Post-pandemic mental health: Understanding the global psychological burden and charting future research priorities

Abstract

The coronavirus disease 2019 pandemic has left an indelible mark on global mental health, with widespread psychological consequences that persist beyond the acute phase of the virus. This review synthesizes current evidence on the post-pandemic mental health burden across diverse populations, highlighting elevated rates of depression, anxiety, posttraumatic stress, and substance use disorders linked to prolonged social isolation, economic instability, and grief. We examine disparities in psychological outcomes among vulnerable groups (e.g., healthcare workers, survivors, marginalized communities) and identify key challenges in addressing these issues, including fragmented healthcare systems, stigma, and the limited scalability of interventions. Emerging evidence on resilience factors (e.g., social support and adaptive coping) is also discussed. Finally, we propose critical priorities for future research, including longitudinal studies on the chronic mental health effects, the development of culturally tailored interventions, and the integration of digital mental health solutions. This review distinctively addresses enduring post-pandemic mental health challenges, integrating neurobiological insights, equity-focused interventions, and critical perspectives on digital solutions, gaps underrepresented in prior syntheses. By charting a roadmap for multidisciplinary collaboration, this review aims to inform policymakers and researchers in mitigating the long-term psychological aftermath of the pandemic.

Key Words: COVID-19; Mental health; Psychological burden; Postpandemic; Research priorities; Global health

Core Tip: The coronavirus disease 2019 (COVID-19) pandemic has exacerbated global mental health disparities, disproportionately affecting vulnerable groups (e.g., healthcare workers, youth, and marginalized communities). Unique pandemic stressors (e.g., social isolation, economic instability, and long COVID-related neuropsychiatric symptoms) have created new risk pathways. Systemic barriers such as fragmented care, stigma, and digital inequities limit intervention scalability, especially in low-resource settings. Evidence highlights resilience factors (social support, adaptive coping) and urgent priorities: Longitudinal research on chronic outcomes, culturally adapted interventions, and policy reforms integrating mental health into primary care and digital platforms. This crisis demands equity-focused, multidisciplinary action to mitigate long-term consequences.

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been one of the most disruptive global health crises in modern history, with profound and lasting impacts that extend far beyond its immediate medical consequences[1-3]. While much attention has been devoted to understanding the virological and immunological aspects of SARS-CoV-2[4,5], the psychological repercussions of the pandemic have emerged as a parallel public health emergency[6,7], with increasing evidence suggesting that the mental health toll may persist for years to come[8,9]. Even as the acute phase of infection subsides, societies worldwide continue to experience elevated rates of depression, anxiety, posttraumatic stress disorder (PTSD)[10,11], and other psychiatric conditions, exacerbated by prolonged social isolation, economic instability, and collective grief[6,12,13]. The unique combination of mass morbidity, mortality, and sustained public health restrictions during and after the COVID-19 pandemic has created an unprecedented mental health burden, necessitating urgent scholarly and policy attention[13-15].

The psychological aftermath of the pandemic has not been uniformly distributed, with significant disparities observed across demographic and socioeconomic groups[16,17]. Unlike pre-pandemic mental health challenges, the COVID-19 crisis introduced unique stressors such as mass morbidity, sustained public health restrictions, and collective grief, which exacerbated existing conditions and triggered new forms of psychological distress (e.g., pandemic-related PTSD)[18-20]. Frontline healthcare workers, COVID-19 survivors, individuals with preexisting mental health conditions, and economically vulnerable populations have been disproportionately affected, highlighting the role of structural inequities in shaping mental health outcomes[21-24]. Furthermore, the pandemic has exposed critical weaknesses in mental healthcare systems globally, including insufficient resources, fragmented service delivery, and persistent stigma surrounding mental illness[22,25,26]. Despite the growing recognition of these challenges, there remains a pressing need to consolidate existing research, identify gaps in knowledge, and establish a cohesive framework for future intervention strategies[26,27].

