Impact of COVID-19 Confinement on Vulnerable Populations: History
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Contributor:
Manuel Reiriz
,
Macarena Donoso-González
,
Benjamín Rodríguez-Expósito
,
Sara Uceda
,
Ana Isabel Beltrán-Velasco

The confinement caused by the pandemic has been especially hard for young people belonging to certain vulnerable populations and it has had a greater impact on previously existing pathologies and on those that have appeared because of this period. There was an increase in the diagnosis of mood disorders and the use of medication associated with these disorders, mainly during the period of reclusion that was declared worldwide in March 2020. In addition, risk factors such as loneliness, a lack of resilience, and a lack of adequate coping strategies negatively impacted these groups. 

  • COVID-19
  • mood disorders
  • confinement

1. Introduction

People had to adapt to an exceptional situation during the confinement decreed by the global health authorities after the emergence of COVID-19. This period meant a radical change in the habits of everyone, from the youngest to the oldest, which had a high impact on different areas of life.
Confinement had a high impact at the psychological level, which was caused by the political and health measures taken by different governments with the aim of slowing down the advance of the disease [1]. These measures first proposed home confinement which, on many occasions, was associated with loneliness or, even worse, made it easier for people to have access to causing distress to the people they were living with [2].
This extreme situation, which caused a change in the lifestyle habits of the entire population, was not determined with the possible consequences on people’s mental health, but to prevent the spread of a disease that caused thousands of deaths. However, another pandemic appeared at the end of the first one, and it is that of mental disorders whose diagnosis is associated with confinement [1].
Any epidemic or natural catastrophe is a stressful event, whose medium- and long-term effects can be present in different ways, particularly at the cognitive and psychological level as this type of event places people in a situation of psychological vulnerability. These circumstances and the events related to them caused a significant increase in deaths worldwide, involving the loss of loved ones, friends, co-workers, etc., and increasing the level of uncertainty and fear that can trigger the emergence of certain negative feelings and misperceptions of reality. However, it also increases the need to cope with these experiences and the associated traumatic events, as well as the presence of a nearby danger that can directly affect the person. This causes emotions such as uncertainty, uneasiness, and fear. All of them put the person on alert and predispose him/her to develop anxious–depressive pathologies [3].
Social isolation is associated with feelings of loneliness and general discomfort that have a great psychological burden but also affect the physiological level. In fact, studies in this line indicate that a percentage of close to 85% of the participants reported sleep disturbances, both in terms of falling asleep and during the night, with interrupted sleep, light sleep, early awakening, etc. [4]. Other participants indicated presenting with muscular pain, recurrent headaches, difficulties in attention and concentration, panic attacks, and feelings of aggressiveness and irritability, which are associated with muscular tension and the presence of dysfunctional anxious symptoms [5]. In addition, these individuals had feelings of insecurity, a fear of death, both their own and that of loved ones, a fear of COVID-19 infection, and even thoughts of death, self-harm, and, in the most severe cases, suicidal ideation [6].
Another important factor in this scenario was social networks and communication channels. At this time, news about the disease was published very quickly, with hardly any time to confirm it, which caused an avalanche of information for the entire population. This type of information fostered an increase in fear or embarrassment in the face of the impossibility of being able to implement protective actions or behaviors. In addition, it provoked a feeling of absolute helplessness in the face of a silent disease that was spreading without distinction and with a daily increase in the number of deaths, which made the fear even greater [7]. In addition, social networks were filled with people sharing their experiences, their ideas, and their subjective and individual perceptions of what they were experiencing, and this provoked a feeling of extreme fear in certain groups, who made attributions and inferences based on opinions that may or may not have a scientific basis [8]. Although on many occasions this type of testimony was made with the intention of helping other people, the reality is that it provoked a greater sense of fear, hopelessness, and uncertainty about the future and with it, the appearance of avoidance behaviors and emotional and psychological problems [9].

