Enhancing GP care of mental health disorders post-COVID-19: a scoping review of interventions and outcomes

Abstract Objectives: Considerable literature has examined the COVID-19 pandemic’s negative mental health sequelae. It is recognised that most people experiencing mental health problems present to primary care and the development of interventions to support GPs in the care of patients with mental health problems is a priority. This review examines interventions to enhance GP care of mental health disorders, with a view to reviewing how mental health needs might be addressed in the post-COVID-19 era. Methods: Five electronic databases (PubMed, PsycINFO, Cochrane Library, Google Scholar and WHO ‘Global Research on COVID-19’) were searched from May – July 2021 for papers published in English following Arksey and O’Malley’s six-stage scoping review process. Results: The initial search identified 148 articles and a total of 29 were included in the review. These studies adopted a range of methodologies, most commonly randomised control trials, qualitative interviews and surveys. Results from included studies were divided into themes: Interventions to improve identification of mental health disorders, Interventions to support GPs, Therapeutic interventions, Telemedicine Interventions and Barriers and Facilitators to Intervention Implementation. Outcome measures reported included the Seven-item Generalised Anxiety Disorder Scale (GAD-7), the Nine-item Patient Health Questionnaire (PHQ-9) and the ‘The Patient Global Impression of Change Scale’. Conclusion: With increasing recognition of the mental health sequelae of COVID-19, there is a lack of large scale trials researching the acceptability or effectiveness of general practice interventions. Furthermore there is a lack of research regarding possible biological interventions (psychiatric medications) for mental health problems arising from the pandemic.


Introduction
There is now considerable evidence that there has been an increase in prevalence of mental health problems since the COVID-19 pandemic.A systematic review and meta-analysis of observational studies, published from January 1 st 2020 to July 11 th 2020 and spanning 32 countries, reported global prevalence estimates at 28.0% for depression; 26.9% for anxiety; 24.1% for post-traumatic stress symptoms; 36.5% for stress; 50.0% for psychological distress; and 27.6% for sleep problems (Nochaiwong et al. 2021).The findings indicate the prevalence of common mental health disorders is higher during the pandemic compared to pre-COVID-19.A study by Steel et al.,based on 174 surveys across 63 countries from 1980 to 2013 estimated lifetime prevalence was 29.1% for all mental disorders, 9.6% for mood disorders, 12.9% for anxiety disorders, and 3.4% for substance use disorders (Steel et al. 2014).A prospective online study assessing health anxiety/somatoform disorder, general anxiety disorder, panic disorder, OCD, and depression reported prevalence of any of these disorders was 50.6%, much higher than pre-pandemic (Munk et al. 2020).In a cross-sectional study of 15,037 people in Germany, participants reported a significant increase in depression and anxiety symptoms, and distress, while health status deteriorated since the COVID-19 outbreak (Bäuerle et al. 2020).These trends indicate the mental health problems which health systems face since the pandemic.Studies of long-term psychiatric morbidities after previous pandemics support this hypothesis.In a retrospective cohort study of SARS survivors, the prevalence of any psychiatric disorder at 30 months post-SARS was 33.3% (Mak et al. 2009).
The impact of this phenomenon on population health is further compounded by the extent to which the capacity for health systems to make new diagnoses may have been impacted.In the UK, a retrospective cohort study of data from 47 GPs reported a 50% reduction in first diagnoses of anxiety disorders and depression between March 1 st and May 31 st 2020, and a 39.1% reduction in first prescriptions of SSRI's (Williams et al. 2020).
How primary care can address the needs of people experiencing mental health disorders has always been important, but is especially the case now.Internationally, proposed initiatives to enhance primary care of mental health disorders in the post-pandemic era include United Nations policy: 'COVID-19 and the Need for Action on Mental Health', advocating for investment in remote mental health interventions and in mental health reforms to shift care towards community services (United Nations 2020).In Ireland, the policy document 'Psychosocial Response to the COVID-19 Pandemic' proposes a six-layered care framework (HSE 2020), with level four involving primary care providing one-to-one supports to reassure, promote wellbeing and resilience.'Population Mental Health Perspective' is a similar initiative, using primary, secondary and tertiary interventions (Boden et al. 2021).GPs will require further training in early detection of 'at-risk' individuals, and providing them with rapid interventions (HSE 2020, Boden et al. 2021).Early career psychiatrists composed a 'Mental Health Preparedness and Action Framework' modelled on the WHO-Global Influenza Preparedness Plan, to guide development, implementation and evaluation of mental health interventions during and post-pandemic.If this is implemented and suitably resourced, it is postulated to reduce the impact of the mental health epidemic (Ransing et al. 2020).
There have been many studies involving interventions to improve the psychological impact of medical pandemics.These interventions include Psychological First Aid (Yue et al. 2020), Cognitive Behavioural Therapy (CBT) programmes and mobiledelivered interventions (Soklaridis et al. 2020), internet-based self-help interventions (Wei et al. 2020) and physical activity and mindfulness meditation (Green et al. 2021).These interventions mainly involved COVID-19 positive patients or frontline healthcare workers, but could be adopted in primary care, as will be explored in this paper.
The requirement to physically distance during the COVID-19 pandemic has increased utilisation of tele-healthcare in general practice in Ireland (Homeniuk and Collins 2021) and internationally (Murphy et al. 2021, Pierce et al. 2021).Increased use of telemedicine can be expected post-COVID-19, in line with Ireland's two strategies promoting technology in healthcare: Sláintecare (HSE 2019) and the 2013 e-Health policy (HSE 2013, Homeniuk andCollins 2021).Studies are included which evaluate the effectiveness of telemedicine as an intervention to enhance care of mental health disorders in primary care.
Essentially there is a need for increased research into interventions which can improve GP care of mental health disorders post-COVID-19.The literature at present mainly focuses on mental health interventions for COVID-19 inpatients, frontline healthcare workers, or those presenting to psychiatry departments.GP interventions are mainly in relation to increased use of telemedicine in general, not specific to mental health.We aim to address this knowledge gap by examining the extant literature on interventions to enhance the care of mental health disorders among patients attending primary care since the COVID-19 pandemic.

