Coronavirus disease 2019 (covid-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has resulted in an ongoing pandemic. As of April 2021, reports point at more than 130 million cases worldwide, with more than 106 million survivors (WHO, 2021). In Portugal, there are more than 800,000 survivors (WHO, 2021).

The spread of the covid-19 infection may have important implications for populations’ mental health, especially for survivors. Coronaviruses can foster psychopathology symptoms through direct viral infection of the central nervous system or indirectly through an immune response (Wu et al., 2020). This is particularly relevant as a recent study involving 236,379 survivors of covid-19 has provided evidence for substantial neurological and psychiatric morbidity after the infection (Taquet et al., 2021).

These data point to the need to understand the prevalence of psychiatric problems in SARS-CoV-2 survivors and which psychological processes may be linked to more resilient outcomes and help individuals respond successfully to survivorship. 

The sample used in the current study comprise 210 SARS-CoV-2 survivors (people who tested positive for SARS-CoV-2, whether or not they developed covid-19 symptoms), 200 individuals who had been tested for the infection but never presented a positive result, and 230 individuals who were never tested for SARS-CoV-2. The sample was collected in Portugal through a web-based survey in Portuguese during February 2021. Figure 1 presents the demographic characteristics and time spent in isolation of the studied groups.

Figure 2 shows data on the type and duration of symptoms presented by the survivors group. The most reported symptoms were decrease or loss of sense of smell, decrease or loss of sense of taste, and muscle aches. For most participants, most symptoms lasted between 1 and 10 days.

About 58% of survivors were infected during the third wave of the pandemic in Portugal (from the last week of December 2020 to the time of data collection [February 2021]), 37.1% during the second wave (October 2020 - December 2020), and 4.8% during the first wave (March 2020 - September 2020). Only 3.3% were admitted to a hospital due to the SARS-CoV-2 infection. Most survivors (62%) recovered without the need of prescription medication. The percentage of asymptomatic individuals was 11%.

As can be seen in Figure 3, about 40% of SARS-CoV-2 survivors reported feelings of insecurity due to having had the SARS-CoV-2 infection (42.8% answered “sometimes true”, “often true”, or “always true”), the perception that others may evaluate them negatively for having been infected (41.4%), and feelings of isolation (44.3%). The analysis of the items of the Chronic Illness Shame Scale showed that survivors’ shame feelings seem to be more focused on other people’s judgements than their own.

According to the recommended cut-off score for individuals receiving specialised medical care, about 42% of SARS-CoV-2 survivors presented a possible diagnosis of post-traumatic stress disorder (PTSD) related to their experience of having had a SARS-CoV-2 infection.

The prevalence of symptoms of anxiety and depression was similar for survivors, people who tested negative, and people who were never tested. The study groups did not differ significantly regarding anxiety and depression scores, after controlling for previous diagnosis of a psychiatric disorder (Wilks´ л = 0.99, F(4, 1270) = 1.95, p = .100, partial η2 = .01). These results seem to indicate that the pandemic is having similar mental health effects on individuals, regardless of whether they have contracted SARS-CoV-2. 

Most participants (59.2%) presented borderline abnormal to abnormal anxiety (23.3% mild, 28.1% moderate, and 7.8% severe), as shown in Figure 5. These numbers contrast with pre-pandemic anxiety levels found in a previous community sample study (Breeman et al., 2014), in which more than 80% of individuals presented normal anxiety.

Regarding depression (Figure 5), most participants (65%) presented normal levels, while 35% presented borderline to abnormal depression levels (17.5% mild, 14.7% moderate, and 2.8% severe). These percentages also contrast with previous data in which the percentage of those classified as having borderline abnormal or abnormal depression was below 20% (Breeman et al., 2014).

Individuals with previous psychiatric disorders presented more anxiety (F(1, 637) = 96.61, p < .001, partial η2 = .13) and depressive symptoms (F(1, 637) = 54.42, p < .001, partial η2 = 0.08) than individuals with no previous psychiatric diagnosis, independently of infection status. These findings suggest that having a previous psychiatric diagnosis may be a particularly relevant vulnerability factor for presenting anxiety and depression symptoms during the covid-19 pandemic.

Psychological flexibility is an adaptive process defined as the ability of having an open, accepting, and nonjudgmental attitude towards thoughts, memories, emotional distress, and physical sensations (Hayes et al., 2012). Among SARS-CoV-2 survivors, psychological flexibility was significantly associated with lower anxiety (r = - .52; p < .001) and depression (r = -.50; p < .001) as well as with fewer PTSD symptoms (r = - .47; p < .001). Individuals with higher levels of psychological flexibility tended to present lower depression and anxiety levels. This suggests that psychological flexibility may be linked to significantly better psychological outcomes in SARS-CoV-2 survivors. This association is consistent with previous studies, in other populations, and shows the importance of psychological flexibility for better mental health, including during the covid-19 pandemic.

As shown in Figure 6, more than half of the individuals who were not infected with SARS-CoV-2 showed high levels of fear of having complications due to covid-19 (74.2%), dying from covid-19 (60.9%), and having contact with someone that is infected (70.4%), someone with respiratory symptoms (64.4%), or someone that had contact with a patient (60.4%). While it is not surprising that uninfected people would express fear of covid-19, the finding is interesting in light of the low mean age of participants (around 36 years old), meaning that a significant proportion of participants were in low-risk age groups. The least reported items of the Fear of COVID-19 Scale were having contact with healthcare professionals (16.1%) and going outside (10.0%).

There is a considerable gender imbalance in the studied sample (which includes considerably more women than men). Also, young adults are represented disproportionately, and the sample’s groups are not matched for the main demographic characteristics. These limitations should be taken into consideration in future research, which should attempt to replicate these findings.

The present study sheds light on the mental health of Portuguese people during the covid-19 pandemic, in particular in the population of SARS-CoV-2 survivors. Shame feelings and PTSD symptoms in SARS-CoV-2 survivors are of particular concern. Further studies are needed to analyse the progression of psychological distress in the studied groups. At the current moment, it seems important to be attentive to the general population’s mental health and potential needs for psychiatric/psychological intervention. 

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