2. Increased Diagnosis of Mood Disorders

The COVID-19 pandemic brought populations to an environment and emotional situation that resulted in a significant increase in psychological disorders such as depression, stress, irritability, mood swings, emotional distress, fear, and anxiety [10][11]. In this line, the experiences lived by people during the months that the pandemic lasted (the pathogenicity of the virus, the resulting high mortality rate, or the quarantine experience) affected the mental health of the general public, especially healthcare workers, patients with mental illnesses, or infected patients. Because of this, it is important to note that there are several groups that could be called vulnerable, with the groups mainly being those who remained alone during confinement, those who already had a clinical diagnosis of physical or mental pathologies, and those who were dependent or living with dependent people [12][13][14].
Due to this, there was an increase in the diagnosis of mood disorders in different countries around the world compared to the period prior to the pandemic. Thus, a study conducted by McGinty et al. (2020) in the USA reported an increase in psychological distress in April 2020 (one month after the USA quarantine) compared with in 2018 in adults. In this sense, in April 2020, 13.6% of this population showed symptoms of psychological distress compared to 3.9% reported in 2018, showing that the subgroups examined in April 2020 had the lowest prevalence of serious psychological distress in adults aged 55 years or older [15]. The same results were obtained by Pierce et al. (2020) in the population of the UK, where the prevalence of mental distress raised from 18.9% in 2018–2019 to 27.3% in April 2020 (one month after the UK quarantine). In addition, the diagnosis of anxiety in the general population measured with GHQ-12 also increased in that period from 11.5% in 2018–2019 to 12.6% in April 2020 [16].
On the other hand, in vulnerable groups, such as people with mental illnesses, the emotional responses generated by the unprecedented stressor that the pandemic and its management could be more important than in the general population [17][18]. In this sense, different studies have found that the levels of mood disorders such as symptoms of loneliness, anxiety, depression, and worry increased systematically in people with pre-existing psychiatric conditions during the pandemic compared with the pre-COVID-19 situation [17][18][19]. This fact could be explained because in people with mental illnesses, factors such as small social networks or financial instability are common, and the quarantine experience could have aggravated this situation [20].

3. Increased Medication Use

A significant proportion of the general population has been negatively affected by home confinement, which was carried out for more than 100 days in most countries around the world [21]. The impact of this extraordinary state that modified the way of life of all people is related to social isolation, as well as a significant reduction in perceived support through networks of friends, partners, and even family [22]. Other factors that influenced the appearance of mood disorders include the loss of employment, exposure to violent environments in the home, alcohol and other substance use, abusive situations, the presence of other pathologies, etc. [23].

This rather complex scenario has led to an increase in the intake of drugs associated with anxious and depressive disorders, i.e., anxiolytics and antidepressants. Along these lines, several studies have been able to compile data on the use of drugs during and after this time of confinement [24]. During the confinement period, there was a paradoxical effect in which the prescription of anxiolytics, hypnotics, and sedatives in general decreased considerably, probably due to a reduction in health services, as well as to the fear generated in the population of going out into the street and becoming infected. Therefore, this decrease in the prescription of these drugs could be explained by the need to acquire them under medical prescription and by the decrease in access to health services [25]. However, this is not related to the symptomatology of mood disorders, which increased during these months, along with the appearance of emotions such as fear and anxiety, and the increased prevalence of pathologies such as depression and anxiety. Therefore, this seems to indicate that this decrease in the consumption of anxiolytics is not a good indicator of people’s mental health during this period. Even more so knowing that social distancing and the suspension of life habits and social interactions had a precisely predisposing effect on the vulnerability to these mental pathologies [26].

Regarding antidepressants, an increase in the prescription of these drugs was observed just before the pandemic was declared, and at the beginning of the confinement period there was a decrease in their use [27]. This can be explained by the same reason as in the case of anxiolytics and sedatives, i.e., restrictions on access to health services, as well as an evident decrease in medical visits at a time when the health priority was the devastating reality of the daily number of deaths due to COVID-19.