Methods
To gain a comprehensive overview of the literature in relation to interventions which may improve the treatment of mental health disorders post-pandemic, a scoping review methodology was chosen.This scoping review was conducted from May to June 2021, using the six-stage framework described by Arksey and O'Malley (2005) to collate existing literature, identify key findings and outline current research gaps in this area.

Stage 1: Identifying the research question
The COVID-19 pandemic has led to a reported rise in mental health disorders globally.Due to the important role of general practice as the gateway for treatment of mental health disorders in the community, it is necessary to research interventions which could improve care offered post-pandemic.Therefore, the objective of this scoping review was to examine the literature for effective interventions which could be implemented to enhance GP care of mental health disorders post-COVID-19.We formulated the following research question: 'What interventions may be used to improve GP care of mental health disorders post-COVID-19?' Stage 2: Identifying relevant studies A preliminary search of key databases was performed, using multiple search terms to create a reading list.From this, keywords were identified and medical subject heading (MeSH) terms were generated.The electronic databases used in the searches were 'PubMed', the 'Cochrane Library', 'PsycINFO', 'Google Scholar' and the WHO 'Global Research on COVID-19' database.The search terms were grouped, with results requiring reference to one or more search term in each of the following categories: Interventions, General Practice, Mental Health Disorders, COVID-19 (See Fig. 1).We chose not to limit the study search by year as research on interventions implemented during other pandemics would be useful to study.Several additional articles of relevance were identified by 'hand-searching' from references found on databases mentioned above.

