sudden changes in the general state. All these factors combined contribute to the creation of a work environment characterized as stressful and generating a compromised emotional atmosphere (Maslach & Schaufeli, 2001).

It is noteworthy that this group of workers does not constitute a homogeneous group, as they present numerous differences regarding age group, level of professional education and varying degrees of resilience. All this will also reflect on the daily work relations and coping mechanisms. Therefore, it is expected that these demands will not affect the various categories in the same way, and it is necessary to look at the specificities of each one, so that specific measures for the prevention and treatment of mental demands caused by COVID-19 are created.

In this sense, it is estimated that health professionals, in particular, those who work on the frontline, in the fight against COVID-19, will present psychiatric symptoms of various types, such as: anxiety, stress, depressive symptoms, Burnout syndrome, addiction behaviors, as observed in the H1N1 and SARS-CoV-1 crises (Dong, 2020).

A study with health workers showed higher levels of stress and psychological distress than in non-occupational health survivors. Compared to working in different lines of action, working on the frontline treating patients directly with COVID-19 seemed to be an independent risk factor for all psychiatric symptoms. It is noteworthy that, in times of pandemic, a peculiar syndrome known as "stress disorder of the headlines" can be observed, which is characterized by a high emotional response, such as stress and anxiety caused by endless reports, which can cause physical symptoms, including palpitations and insomnia, with the possibility of progression to physical and mental disorders (El-Hage et al., 2020; Zhu et al., 2020).

Health professionals are met with a large influx of patients and organizational instructions, which change constantly, resulting in great cognitive demands. In addition, rapid, repeated and difficult decision-making can lead to strong psychic tension and possible cognitive exhaustion.

In the search for prevention and management of psychic demands, some actions can be developed, including: reception and crisis care, with rapid psychosocial intervention; the guarantee of a set of preventive actions, in order to reduce the probability of professionals suffering psychosocial damage in the medium term; actions that promote protected environments favorable to the mental health of health workers, with an emphasis on psych education.

As a strategy to support workers, who are on the frontline, first psychological care (PC) actions have been proposed, through psychological support services (face-to-face or online), for a first listening of psychological care needs.

It is important to highlight that the social support and logistical help of the institution were related to the reduction of stress, anxiety and depression of health professionals, as well as the reorganization of the team and guarantee of the use adequate PPE (Ortega et al., 2020).

It is known that the transmission routes of SARS-CoV-2 are contact with respiratory droplets and aerosols, an infected person and/or contact with contaminated surfaces or objects. Thus, the best way for health professionals to prevent infection is through the proper use of PPE. PPE include: gloves; masks (classification N95 or higher); full face protection (face shield) or glasses; apron or fluid-resistant jumpsuit, which covers the body at least from the neck to half of the calf.

Other measures include minimizing concern for family members through the creation of disinfection protocols and priority access to exams, in addition to maintaining breaks at work (Adams, 2020).  

Therefore, it is important to engage governments and institutions with the demands related to the physical and mental health of health professionals, enabling the adequate supply of PPE, as well as the development of mental health prevention and promotion measures of all health professionals, who are in the care of patients with COVID-19, directly or indirectly (Table 1).

Table 1: Strategies for improving the mental health of frontline workers

The physical and/or psychic illness of a professional, in these times, represents a serious damage to the structure of health centers, and can create a chain reaction, which will lead other professionals to a restructuring path.

In the course of a pandemic, the requests of the health team are surprising and work-related stress affects these professionals too much. Such physical and mental exhaustion sits linked to excessive workloads, emotionally charged environments, poor infrastructure conditions, difficult ethical decisions, and multiple deaths, along with confinement and fear of contamination for themselves and their families.

Although there are still no systematic Brazilian reviews of the impacts of the pandemic by COVID-19 on mental health, it is predicted that the outbreak will have sinue implications, which may last for years. New scientific studies addressing epidemiological data and intervention models, focusing on the psychosocial of health professionals involved in the care of patients with COVID-19, should be conducted to better dimension the real impact caused by the pandemic on the mental health of these professionals.

Therefore, interdisciplinary intervention is necessary to support these workers and provide prevention services, such as: mental health screening; psychoeducation and psychosocial support, through a team composed of psychiatrists, clinical psychologists and occupational therapists, who must establish safe reception and counseling services.

It is essential to engage institutions in adopting measures that integrate prevention and promotion of care, especially to mental health problems of frontline professionals, since they constitute demands with invaluable sequelae and, often, neglected many of them. By the way: “out of sight, out of mind!”