4. Loneliness and Depression

As a result of social isolation, the feeling of loneliness emerges as one of the main elements that has contributed to the deterioration of the psychosocial health of both groups [28]. Thus, due to various limitations and restrictions, contact with partners was drastically reduced, increasing the negative psychological effects associated with loneliness, anxiety, and depression [29]. This disruption of social activities has led to the emergence of new feelings of negativity and psychological pathologies, as well as the deterioration of existing ones in this group of people [30][31]. Stress, anxiety, negative self-perception, homesickness, and a strong feeling of helplessness and loneliness have led to a significant increase in psychological risks and uncommon diseases in this population [32][33][34]. 

The breakdown of daily activities in these age groups promoted the appearance of feelings of apathy. These included sports, school, and artistic activities for the younger ones, and walks, shopping, and meetings with peers for the oldest. In short, activities of an imminently social nature were paralyzed, leading to emotions of loneliness and loss of interest, associated with depression (32.4% in the population >30 years and 18.9% in the population <50 years), which transgressed certain psychosocial limits, giving way to a lack of energy and lethargy, both breeding grounds for depressive processes of a certain depth [35][36]. In addition to these important consequences, it has been shown that during the pandemic, other pathologies appeared and worsened in young people and the elderly: an increase in the youth population in the obese range, changes and disorders associated with eating disorders in adolescents, continued irritability and anger (36.4% in the population >30 years and 12.2% in the population <50 years), difficulty in attentional processes and concentration (25.7% in the population >30 years and 14.4% in the population <50 years), body pain as a consequence of prolonged maintenance of unhealthy postures, cognitive impairment and loss of mobility in the elderly, etc. [37][38][39][40].

Regarding social isolation, other factors have increased depressive and stressful tendencies among young and old people; the loss of family members and other relatives (more than 70% of the population has shown concern about this issue), the loss of their own or their parents’ jobs, the fear of death, job uncertainty, the management of new family and work relationships (teleworking), among others, have been the most prominent causes of this population’s unease [41][42]. In this sense, we should add more extreme cases, such as those existing in the homes of the youngest, such as abuse and domestic violence, which have caused a collapse in the psychosocial well-being of this vulnerable population.

5. COVID-19 Confinement and Its Impact on Vulnerable Populations

5.1. COVID-19′s Impact on the Homeless

Since the start of the coronavirus pandemic, the impact of COVID-19 has not been the same in all populational groups. To deal with this, many governments implemented different measures to attend to many groups such as elderly people [43], communities from different races, or people with disabilities [44][45]. However, the measures adopted for the homeless (a community that represents 1.6 billion people around the world with, for example, 900,000 people in France alone or 1.7 million in India [46][47][48]) were few and late [49][50], showing again how this population group, especially those who have drug addiction or mental health problems, has been considered as a highly marginalized and neglected population worldwide [51][52]. Effectively, the homeless have a higher probability of suffering from mental health problems or drug abuse [53][54]. For example, in Hong Kong, the homeless are more likely to suffer from depressive disorders than the general population [55]. Other studies have shown that the homeless have severe mental disorders (such as schizophrenia and bipolar affective disorder) or intellectual disabilities [56].