Stage 3: Selecting studies
The initial search identified 139 studies with an additional nine studies added from hand-searching references from key literature.
A title and abstract review was then conducted to identify relevant articles, followed by full-text reviews.The 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)' flow diagram below (Fig. 2) outlines the selection process.The literature was included irrespective of study design/methodology, therefore a variety of study types and reviews are included.
Once the initial search was performed, four duplicates were removed.Endnote 20 software was used to track and group studies, manage citations and remove duplicates.Studies were included if Enhancing GP care of mental health disorders post-COVID-19 they were considered to examine the research question, if they were published in English and if the full article was available.
Findings were reviewed by a second reviewer, and a finalised list of studies was agreed.

Stage 4: Charting the data
Once all relevant articles were identified (n = 29), to facilitate comparison and thematic analysis, the following data was charted from the articles:

Stage 5: Collating, summarising and reporting results
An overview of the literature is detailed in Table 1 below, summarising and charting the results.This will be discussed further in the results section.

Stage 6: Consultation
In line with recommendations by Levac et al., (Levac et al. 2010) studies were also included and excluded according to advice received during consultation with experts in the field of mental healthcare and research.

Results
The initial database searches identified 148 records.After four duplicates were removed, reviewers screened the remaining 144 records by title and abstract, during which 109 records were excluded.35 articles met the inclusion criteria and were selected for full-text review.Following full-text review, six records were excluded due to a lack of relevance or unavailability of the full-text article, leaving 29 records which examined interventions that could be implemented to enhance GP care of mental health disorders post-COVID-19.The search process, as guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), is summarised in Fig. 2. Data were extracted from the final selection consisting of 29 records which met the eligibility criteria for the review.

Description of included studies
A variety of study types are included, with some articles including more than one study type.Six studies used randomised control designs (RCT), five used qualitative interviews and seven used Enhancing GP care of mental health disorders post-COVID-19 Enhancing GP care of mental health disorders post-COVID-19 surveys, some of which were cross-sectional, online or by telephone.Others include systematic reviews (n = 4), observational studies (n = 3), retrospective case/chart notes review (n = 2), a quantitative quasi-experimental pre-test/ post-test design (n = 1), consensus study (n = 1), a quality improvement project (n = 1) and narrative review (n = 1).The majority of studies were conducted in the USA (n = 12), Europe (n = 6) and China (n = 5).Four systematic reviews were included providing international data.Single studies from Israel and New Zealand were included.The sample sizes of studies ranged from 14 to 350,966 participants.Most studies examined adult participants.

Study populations and settings
Specific study populations varied between studies, with most including members of the public (n = 13), healthcare professionals (n = 9), individuals with pre-existing mental health conditions (n = 4), COVID-19 positive patients (n = 3), older adults (n = 2) and other specific groups (n = 2; including an ethnic minority and military service members).The majority of interventions took place in community or primary health care settings (n = 23).Others took place in COVID-19 hospital wards (n = 2).Interventions reported in systematic and narrative reviews covered each of these settings (n = 4).One study focused on policy development.

Improving identification of mental health disorders in general practice
Interventions in general practice to improve identification of mental health disorders arising from the pandemic are essential, and have been reported in three included studies (Ahmad et al. 2020, Kaufman-Shriqui et al. 2021, Sivan et al. 2020).A RCT reported the effectiveness of an interactive pre-consultation health risk assessment tool for common mental health disorders (Ahmad et al. 2020).The C19-Yorkshire Rehabilitation Screen (C19-YRS) tool was developed with referral criteria to determine management of individuals with sequelae of COVID-19, including mental health disorders, and can be completed over the phone with a GP.

Interventions to increase support for GPs treating mental health issues
Many primary care professionals are overburdened at present, and cannot adequately meet increased psychosocial needs of vulnerable patients, therefore a 'task shift' approach may be taken.A study involving a new integrated primary care team, with the primary care physician collaborating with a behavioural health care manager and a psychiatric consultant to treat patients with mental health disorders had positive results (Birch et al. 2021).In a RCT Community Healthcare Workers (CHW) provided psychosocial support, resulting in significant improvement in participants self-rated psychosocial health, and high participant satisfaction (Vanden Bossche et al. 2021).This shows the added value of CHW to alleviate mental healthcare burden in primary care settings .