This review seeks to address these gaps by providing a comprehensive synthesis of the post-pandemic mental health landscape. Specifically, we aim to assess the magnitude and scope of psychological distress across different populations; examine the underlying biological, social, and economic determinants of these outcomes; and propose actionable research priorities to guide policymakers, clinicians, and researchers in mitigating long-term mental health consequences. While existing reviews catalogued acute-phase distress, our work uniquely analyzes longitudinal data on chronicity (> 24 months post-outbreak), bridges neuropsychiatric (e.g., viral persistence) and social determinants (e.g., pandemic-driven inequities), and evaluates scalable interventions post-2022, including low-cost artificial intelligence (AI) tools and policy reforms for low- and middle-income countries (LMICs)[23,28,29]. We synthesized evidence from English-language literature published between 2019 and 2025, retrieved from databases including PubMed, Web of Science, and PsycINFO. Key search terms included combinations of “post-pandemic mental health”, “COVID-19”, “psychological burden”, “mental health outcomes”, and “global mental health”. Priority was given to peer-reviewed articles, meta-analyses, and longitudinal studies addressing post-pandemic psychological effects. Grey literature and non-English publications were excluded to maintain focus on high-impact, widely accessible research. While this is not a systematic review, the selection aimed to represent diverse populations, geographic regions, and methodological approaches to ensure comprehensive coverage of the topic. By integrating findings from epidemiological studies, clinical reports, and public health analyses, this review underscores the necessity of a multidisciplinary approach to effectively respond to what has been termed the “shadow pandemic” of mental health deterioration.

GLOBAL PSYCHOLOGICAL BURDEN

While depression and anxiety existed pre-pandemic, their prevalence surged post-COVID-19 due to pandemic-specific drivers (e.g., economic instability, healthcare system strain), with meta-analyses showing a 20%-30% increase in cases compared to baseline rates[13,30,31]. The Global Burden of Disease Study 2021 highlights significant trends in mental health, with depressive and anxiety disorders ranking as the second and sixth leading causes of years lived with disability globally[32,33]. Between 2010 and 2021, age-standardized disability-adjusted life-years increased by 16.4% for depressive disorders and 16.7% for anxiety disorders, underscoring their growing burden[11,32,33]. Depression and generalized anxiety disorder have emerged as two of the most commonly reported conditions, affecting approximately 25%-30% of the surveyed populations in multiple countries[34-36]. Notably, PTSD symptoms linked to pandemic-related experiences have been documented in 15%-20% of individuals, with healthcare workers and COVID-19 survivors exhibiting particularly high vulnerability[18,19,37]. Substance use disorders, including alcohol misuse and opioid dependence, have also increased, reflecting maladaptive coping mechanisms in response to prolonged stress and social disruption[38,39].

Critically, pre-pandemic mental health burdens (e.g., chronic depression linked to socioeconomic status) persisted independently of COVID-19. However, pandemic-specific stressors, such as social isolation[40] or long COVID-related cognitive impairment[41], created new risk pathways not observed in earlier data. This divergence underscores the importance of disaggregating enduring inequities from acute pandemic effects. In addition, the psychological toll extends beyond clinically diagnosable conditions, encompassing subthreshold distress that nevertheless impairs daily functioning[42]. Insomnia, fatigue, and emotional dysregulation have become widespread and often co-occur with more severe disorders[43-45]. The pandemic’s mental health consequences are further compounded by delays in help-seeking behavior, as many individuals avoid clinical settings due to fear of infection or perceived stigma[46-48]. This treatment gap underscores the need for proactive mental health screening and accessible interventions[49,50].

The COVID-19 pandemic exacerbated mental health burdens in specific populations, though the magnitude varied across demographics and pre-existing conditions. While pooled estimates indicate a 25%-30% rise in depression and anxiety globally [95% confidence interval (CI): 22%-34%][10,11,13,51], certain groups such as particularly women, youth, and frontline workers experienced disproportionate rises in psychiatric morbidity due to pandemic-specific stressors (e.g., caregiving burdens, educational disruptions)[6,24,52-54]. Notably, some general population studies found stable or only transiently elevated distress post-COVID-19, underscoring the need for subgroup-specific analyses[11,55]. Vulnerable populations bear a disproportionate share of this burden. For example, frontline healthcare workers exhibit PTSD rates comparable to those observed in military combat veterans, driven by exposure to patient deaths, moral injury, and workplace exhaustion[21,56,57]. COVID-19 survivors, particularly those with long-term physical symptoms (“long COVID”), frequently report cognitive impairments (“brain fog”) and emotional lability, suggesting a bidirectional relationship between viral infection and mental health deterioration[41,58-61]. Economic disparities further stratify risk: Low-income households, ethnic minorities, and informal laborers face heightened psychological distress due to job loss, housing insecurity, and limited healthcare access[34,53,62,63]. Pooled data indicate a 25%-30% relative increase in depression and anxiety for women, especially caregivers (vs 10%-15% in men), linked to gendered caregiving roles and economic precarity[6,11,52,64,65]. The COVID-19 pandemic exacerbated mental health challenges, particularly among youth, due to social restrictions and educational disruptions rather than direct viral effects[14,54,66]. Adolescents showed significantly higher risk of suicidal ideation post-pandemic compared to pre-pandemic baselines[53,67], conversely, older adults, while initially assumed to be at the highest risk, demonstrate surprising resilience in some cohorts, possibly due to greater life experience and coping skills[11,52,65,68]. A concerning trend is the rise in suicidal ideation, especially among young adults and adolescents, with studies attributing this to disrupted education, social isolation, and economic precarity[69-72].

