**4. Discussion**

This survey evaluated the mental health of Brazilians during the SARS-Cov-2 pandemic and identified characteristics that increased the risk of psychological symptoms. A high prevalence of depression (61.3%), anxiety (44.2%), stress (50.8%), avoidance (59.2%), intrusion (46.8%) and hyperarousal (50.1%) symptoms was observed.

The increase in mental health symptoms in populations during epidemics is not a novelty [8–15], however, the current context deserves attention. In addition to being the largest pandemic in the last 100 years, the eradication of the disease is still a scientific and social challenge, and the effectiveness of control measures (such as hand hygiene, isolation, and quarantine) is thus still unknown,. Thus, the quarantine has been extended, with an unknown end date and the return to normal activities. In addition to the pandemic, the country's economic, political, and social crises related to it contribute to a lack of feeling safe [3–6], creating an environment of multi-faceted vulnerability and unpredictability that affects the general population, especially in those who lack coping skills to manage the conflicts of this scenario.

The lack of feeling safe affected the majority of the study population (84.4%) and significantly increased the risk of developing psychological symptoms. This may be related to both the pandemic itself and the large volume of inaccurate and often conflicting information from the media and the government regarding the coronavirus disease and its control and treatment measures [1,5]. Gao et al. [21] concluded that the amount of false or manipulated information can generate unfounded fear and confuse people. The authors also reported that greater exposure to the news increases the chance of developing symptoms of depression and anxiety, which was also found in the present study. The time spent with the news was a protective factor for the avoidance symptom, indicating that individuals that are more exposed to the news (low avoidance behavior) could be aiming at acquiring the maximum information on the pandemic to gain some control of the situation. However, a false sense of control could aggravate the other psychological symptoms assessed in this study.

Less than one third of individuals reported medical diagnosis related to mental disorders before the pandemic. The prevalence of psychological symptoms among these individuals was extremely high (96.2%) after the beginning of the pandemic. In the total sample, 88.8% of people reported the appearance of one or more psychological symptoms after the beginning of the pandemic. It should be noted that this information was self-reported by the participants. These results are especially important, as they may suggest difficulties in dealing with emotional reactions in the context of the pandemic, whether due to the lack of coping strategies, the unpredictability of the new condition, and/or the feeling of vulnerability. Cullen et al. [35] suggest that psychological intervention measures be provided for the COVID-19-affected communities in primary and emergency healthcare services, especially for people with previous psychological problems.

Actions to raise awareness on mental disorders and help symptom diagnosis are also suggested to reduce psychological distress and prevent new mental health problems [24,35]. In addition, Holmes et al. [2] highlight that individuals with previous symptoms are more vulnerable and have increased risk of physical and psychological effects from the pandemic [35], which was also observed in this study. Moccia et al. [25] point out that people with a depressive or anxious temperament are also more vulnerable. A striking finding in our study was that 85% of those who reported never having received a medical diagnosis related to psychological problems, reported appearance of symptoms during the pandemic, corroborating the findings by Cullen et al. [35] Furthermore, the presence of moderate to severe symptoms of psychological impact (IES-R) can indicate a risk for future development of post-traumatic stress disorder. Therefore, mental health care must be expanded to restrain these symptoms and prevent their aggravation.

In accordance to the literature, psychological symptoms were more common among younger individuals and women [22–29]. The uncertainty of the future, school and university closings and new teaching formats, the breakdown of interpersonal relationships and an immature cognitive and behavioral repertoire to cope with the pandemic demands could explain the greater risk of psychological symptoms in young adults. The results presented by Palgi et al. [26] point out that the feeling of loneliness due to social isolation is greater among young people, which can increase the risk of developing depressive and anxious symptoms. Still, Bruin [27] showed that older individuals report less negative emotions, have better mental health and less responsiveness to daily stressors, which favors a lesser experience of symptoms of depression and anxiety. To explain why stressful factors have a greater impact on women, Almeida and Kessler [36] suggest that women tend to ruminate negative thoughts more, prolonging distress, increasing the effects of stressors on mood, interfering with behaviors, and impeding the development of a strategies to eliminate stressors. Moccia et al. [25] suggest that women's greatest vulnerability to psychological distress is related to genetic, socio-cultural, hormonal, and developmental factors.

The effect of the economic level on psychological symptoms was expected as people in disadvantaged economic and social situations are affected at a much greater extent due to lower access to health care, inability to quarantine without risking losing a job or decreasing income, among several other factors, making this group even more vulnerable.

This study was conducted on a large sample of individuals that covered the entire country and presented valid and reliable findings. However, some limitations should be reported. First, data collection was carried out online, which certainly resulted in more younger individuals and with higher economic level and education being selected. It should be remembered that older people and those with less economic power or education have lower access to or literacy in digital resources. However, this was the feasible strategy for gathering information during the pandemic. Sample selection could also have been biased by the snowball process starting within universities. Despite contacts with NGOs from populations with low income and education levels, the adherence of this group was not representative of the country population, which was confirmed by the absence of a cluster by States in a country with great inequalities among regions. Finally, the cross-sectional study design does not allow causality inference, and therefore, future longitudinal studies should the developed.

Another aspect to be reported is the absence of a national mental health survey that could be used to compare pre, peri and post-pandemic data and/or to monitor the mental health of the Brazilian population. It is expected that the impact generated by the current context of the pandemic may trigger the need to develop this type of tracking in a continuous and rigorous manner, as in the United Kingdom [28].

Despite these limitations, this is the first Brazilian nation-wide study to present quality evidence that deserves a careful look from government officials, managers, and mental healthcare professionals. The development of a national plan is suggested for epidemiological surveillance and minimization of the psychological impacts of the COVID pandemic in the population. As Qiu et al. [24] proposes, a nation-wide program for coordinating psychological first aid [potentially using telemedicine] and establishing a prevention and intervention system could be highly effective. The psychological and psychiatric needs cannot be neglected during any phase of pandemic management, as they play an important role in public policies adherence and dealing with infection threats and possible losses [34]. Moreover, attention to mental care provided during the crisis can help in the reconstruction process of all individuals and provide the skills needed for the post-pandemic world.