Therapeutic interventions
In systematic reviews (Soklaridis et al. 2020, Yue et al. 2020), psychosocial interventions implemented during medical pandemics were assessed.A study involving well-being workshops and CBT programmes improved well-being, anxiety and depression among Ebola clinic staff (Soklaridis et al. 2020).A RCT of arts-based therapies for children suffering from trauma due to the Ebola crisis resulted in significant stress reduction (Soklaridis et al. 2020).It is projected there will be increased population incidence of PTSD (post-traumatic stress disorder) following COVID-19 (Wells et al. 2020), as has been reported after other medical pandemics (Mak et al. 2009).Interventions to improve PTSD primary care treatment include a brief CBT termed 'Prolonged Exposure for Primary Care' (Cigrang et al. 2017).Video teleconferencing can be used to effectively deliver prolonged exposure for primary care remotely (Wells et al. 2020).Therefore this intervention could be adopted to the current telemedicine revolution.
Studies have found that engaging in meditation and physical activities can buffer against negative mental health impacts of Zhu et al.,Liu et al.).A survey of CALM app users found decreases in physical activity and meditation habits were linked with increased stress and worry about COVID-19 (Green et al. 2021).An observational study found lower levels of pandemic-related distress in mindfulness practitioners (Zhu et al. 2021).Progressive muscle relaxation was found to improve mental health outcomes in COVID-19 patients, lowering anxiety and improving sleep quality (Liu et al. 2020).This intervention could be tested in general practice patients who present with anxiety and disturbed sleep post-COVID-19 (Liu et al. 2020).

Telemedicine
The COVID-19 pandemic has made obvious the need for effective digital mental health care interventions (Weineland et al. 2020).Several studies report increased use of telemedicine internationally during COVID-19 (Atmore and Stokes 2020, Murphy et al. 2021, Ramaswamy et al. 2020, Verhoeven et al. 2020, Wynn 2020).Telemedicine can be used for a broad range of consultation types, and its use has particularly increased in mental health service provision (Pierce et al. 2021, Wynn 2020, Atherly et al. 2020).Quality of care can be maintained when providing mental health care via telemedicine (Frank et al. 2021).Telephone triage has become common in general practice, making necessary face-to face time more 'focused and productive' (Murphy et al. 2021).This is an intervention GPs are eager to continue post-pandemic (Murphy et al. 2021, Verhoeven et al. 2020).

Digital interventions
Several included studies pointed to digital interventions that could be adapted to improve care of mental health disorders in general practice (Cheng et al. 2021, Kerst et al. 2020, Maldonado 2021, Shapira et al. 2021, Soklaridis et al. 2020, Wei et al. 2020, Weiskittle et al. 2021, Wells et al. 2020).Digital CBT for insomnia (dCBT-I) has been shown to offer long-lasting protection across multiple health domains, increasing health resilience and lowering
risk of depression during COVID-19 in adults with a history of insomnia and ongoing mental health symptoms (Cheng et al. 2021).Mobile phone interventions could be encouraged by GPs to promote mental health.All studies in a systemic review of smartphone treatment applications for depression reported decline in symptoms after the intervention (Kerst et al. 2020).A music therapy intervention delivered by mobile for hospital staff during COVID-19 reduced participant levels of sadness, fear, worry and tiredness (Soklaridis et al. 2020), and a study of supportive individual phone consultations between patients and nurses improved mood (Soklaridis et al. 2020).
Two studies reported the success of online mental health selfhelp interventions (Wei et al. 2020, Maldonado 2021).These results indicate internet-based interventions show rapid improvement in mood disturbance and should be considered in patients whose mental health has been negatively impacted by COVID-19 (Wei et al. 2020).Group interventions via telephone/video to relieve loneliness and worry among older adults during COVID-19 have had positive results, enabling participants to practice coping techniques and providing opportunities for social interaction (Shapira et al. 2021).55.6% of clinicians surveyed about their experiences implementing a 'Telehealth Support Group for Socially Isolated Older Adults during the COVID-19 Pandemic' described it very/ extremely effective in addressing social isolation and COVID-related worry.All respondents reported interest in a modified version post-COVID.(Weiskittle et al. 2021).Group interventions for older people are relatively simple measures that could be implemented in the community.Other successful digital mental health interventions during COVID-19 include the Canadian 'Text4Mood' service and Germany's 'Coping with Corona: Extended Psychosomatic care in Essen' (Yue et al. 2020).