Geographical variations in mental health outcomes highlight the role of structural and cultural factors[73,74]. High-income countries with robust mental health infrastructures, such as those in Western Europe, still face service overload and unmet demand[75-78]. While high-income nations with robust safety nets (e.g., Germany, Australia) saw transient distress spikes (SMD = 0.15-0.30)[75,79,80], LMICs faced sustained elevations (SMD = 0.45-0.60), mediated by healthcare gaps[53,73,81], highlighting the moderating role of policy. The stigma surrounding mental illness remains a pervasive barrier in many LMICs, while high-income nations face challenges in equitable service distribution[75-78,82,83]. Emerging longitudinal studies (2023-2024) reveal that 25%-40% of long COVID patients in LMICs develop persistent depression or cognitive impairment[84,85]. In Brazil and India, socioeconomic disparities exacerbate these outcomes, with low-income survivors reporting 2.3-fold higher PTSD rates than high-income cohorts[19,86]. Post-2022 studies highlight divergent recovery trajectories. while high-income nations show stabilization[55], LMICs face compounding crises. In sub-Saharan Africa[73], pandemic-related job losses correlated with a 32% rise in depression prevalence, double pre-pandemic rates. South Asian studies[87] report escalating adolescent suicidality linked to school closures and child labor resurgence, emphasizing the need for culturally grounded interventions. Cross-cultural studies also reveal differences in symptom expression: Somatic complaints (e.g., headaches, gastrointestinal distress) are more commonly reported in Asian and Latin American populations than overt psychological symptoms are emphasized in Western populations[88,89].

The cumulative evidence highlights a picture of a global mental health emergency that transcends national borders and healthcare systems. While acute pandemic measures may have receded, their psychological aftershocks persisted, demanding urgent, coordinated responses[3,18,19,36].

DRIVERS AND MODERATORS OF POST-PANDEMIC MENTAL HEALTH OUTCOMES

This section focuses exclusively on risk and resilience factors amplified or uniquely triggered by the COVID-19 pandemic, supported by longitudinal studies comparing pre- and post-pandemic data. General mental health determinants (e.g., genetic predisposition) are noted only where they interact with pandemic-specific stressors (e.g., SARS-CoV-2 neurotropism exacerbating pre-existing depression).

The mental health repercussions of the COVID-19 pandemic stem from a complex interplay of biological, psychological, and socioeconomic factors. Understanding these multifaceted determinants is crucial for developing targeted interventions and mitigating long-term consequences. Emerging research highlights several key mechanisms through which the pandemic has exacerbated psychological distress while also identifying protective factors that foster resilience amid adversity.

PANDEMIC-SPECIFIC STRESSORS AND RISK FACTORS

The unprecedented nature of COVID-19 has introduced unique stressors that have profoundly disrupted daily life. Prolonged social isolation, a hallmark of public health measures, erodes support networks and increases feelings of loneliness, particularly among older adults and young people[10,34,40,90-92]. Economic instability, including job losses, business closures, and financial insecurity, has emerged as a major predictor of anxiety and depression, with studies showing that individuals facing unemployment are twice as likely to report suicidal ideation as those with stable incomes[93,94]. Bereavement, compounded by restrictions on traditional mourning practices, further intensifies grief-related mental health challenges, with many individuals experiencing prolonged or complicated grief reactions[21,95,96].

