**9. Conclusions**

While the mechanisms behind the COVID-19 disease burden are being studied, it is now clear that patients suffering from diseases may develop a variety of psychoneurological signs and symptoms. As the numbers of COVID-19 cases continue to rise worldwide, there is an increasing number of studies that have reported psychoneurological symptoms, with the latest reports suggesting that COVID-19 patients suffer from Guillain–Barré syndrome and other long-lasting neurological

complications. Studies published mainly from China and France have also reported the significance of neurological and mental health disorders in COVID-19 patients. According to these reports, up to 36% of patients have demonstrated psychoneurological symptoms. As such, the neurological and subsequent neuropsychiatric burden of the disease would require even further attention in our today's clinical practice against the virus. COVID-19 can potentially affect anyone, regardless of age, gender, and ethnicity.

Meanwhile, when someone has had mental traumas or experienced mental or long-term physical illness, or when an elderly finds himself/herself more vulnerable to the effects of coronavirus, the distressing worry turns to be off the chart. Thus, one needs to develop skills and awareness instead of making assumptions while acknowledging stress and managing it. This pandemic will be expected to continue reshaping the patient–physician relationship with the emergence of telemedicine. The pandemic would also continue to reinforce the global healthcare system to avoid further unpreparedness for similar crises. Over and above, public awareness campaigns and academic efforts need to be synergized to help people refrain from judging who is responsible for the virus spread instead of assisting them with how to stay mentally and physically safe by adequately following the outbreak updates from trusted resources. Increased screening of mental health symptoms during primary care or other medical specialty visits, and offering mental health services with the slightest degree of suspicion, can decrease the mental health burden.

In most cases, the COVID-19 related stress in a person without significant past psychiatric history can be diagnosed as an adjustment disorder. Adjustment disorder can be treated with counseling and minimal use of psychotropic medications. On the other hand, patients with pre-existing or chronic psychiatric illnesses may decompensate due to increased stress related to COVID-19. This patient population may benefit from more frequent mental healthcare visits, even if this can be provided via telemedicine. Increased visits with their mental health provider can ensure medication compliance and early detection of any relapse of their psychiatric symptoms. In specific cases, the physician may consider more liberal but very brief use of anxiety and sleep medications. The decision to use medication should be based upon the most recent evidence-based guidelines.

An accumulating body of recent evidence proposes that anxiety, depressive, and psychotic symptoms are all likely to worsen during extreme COVID-induced stress and social disruption. Moreover, patients will be at increased risk of relapse or recurrence of affective and psychotic illness. As such, it will be important when deciding on the best management plan (non-pharmacological/pharmacological) to consider all the relevant factors, including risk to self and others. It is important to understand the difference between short- and long-term use of psychotropic medications, and also to clarify the myths related to the addiction potential of all psychotropic medications. Although many psychiatric medicines are tightly regulated and prescribed only for long-term mental illnesses, it may be necessary for the governments to ease up prescription refill regulations. Teletherapy and online consultations with e-prescriptions would allow ease of access to the prescribed medications without referring to the mental healthcare provider in person. Perhaps in many occurrences, designated pharmacies might collect e-prescriptions plus the related contact info of the patients for home-delivery medicines. Notwithstanding the above, possible untoward or side-effects of such medication need to be noted. In other words, upon treatment with commonly prescribed psychotropic drugs, careful consideration should be given to whether now is the best time to commence, withdraw, or change patients from antidepressant, anxiolytic, or antipsychotic medications. For instance, in patients who receive ongoing treatment with benzodiazepines, the potential for tolerance and dependence needs to be considered. With regards to lithium carbonate, the optimal dosing should be governed by blood levels. Likewise, when prescribing or refilling clozapine, blood tests to monitor possible or probable neutropenia should be advised.

**Author Contributions:** Writing—original draft preparation, K.S.R., M.N., B.S.G., G.P.; writing—review and editing, K.S.R., B.S.G., S.S.G., U.G., A.M., D.K., L.C., S.J.K.A.; visualization, K.S.R., M.N., B.S.G., G.P., S.S.G., S.J.K.A., D.K., L.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** KS Rao is thankful to the National Science system (S.N.I.) of SENACYT, and COVID19 Rapid Grant number 077 of SENACYT, the Republic of Panama for the support.

**Acknowledgments:** S.S.G. is a CPRIT (Cancer Prevention and Research Institute of Texas) scholar in cancer research, and also funded by a grant from CPRIT (RR170020). The figure illustration was created using the Biorender online tool. B.S.G. is supported by The Brain Behavior Research Foundation (NARSAD) grant and Mc. Kee Foundation grant.

**Conflicts of Interest:** The authors declare no conflict of interest.