Telemedicine improves accessibility
Telemedicine may improve accessibility of mental health services.One study reported use of telehealth significantly improved attendance rates (p = 0.002) and reduced cancellations (p < 0.001) (Frank et al. 2021).Telemedicine use overcomes barriers to care for families with limited resources, including inconvenient appointment times and securing childcare and transport (Frank et al. 2021).Some practitioners believed internet-delivered interventions may be more accessible to young patients who have social phobia or feel stigmatised.'When it is easily accessible and without closed doors, I think it is not so shameful : : : , you don't have to feel that it is something strange and stigmatising : : : ' (Weineland et al. 2020).

Patient and practitioner satisfaction with telemedicine
Patient satisfaction has been cited as the most important factor in the success of telemedicine initiatives (Ramaswamy et al. 2020).A study of primary care patients revealed 79% were more likely to use telemedicine now than pre-pandemic (Atherly et al. 2020).Another study reported patient satisfaction with video visits was significantly higher than in-person visits (p < 0.001), through pre-COVID and COVID-19 periods studied (Ramaswamy et al. 2020).Many studies have reported practitioner satisfaction with telemedicine (Weinland et al, Murphy et al, Pierce et al).Practitioners appreciated the variety telemedicine brought to their schedules, finding it a relief from challenges of face-to-face psychotherapy (Weineland et al. 2020).GPs report telemedicine gives them greater control of their working day (Murphy et al. 2021).
In a study of psychologists, 89.19% anticipated using telepsychology in their clinical practice, in contrast to 45.70% reporting they had never used telepsychology pre-pandemic.This indicates longlasting changes in the use of telepsychology are likely post-COVID-19 (Pierce et al. 2021).There was greater use of telepsychology by clinicians who reported more telepsychology training and supportive policies (Pierce et al. 2021).

Barriers and facilitators to intervention implementation
Barriers to intervention implementation have been reported to include healthcare workers/ organisations lacking awareness of what is required to support their mental well-being, lack of equipment or time, and inadequate skills (Pollock et al. 2020).GPs have voiced concerns about telemedicine.Some consider continuing remote consulting at such high levels unsustainable (Murphy et al. 2021).They reported lack of clarity regarding thresholds for face-to-face consultations, and that telephone consulting at high volumes was more mentally intense and less satisfying, removing ' : : : the most enjoyable part of their jobtalking and touching and sensing patients in the room : : : ' (Murphy et al. 2021).Intercultural communication and language difficulties pose problems due to lack of non-verbal cues.(Verhoeven et al. 2020, Weineland et al. 2020).Other telemedicine concerns include that it would lead to 'double doing' and enforce already existing health inequalities by increasing access only for those with IT skills (Murphy et al. 2021).
Effective communication and having a positive, safe learning environment were facilitators to implementation.Personal knowledge or beliefs regarding the intervention can act as either barriers or facilitators to implementation (Pollock et al. 2020).A systematic review highlighted the importance of establishing an open entry system at primary care level for detection and intervention of mental health problems (Yue et al. 2020).Two qualitative studies reported telemedicine was more effective when the therapeutic relationship had already been established between clinician and patient (Rowen et al. 2021, Verhoeven et al. 2020).Patient motivation and careful patient selection is critical, especially for specific interventions such as iCBT (Weineland et al. 2020).Practitioners need more training to implement telemedicine effectively in practice to treat mental health disorders, and seamless technology is essential (Murphy et al. 2021, Pierce et al. 2021).