Healthcare systems themselves have become sources of trauma, particularly for frontline workers[97,98]. Moral injury is widespread among clinicians forced to ration care or witness preventable deaths[21,23,99]. Media saturation and misinformation amplify fear and uncertainty, contributing to “pandemic fatigue” and a pervasive sense of helplessness[100,101]. Additionally, the virus’s direct neurological effects, including neuroinflammation and hypoxia, may exacerbate psychiatric symptoms in COVID-19 survivors, particularly those with preexisting mental health conditions[102-104].

PROTECTIVE FACTORS AND RESILIENCE

Despite these challenges, research has also identified factors that buffer against psychological distress. Social support, whether from family, friends, or online communities, significantly mitigates the effects of isolation, particularly when individuals maintain regular virtual contact[105,106]. Adaptive coping strategies, such as mindfulness, physical exercise, and structured routines, are associated with lower levels of anxiety and depression[107-110]. Compared with more fragmented societies, communities with strong social cohesion have better mental health outcomes[111,112].

Individual differences in resilience also play a critical role. Personality traits such as optimism, emotional regulation skills, and a sense of purpose are linked to lower levels of psychological distress, even in high-stress environments[113-115]. Access to mental health resources, including teletherapy and crisis hotlines, provides critical lifelines for those in need, although disparities in access remain a persistent issue[116,117]. Interestingly, some studies suggest that prior exposure to adversity (e.g., natural disasters, economic recessions) may confer psychological resilience in certain populations, enabling them to navigate pandemic-related stressors more effectively[10,118-120].

BIOLOGICAL AND PSYCHOSOCIAL MECHANISMS

At the biological level, chronic stress from the pandemic likely dysregulated hypothalamic-pituitary-adrenal axis function, contributing to increased cortisol levels and inflammatory responses linked to mood disorders[121-123]. Emerging evidence highlights that SARS-CoV-2 infection triggers neuroinflammatory cascades, including microglial activation, blood-brain barrier disruption, and elevated pro-inflammatory cytokines (e.g., interleukin-6, tumor necrosis factor-α), which correlate with persistent depression, anxiety, and cognitive dysfunction in long COVID patients[59,84,102]. Notably, recent studies identify biomarkers such as glial fibrillary acidic protein and neurofilament light chain as predictors of neuropsychiatric sequelae, suggesting axonal injury and astrocyte activation as underlying mechanisms[84,85,103].

Furthermore, viral persistence in neural tissues and mitochondrial dysfunction may exacerbate oxidative stress, while autoantibodies targeting neural antigens [e.g., anti-N-methyl-D-aspartic acid (NMDA) receptors] could contribute to psychiatric symptoms independently of infection severity[59,104]. These findings underscore the need for targeted immunomodulatory therapies (e.g., interleukin-6 inhibitors, NMDA antagonists) and neuroprotective strategies in post-COVID mental health care, which is a paradigm shift from traditional monoamine-based treatments. Psychosocially, the erosion of daily structure and loss of meaningful activities (e.g., work, social gatherings) undermined a sense of control, a known protective factor against anxiety[124-126]. Sleep disturbances, which are prevalent during lockdowns, further disrupt neurobiological processes, exacerbating emotional instability[60,123]. Psychosocially, the erosion of daily structure and loss of meaningful activities (e.g., work, social gatherings) undermined a sense of control, a known protective factor against anxiety[124-126].

IMPLICATIONS FOR FUTURE RESEARCH AND INTERVENTION

Identifying these drivers and moderators is not merely an academic exercise. This study has direct implications for mental health strategies. Interventions must account for the diverse pathways through which COVID-19 has affected psychological well-being, from economic policies that reduce financial strain to community-based programs that strengthen social ties[124,127]. Future research should prioritize longitudinal studies to track how these factors interact over time, particularly in understudied populations such as children, refugees, and rural communities[52,128-130]. By dissecting these mechanisms, we move closer to a nuanced understanding of post-pandemic mental health that recognizes both the vulnerabilities exposed by COVID-19 and the resilience that persists despite it.

