Impact of SARS-CoV-2 pandemic on mental health in the elderly: perspective from a psychogeriatric clinic at a tertiary hospital in São Paulo, Brazil

Recent studies emphasize the high frequency of subsyndromal mental abnormalities in the general population during the new coronavirus pandemic, affecting up to one-third of the exposed individuals (Rajkumar, 2020). These manifestations can be represented by a simple increase in the selfperception of stress, but also by a higher prevalence of anxiety and depression symptoms, sleep complaints and relapse of pre-existing psychiatric disorders (Pfefferbaum and North, 2020). This perspective has been depicted by early population studies conducted in eastern Asia in the first months of the pandemic but seems to be replicable in Western countries as well. In Brazil, much attention is being paid to this secondary but not less important wave of morbidity. The rapidly progressive dissemination of the viral infection causing a consistent growth of incidence rates, along with the high clinical severity of a substantial proportion of coronavirus disease 2019 (COVID-19) cases, may warrant the outburst of a true mental health crisis in the general population. To date, scientific publications addressing mental health issues in the Brazilian COVID-19 pandemic have focused on its impact on mental health professionals (Ornell et al., 2020), and no systematic evaluation of the mental state of the elderly population has been made so far. In spite of having a younger population compared to European countries, many structural deficiencies (or at least inequalities) in the Brazilian public health services across different regions of the country render the treatment of severe COVID-19 less effective, therefore increasing lethality rates. In addition, several social characteristics render the Brazilian population particularly prone to a high morbidity from the infectious disease, with a putative subsequent effect on mental distress. Brazil has the sixth largest population in world with over 211 million inhabitants (IBGE, 2020), and socio-demographic conditions may preclude physical distancing in densely populated communities. Certain cultural peculiarities also play an important role in the fast dissemination of the disease, with large and belonging families – frequently with two to three generations dwelling in the same household with limited private space and sanitation. The first confirmed case of COVID-19 in Brazil was reported on 25th February 2020 in São Paulo, affecting a 61-year-old man who had just returned from Lombardy, the epicenter of the epidemic in Italy (MHB, 2020a). Three months later, São Paulo turned out to be the most affected state in Brazil, with almost 86,000 confirmed cases and 6,500 deaths from COVID-19, along with almost 400,000 confirmed cases and 25,000 deaths in the whole country, with mortality and lethality rates of 11.7% and 6.3% (estimates of 27th May) (SEADE, 2020). Currently, with the highest transmission rate (2.8) in an estimation involving 48 countries worldwide, casualty counts doubling every 5 days (The Lancet, 2020), the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) health crisis in Brazil is heading straightforward toward the epidemic peak (MHB, 2020b). Brazil currently stands second in the world ranking of total number of cases and has become the epicenter of the pandemic in Latin America, with mortality numbers increasing steadily (WHO, 2020). The highest counts were so far registered in the most populated regions of southeastern Brazil, particularly in the states of São Paulo and Rio de Janeiro. However, much less densely populated regions in the Amazon basin have also been severely affected. Many communities in these regions face important limitations in sanitation and access to health services, making the states of Amazonas and Pará (along with two other states in the north-eastern coast, i.e. Ceará and Pernambuco) the ones with highest mortality rates per 100,000 inhabitants (SEADE, 2020). The distribution of deaths across these states accounts for 81% of deaths reported in Brazil, and the percentage of people who have been infected with SARSCoV-2 ranges from 3.3% in São Paulo to 10.6% in Amazonas (Mellan et al., 2020).