Outcomes to measure acceptability and/or feasibility
The majority of included studies utilised surveys or questionnaires which participants completed before and after completing an intervention, to measure the acceptability and/or feasibility of interventions.Many of these surveys incorporated validated scales including the 'Seven-item Generalised Anxiety Disorder Scale' (Kaufman-Shriqui et al. 2021, Kerst et al. 2020, Maldonado 2021, Rowen et al. 2021, Soklaridis et al. 2020, Zhu et al. 2021), the 'Nine-item Patient Health Questionnaire' (Birch et al. 2021, Cigrang et al. 2017, Kerst et al. 2020, Rowen et al. 2021, Shapira et al. 2021, Soklaridis et al. 2020), the 'Post-Traumatic Stress Checklist-Civilian Score' (Cigrang et al. 2017, Soklaridis et al. 2020) and the 'Revised Children's Anxiety and Depression Scale' (Weineland et al. 2020).The success of the intervention was interpreted from the score difference before and after the intervention.Another study used the 'Patient-Reported Outcomes Measurement Information System' and 'The Patient Global Impression of Change Scale' (Vanden Bossche et al. 2021).The 'Self-Report Habit Index' (SRHI) was used along with Enhancing GP care of mental health disorders post-COVID-19 the 'Perceived Stress Scale', 'Impact of Events Scale' (IES) and 'Hospital Anxiety and Depression Scale' to assess the link between strength of physical activity and meditation habits and mental health (Green et al. 2021).Similarly in another study, a questionnaire assessing frequency of mindfulness practice was completed together with GAD-7 and IES questionnaires (Zhu et al. 2021).The SRHI or similar scales used alongside measures of mental well-being is useful to highlight health promoting behaviours.
Many studies included qualitative interviews with participants.Common interview themes were identified, and used to assess the feasibility/ accessibility of the intervention (Murphy et al. 2021, Soklaridis et al. 2020, Weiskittle et al. 2021).Chart Reviews were also used, to assess clinician symptom detection (Ahmad et al. 2020), investigate if appointment attendance differed with telemedicine use, and to check if EBI's continued to be provided using telemedicine (Frank et al. 2021).The 'Working Alliance Inventory Scale' was used to evaluate therapeutic alliance during a telemedicine intervention (Rowen et al. 2021).

Key findings
As COVID-19 infections continue to rise globally, it is anticipated that many interventions to address its mental health sequelae are ongoing and will continue to be evaluated in the months and years ahead.Research to date has predominantly focused on interventions to improve identification of mental health disorders, new or existing psychological therapies to treat these disorders, and the use of telemedicine to enhance the care GPs offer to this cohort of patients.Interventions studied that required active involvement of patients in their own care had positive results, and thus should be considered for patients with declining mental health stemming from the pandemic (Soklaridis et al. 2020).
A key theme identified was the usefulness of digital mental health interventions.The surge of interest in and acceptance of digital tools among clinicians and patients precipitated by the global pandemic has offered an opportunity to explore their potential to enhance mental health care.Many studies documented success of online programmes, mobile applications and zoom group meetings to improve mental health.GPs should become familiar with these interventions and encourage patients to engage with them as an aspect of their care.In particular, small group meetings of older adults over video/phone have shown to improve mental health during the pandemic.This intervention should be considered not just in the immediate post-pandemic period but into the future, as loneliness and social isolation among older people were problems long before COVID-19.
Based on the findings from this review, it is recommended that encouraging participation in health behaviours including physical activity and meditation should be an important public health objective, and should be promoted by GPs.Interventions proven to be accessible and that reduce stigma are important.Delivering mental healthcare in primary care settings can reduce the stigma often found in speciality settings (Cigrang et al. 2017).Using telemedicine allows the patient to interact with their clinician from their own home, improving accessibility.