EVOLUTION OF MENTAL HEALTH SYSTEM CHALLENGES DURING AND AFTER COVID-19

The COVID-19 pandemic has exposed and exacerbated systemic weaknesses in global mental health care systems, creating formidable barriers to effective intervention[131,132]. Despite growing recognition of the psychological crisis, multiple intersecting challenges continue to hinder adequate response efforts, leaving large populations without necessary support[105,106]. While mental health systems faced significant challenges before the pandemic, COVID-19 served as both a stress test and a catalyst for transformation. This section examines how these systemic issues have evolved in the post-pandemic era, highlighting both deteriorations and innovations across. These obstacles range from structural deficiencies in healthcare delivery to deeply rooted societal attitudes that perpetuate stigma[131,132]. The pandemic’s legacy includes both deepened vulnerabilities and unexpected opportunities for reform. Sustaining positive changes while addressing new inequities (e.g., digital divides) represents the central challenge for post-pandemic mental health systems.

FRAGMENTED HEALTHCARE SYSTEMS AND RESOURCE LIMITATIONS

Mental health services worldwide were ill-prepared to handle the surge in demand caused by the pandemic. Many countries, particularly LMICs, entered a crisis with preexisting shortages of mental health professionals a gap that became critically apparent as needs escalated[73,81]. The World Health Organization estimates that nearly 75% of people with mental disorders in these regions receive no treatment whatsoever[133,134]. Even in high-income countries with relatively robust systems, psychiatric services struggle with overwhelmed capacities, resulting in prolonged wait times and rushed consultations[75,80]. The pandemic further disrupted care continuity as facilities repurposed resources for the COVID-19 response, inadvertently deprioritizing mental health needs[75,131,135]. This systemic fragmentation is particularly detrimental for vulnerable groups requiring specialized care, such as trauma survivors or individuals with severe mental illnesses[128,136-138]. In addition, the diversion of resources to acute COVID-19 care significantly worsened existing fragmentation. In LMICs, 68% of community mental health programs experienced budget cuts or closures[131], while high-income countries saw 30% longer wait times due to staff redeployment[135]. The pandemic also created new forms of fragmentation, with “long COVID” clinics often operating separately from mental health services despite overlapping patient needs[139].

STIGMA AND CULTURAL BARRIERS

Despite decades of anti-stigma campaigns, negative attitudes toward mental illness remain deeply entrenched in many societies[140]. Cultural narratives framing psychological distress as personal weakness rather than legitimate health concerns continue to deter help-seeking behaviors[141-143]. In collectivist cultures, where mental health issues may be viewed as family shame, individuals often avoid professional treatment to prevent social ostracization[144-146]. The workplace presents another arena of stigma, with employees fearing career repercussions for disclosing mental health struggles[79,147-149]. These barriers are compounded by generational divides: Older populations frequently exhibit lower mental health literacy and greater reluctance to engage with psychological services than younger, more psychiatrically aware demographics do[11,52,65,68].

TECHNOLOGICAL AND ACCESSIBILITY HURDLES

While telehealth emerged as a crucial alternative during lockdowns, its implementation revealed significant digital divides[150,151]. Elderly patients, low-income individuals, and rural communities often lack reliable internet access or technological literacy to benefit from virtual care[150,152,153]. Privacy concerns in crowded living situations further limit the effectiveness of teletherapy for many people[116,154]. Paradoxically, the same digital solutions meant to improve access created new barriers for already marginalized groups[152]. Additionally, the rapid shift to remote care occurred without established protocols for quality control, raising questions about treatment efficacy and patient safety in unsupervised settings[116,153].

WORKFORCE BURNOUT AND PROVIDER SHORTAGES

The mental health care workforce itself became a casualty of the pandemic[21,79]. Clinicians reported unprecedented levels of exhaustion as they confronted both professional demands and personal pandemic stresses[18,21,23,56,79,147]. Frontline mental health workers faced unprecedented burnout, with 45% considering career changes after the COVID-19 pandemic[146]. This burnout phenomenon has led to early retirements and career changes among mental health professionals, further straining systems already operating with insufficient staffing[132]. The problem is particularly acute in child psychiatry and geriatric mental health, where specialist shortages were severe even before the pandemic[155-157]. Training pipelines for new professionals remain inadequate to meet growing needs, suggesting that this crisis will persist for years without substantial investment in education and recruitment[158-160].

RESEARCH AND IMPLEMENTATION GAPS

Significant disparities exist between research knowledge and real-world applications. While studies have identified numerous evidence-based interventions, few have been adapted for diverse cultural contexts or scaled effectively[124,148,161-163]. The use of implementation science in the study of how to translate research into practice remains underfunded and undervalued[164-166]. Furthermore, most mental health research continues to focus on Western, educated, industrialized, rich, and democratic populations, limiting the generalizability of findings to global majority communities[28,62,167,168]. This research bias perpetuates a cycle where interventions developed for specific cultural contexts are applied inappropriately to dissimilar populations with poor results[169-171].