5.2. COVID-19′s Impact on Other Physical Illnesses

5.2.1. Sexually Transmitted Infections and HIV

The COVID-19 pandemic, especially the confinement period, affected the control of other infections such as sexually transmitted infections or HIV [57][58][59][60][61]. Thus, in some countries such as Lebanon, there was an increase in the prescription of post-exposure prophylaxis (PEP) of 34% compared with 2019, although in other countries such as Australia, the confinement period caused a huge reduction in PEP prescription (37% in Melbourne and 46% in Sydney). PEP is a therapy which consists of taking a combination of three antiretrovirals for one month after HIV exposure to prevent infection [62], and its use during the pandemic showed how some individuals continued having sexual intercourse during the confinement period [63]. The study carried out in Australia also found a decrease in the number of HIV tests performed (41% in Melbourne and 32% in Sydney) and in the new cases of HIV diagnosed (44% in Melbourne and 47% in Sydney). Similar results were obtained in other countries such as the UK and Spain where the prescription of PEP, the number of HIV tests performed, and the number of new HIV cases diagnosed were reduced as well [64][65]. Thus, although it is probably the case that these effects could be explained by the reduction in sexual intercourse during the confinement period, there were other reasons such as a fear of attending HIV testing services during the pandemic due to the possibility of COVID-19 infection [66][67]. This situation along with the substantial reduction in HIV prevention measures during the COVID-19 confinement period could have resulted in increased HIV transmission [68] that could have resulted in a significant reduction in the mental health of these persons. Thus, HIV infection produces a higher probability of suffering from mental health problems ranging from acute stress reactions to neurocognitive disorders [69][70].
Another HIV prevention strategy that was affected by the coronavirus pandemic was pre-exposure prophylaxis (PrEP) which consists of daily or even driven usage of an antiretroviral before sexual intercourse to avoid the risk of HIV infection [71]. The use of this prevention measure increased during the pandemic, demonstrating it to be effective to protect against HIV infection and to have a huge impact on mental health. Thus, [72][73] a recent study demonstrated how the use of PrEP reduced anxiety and increased sexual satisfaction in men who have homosexual sex in Spain [74].

5.2.2. Cancer

Another disease treatment that was strongly affected by the COVID-19 pandemic was cancer. Thus, the pandemic and the confinement period produced a huge impact on diagnosis and treatment in patients with cancer. For example, in a study conducted with 20.006 participants with cancer in 61 countries, the surgery to cure it was affected by the confinement measures. Specifically, light restrictions were associated with a 0.6% non-operation rate, moderate confinement with a 5.5% rate, and full lockdowns with a 15.0% rate [75]. In addition, the COVID-19 pandemic and the confinement period have had a huge impact on people with cancer’s mental health. Thus, although loneliness during the pandemic seems to affect both people with and without cancer (in fact, loneliness has been considered as an independent risk factor with a similar effect to smoke 15 cigarettes per day in both cancer and non-cancer people [76][77][78][79][80]), people with any medical condition as such cancer were more likely to be isolated during the COVID-19 pandemic due to the high risk of severe complications [81].

5.2.3. Other Mental Health Issues

Finally, another population group that has suffered specially from the effects of the coronavirus pandemic and the confinement period is people with mental illnesses. In Spain, Solé et al. (2021) evaluated the differences between this population and community controls. They found how community controls used more adaptative strategies (such as following a routine, physical exercise, a balanced diet etc.) than people with mental health issues. Moreover, people with mental illnesses showed more anxiety, depression, weight gain, sleep changes, and tobacco consumption than the community control.

6. Impact of Information during Confinement and the Search for Mental-Health-Related Indicators during Confinement

The coronavirus pandemic has had a huge impact on our lives and from the beginning, there was a lot of information about the virus and the effect of it public health and the economy. As soon as the virus appeared, the information associated with this virus became trending online content and many bloggers, YouTube users, or people sending information via WhatsApp, Facebook, Instagram, or Twitter have appeared [82]. However, this information was not always correct, and the World Health Organization sent out an alert about the existence of an “infodemic”, described as “an overabundance of information, some accurate and some not, that makes it hard for people to find trustworthy sources and reliable guidance when they need it” [83]. According to the WHO, the infodemic generates fear and panic due to unchecked mind-boggling rumors, flamboyant news propaganda, and sensationalism [84].

Sometimes, infodemics directly affected our physical health; for example, in Iran, more than 100 persons died from alcohol poisoning due to the belief that alcohol could kill the virus [85]. Another example was with the access to hydroxychloroquine; many people have used it for decades due to its antimicrobial and immunomodulatory properties; during the COVID-19 pandemic, there was a supply problem due to hydroxychloroquine being proposed as a cure or preventive tool against the coronavirus [86].

This entry is adapted from the peer-reviewed paper 10.3390/su15043087

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