Comparison with existing literature
Previous research has indicated that digital interventions are important in the COVID-19 era.A scoping review reported that technology-based interventions have been designed and implemented for mental health prevention and promotion during COVID-19, and highlighted the shift to telemedicine to provide mental health care (Safieh et al. 2021).This paper also supported our finding that physical activity is associated with improved mental health outcomes (Safieh et al. 2021).Sharing the Vision Ireland's Mental Health Policy (2020) states that all service elements should include access to talk therapies as a first-line treatment option for most people who experience mental health difficulties (Department of Health 2020).As such, it is important that GPs have direct and increased access for their patients to trained providers of these services.Other practical strategies suggested to enhance provision of mental health services include clinic-based telehealth, linking patients with helplines and virtual medication management visits (Kopelovich et al. 2021).

Methodological considerations
Adopting Arksey and O'Malley's framework was beneficial, as it facilitated greater rigour and transparency in the research process.Our early literature review allowed a comprehensive set of search terms to be compiled.Further, we feel the decision to not limit our literature search by year was justified as it facilitated the potential inclusion of studies during other medical pandemics.However, the scoping review methodology itself gives rise to some limitations.We did not evaluate the study quality of the included literature, as scoping reviews do not include an assessment of study qualitythe focus is on covering the range of work that informs the topic rather than limiting the work to studies that meet particular standards of scientific rigour.We also only included literature published in English, which may have excluded relevant studies in other languages.Furthermore, we acknowledge using the PRISMA extension for scoping reviews (PRISMA-ScR) (Colquhoun et al. 2014) rather than the standard PRISMA guidelines may have added to the quality of the manuscript.

Future directions
While literature continues to be published on the mental health sequelae of COVID-19, literature reporting interventions to combat these issues remains lacking.More large scale primary research is needed in the general practice setting, to evaluate feasibility of mental health interventions.In our research, all studies reporting primary care therapeutic interventions have focused on psychological treatments.There is a lack of studies focusing on primary care biological treatments (psychiatric medications) as an intervention to enhance mental health post-COVID-19.This area needs to be explored going forward.As the pandemic is still ongoing, there is no concrete research conducted post-pandemicwe can only draw on interventions proven successful in people presenting with disorders arising during the pandemic, or from studies conducted after previous pandemics.When COVID-19 ends, there may be further negative mental health consequences as people struggle to return to normality.Research in this area must be continued over the coming months and years as we emerge from the pandemic, to gain a comprehensive view of interventions which can improve mental health post-COVID-19.Further research is additionally required to outline the impact of mental health primary care interventions post-COVID-19 in specialist populations such as in prisons and people with intellectual disabilities as these populations were disproportionately affected by the restrictions imposed by the pandemic (Gulati et al. 2020, Gulati et al. 2021).The challenge now posed to practitioners worldwide is facing up to the surge in mental health problems by keeping up to date with relevant research, and actively implementing interventions in their practice which can improve the mental health care they offer to their patients.

Conclusion
The mental health impacts of COVID-19 are only just beginning to manifest, and will have implications for healthcare systems for years to come.This review outlines studied interventions which could be implemented in general practice to enhance care of mental health disorders post-COVID-19.Studies highlighted the feasibility and effectiveness of digital mental health interventions and suggested that their use is likely to persist after the current pandemic.However it is important that digital mental health interventions are supported by requisite standards of evidence, funding, and data protection legislation.This review also established priority areas for future research, particularly in the area of biological treatments (psychiatric medications) for mental health sequelae of COVID-19.Further research is needed in the Irish general practice setting to determine which interventions are most effective in this setting.
Financial support.This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

(Fig. 1 .
Fig. 1.Search strategy for PUBMED and PsycINFO. (Sivan et al. 2020).It has been recommended that GPs should adopt specific interventions to improve identification of and support for individuals at increased risk of anxiety and declining nutrition status post-pandemic.(Kaufman-Shriqui et al. 2021).Interventions recommended include provision of appropriate diagnostic instruments, staff training and raising awareness.(Kaufman-Shriqui et al. 2021).

Table 1 .
Interventions to improve care of mental health disorders post-COVID-19 474B.Keyes et al.