FINANCIAL AND POLICY CONSTRAINTS

Mental health funding consistently lags behind physical health investments, with many governments allocating less than 2% of their health budgets to psychiatric care[160,172-174]. The economic aftermath of the pandemic has intensified fiscal pressures, making new mental health initiatives politically challenging to justify[53]. Insurance coverage limitations create additional financial barriers for patients, particularly for long-term therapy or innovative treatments not yet included in standard formularies[175,176]. At the policy level, mental health is frequently siloed from broader public health planning, resulting in disjointed responses that fail to address social determinants of psychological wellbeing[160,172].

MOVING FORWARD

These challenges, while daunting, are not insurmountable. Addressing them requires coordinated action across multiple sectors, from healthcare redesign and workforce expansion to anti-stigma education and policy reform[82,131,132]. The next section outlines concrete research priorities and intervention strategies that can help overcome these barriers, emphasizing innovative approaches that leverage lessons from the pandemic experience[6,26]. Only by confronting these systemic obstacles can societies hope to mitigate the long-term psychological consequences of COVID-19 effectively[177,178].

EVIDENCE-INFORMED RESEARCH PRIORITIES: LESSONS FROM POST-PANDEMIC IMPLEMENTATION

The post-pandemic mental health landscape demands a reconceptualization of research paradigms and intervention strategies to address persistent gaps in knowledge and service delivery. While the challenges outlined in the previous sections are substantial, they also present opportunities for innovation and systemic improvement. This section prioritizes research directions based on empirical evidence of post-COVID-19 intervention outcomes. We evaluate feasibility and effectiveness across settings, with particular attention to disparities between high-income countries and LMICs.

LONGITUDINAL STUDIES ON CHRONIC AND EMERGING CONDITIONS

The long-term psychological consequences of COVID-19 remain poorly understood, particularly for high-risk groups such as survivors of severe infection, frontline workers, and bereaved individuals[6,84,179]. Prospective cohort studies with extended follow-ups (5-10 years) must integrate policy-relevant endpoints (e.g., healthcare utilization costs, return-to-work outcomes) to inform national mental health budgeting and disability insurance frameworks[20,180,181]. Special attention should be given to delayed-onset disorders, which may emerge years after initial trauma exposure[182,183]. Additionally, research must investigate the interplay between long COVID-19 and mental health, including potential neurobiological mechanisms linking persistent physical symptoms to cognitive and emotional dysfunction[85,139].

CULTURALLY ADAPTED INTERVENTIONS AND GLOBAL MENTAL HEALTH EQUITY

Current evidence-based treatments often fail to account for cultural variations in symptom expression, help-seeking behaviors, and treatment preferences[184,185]. There is an urgent need for implementation research that tests the effectiveness of Western-developed psychotherapies [e.g., cognitive behavioral therapy (CBT)] when adapted for diverse cultural contexts, particularly in low-resource settings where mental health infrastructure is limited[186-188]. Community-based participatory research methods should be prioritized to codesign interventions with local populations, ensuring their relevance and acceptability[87,189,190]. Furthermore, studies must evaluate task-shifting approaches that train nonspecialists (e.g., community health workers, religious leaders) to deliver basic mental health care in regions with psychiatrist shortages[168,191-193]. Culturally adapted CBT shows promising but heterogeneous effects across settings: Meta-analyses report pooled effect sizes of 0.52 (95%CI: 0.34-0.70) for depression in high-income countries[186] vs 0.29 (0.12-0.46) in LMICs[188], with grading of recommendations, assessment, development and evaluation (GRADE) confidence ratings downgraded to “low” for LMICs due to task-shifting challenges and fidelity concerns. Key barriers include stigma[185] and underfunded training pipelines[193], highlighting the need for contextual adaptation frameworks.

LMIC-SPECIFIC PRIORITIES: EVIDENCE FROM PANDEMIC ADAPTATIONS

The pandemic starkly revealed disparities in mental health care capacity between LMICs and high-income countries, demanding tailored research priorities[73]. In LMICs, task-shifting emerged as a critical strategy, with community health workers delivering 80% of mental health services in Kenya[188], though sustainability remains challenged by unpaid labor[193]. Low-tech solutions like short message services (SMS) interventions achieved 60% adherence in India[193], outperforming app-based tools that faced 40% attrition due to digital divides[152]. Structural barriers persist, however, with only 12% of LMICs increasing mental health funding post-pandemic vs 52% of high-income countries[172], exacerbating pre-existing inequities. Recent LMIC adaptations demonstrate promise: Kenya’s peer-delivered CBT achieved 60% remission in depression (vs 35% in standard care) via community health workers[188], while Guatemala’s radio-based counseling reduced anxiety symptoms by 45% in indigenous populations[194]. However, sustainability remains challenged by funding shortages[172]. Culturally adapted, non-stigmatizing platforms, such as radio-based counseling in rural Guatemala[194], showed particular promise, suggesting that LMIC-focused research must prioritize context over technology transfer.

DIGITAL MENTAL HEALTH INNOVATION AND ETHICAL CONSIDERATIONS

The COVID-19 pandemic has significantly accelerated the adoption of digital mental health interventions, yet several critical issues regarding their implementation and impact remain unresolved[195,196]. While these technological solutions have demonstrated potential in expanding access to care, rigorous research is still needed to comprehensively evaluate their efficacy compared with traditional face-to-face therapies across different psychiatric conditions[197-200]. The pandemic also accelerated preexisting trends, such as digital reliance on mental health care. While teletherapy improved accessibility for some, it also highlighted disparities in technological literacy and internet access, particularly among older and low-income populations[116,150,152,153]. These findings underscore the need for interventions that address both individual vulnerabilities and systemic inequities. Particular attention should be given to developing AI-based screening tools with appropriate safeguards against inherent algorithmic biases, as well as investigating optimal strategies to enhance patient engagement and retention in digital therapeutic platforms[198,201,202]. Furthermore, the widening digital divide poses substantial challenges to equitable implementation, potentially exacerbating existing mental health disparities among socioeconomically disadvantaged populations[53,195,196,203].

While digital tools (e.g., chatbots, teletherapy) improved accessibility during the pandemic, disparities persist across socioeconomic and geographic lines. It reported that chatbots reduced depression symptoms by 22% in high-income countries[198], but LMIC trials showed 40% attrition due to low digital literacy[125]. However, AI-based risk algorithms also exhibited racial bias[204], limiting scalability. Recent meta-analyses of digital mental health interventions[196,198] demonstrate moderate efficacy for reducing depression (SMD = -0.45, 95%CI: -0.62 to -0.28) and anxiety (SMD = -0.38) during the pandemic, though effect sizes vary by platform type (chatbots > self-help apps). GRADE assessments indicate moderate-quality evidence for CBT-based tools but low quality for AI-driven solutions due to high attrition rates (40% in LMICs) and algorithmic bias[204]. Scalability remains limited by digital literacy gaps, particularly among older and rural populations[152]. In addition, cultural barriers compound these issues: Western-developed apps often lack linguistic adaptation or fail to address local stigma (e.g., somatic symptom presentation in Asian cultures)[185,194]. Conversely, low-tech solutions (e.g., SMS-based counseling in India, radio programs in Guatemala) show higher adherence (60%-80%) by aligning with existing infrastructure[193,194]. To advance equity, we urge co-designing tools with LMIC stakeholders, subsidizing internet/data costs, and tiered interventions (e.g., hybrid SMS/clinic models). Policymakers must treat digital access as a mental health determinant.

In summary, these technological advancements must be accompanied by parallel developments in ethical frameworks to ensure robust protection for patient confidentiality, appropriate informed consent procedures, and equitable distribution of these innovative mental healthcare solutions[203-207]. In addition, digital tools require tiered implementation as high-resource settings can validate AI chatbots, while LMICs prioritize low-tech hybrids (SMS + community hubs) to bypass internet barriers. Policy action should mandate that mental health apps meet World Health Organization’s digital adaptation kits for cultural/Linguistic adaptation[195].

PREVENTION AND EARLY INTERVENTION PARADIGMS

Reactive approaches to mental health care are insufficient to address the post-pandemic burden[208,209]. Research must identify modifiable risk factors (e.g., childhood adversity, social determinants) that can be targeted through population-level prevention strategies[6,210-212]. School-based programs must embed mental health literacy into core curricula[213], while workplaces adopt “mental health leave” policies tied to screening[214]. Cost-effectiveness analyses should compare universal prevention vs high-risk targeting[67,213,215,216]. Additionally, biomarker research (e.g., investigations of inflammatory markers and epigenetic changes) may enable early identification of high-risk individuals before clinical symptoms emerge[217-220].

HEALTH SYSTEMS RESEARCH AND POLICY INTEGRATION

The COVID-19 pandemic has revealed fundamental deficiencies in mental health service delivery systems worldwide, necessitating comprehensive health system research to develop effective solutions[135,221]. Key areas requiring investigation include determining optimal models for integrating mental health services into primary care settings, establishing sustainable financing mechanisms for long-term program viability, and developing workforce expansion strategies that address both training pipelines and retention incentives[222-226]. Additionally, rigorous policy evaluation studies are needed to assess the effectiveness of mental health parity laws and insurance reforms implemented during the crisis[29,214,227]. Cross-national comparative research represents a particularly valuable approach, as systematic analysis of countries that successfully maintained mental health services throughout the pandemic could yield transferable best practices and innovative care delivery models[29,228,229]. These research initiatives must account for varying healthcare system architectures and resource availability across different national contexts while maintaining a focus on equitable access to quality mental healthcare[29,228-230].

INTERSECTIONAL APPROACHES TO VULNERABILITY

Future studies must move beyond broad demographic categories to investigate how intersecting identities (e.g., race, gender, disability, and socioeconomic status) compound mental health risks[6,10,13,231]. Participatory action research with marginalized communities, including refugees, indigenous populations, and lesbian, gay, bisexual, transgender, and queer + individuals, is essential for developing tailored interventions that address unique stressors and resilience factors[86,194,232-236].

A CALL FOR COORDINATED GLOBAL ACTION

The COVID-19 mental health crisis presents both a formidable challenge and a historic opportunity to reimagine mental healthcare delivery[6,53,230,237]. By investing in these research priorities, the global community can build more equitable, evidence-based systems capable of mitigating not only the aftermath of this pandemic but also future crises[26,238,239]. Addressing these priorities will require unprecedented collaboration between researchers, clinicians, policymakers, and community stakeholders[240,241]. International consortia should be established to harmonize measurement tools, share data, and accelerate discovery[242-244]. In addition, funding agencies must prioritize mental health research with the same urgency according to infectious disease and biomedical research during the pandemic’s peak[9,29,227,245].

CONCLUSION

The COVID-19 pandemic has precipitated a lasting global mental health crisis that demands urgent, multifaceted solutions. This review underscores the disproportionate psychological burden borne by vulnerable populations and highlights critical areas for intervention: Integrating mental health into primary care systems, developing culturally adapted treatments, leveraging digital tools while addressing accessibility gaps, and implementing policy reforms to ensure sustainable funding (Figure 1). The pandemic has revealed both the fragility of existing mental healthcare systems and opportunities for transformative change. By synthesizing evidence on chronic outcomes and innovative solutions, this review fills critical gaps between acute-pandemic reports and emerging next-phase challenges, offering a roadmap for research prioritization. Moving forward, we must capitalize on this momentum by adopting evidence-based, equity-focused approaches that not only address current needs but also build resilience against future crises. The scale of this challenge calls for immediate, coordinated action across research, clinical practice, and policymaking to create mental healthcare systems capable of supporting population wellbeing in the post-pandemic era and beyond. To translate these research priorities into practice, we propose a three-tiered action framework: (1) Policy advocacy: Governments and World Health Organization should integrate mental health into pandemic preparedness plans, with dedicated funding for LMIC-specific interventions (e.g., task-shifting programs); (2) Researcher collaboration: Establish an international consortium to harmonize metrics (e.g., standardized long COVID neuropsychiatric assessments) and share datasets via platforms like the Global Mental Health Databank; and (3) Community engagement: Co-design interventions with marginalized groups (e.g., refugees, indigenous communities) using participatory methods. The post-COVID-19 mental health crisis demands a coordinated response, requiring researchers, policymakers, and communities must act now to avert a generational catastrophe.

Figure 1 Summary of global psychological burden and charting future research priorities during post-pandemic of coronavirus disease 2019. COVID-19: Coronavirus disease 2019.