The impact of the COVID-19 pandemic and its related restrictions on people with pre-existent mental health conditions: A scoping review

Context Globally, governments have introduced a variety of public health measures including restrictions and reducing face-to-face contact, to control the spread of COVID-19. This has implications for mental health services in terms of support and treatment for vulnerable groups such as people with pre-existent mental health conditions. However, there is limited evidence of the impact of COVID-19 and its related restrictions on people with pre-existent mental health conditions. Objectives To identify the impact of COVID-19 and its related restrictions on people with pre-existent mental health conditions. Methods A scoping review of the literature was employed. Eight electronic databases (PsycINFO, Cochrane, Web of Science, MEDLINE, EMBASE, CINAHL, Scopus, Academic Search Complete) were searched and 2566 papers identified. 30 papers met the criteria for this review and findings were summarised under three key review questions. Results COVID-19 and its related restrictions have had a notable effect on people with pre-existent mental health conditions. Public health restrictions have contributed to increased levels of social isolation, loneliness, and reduced opportunities for people to connect with others. Reduced access to health services and treatments has compounded matters for those seeking support. Exacerbation and deterioration of symptoms are commonly reported and can lead to greater susceptibility to COVID-19 infection. Implications The importance of proactive planning, alternative accessible healthcare services and supports for vulnerable and at-risk groups is illuminated. Increased monitoring, early intervention and individually tailored care strategies are advocated. Recommendations revolve around the need for enhanced provision of remote support strategies facilitated using technology enhanced resources. Accessible summary ￭ COVID-19 is a serious public health threat to people across the globe.￭ COVID-19 related factors have negatively impacted on the health outcomes of people with pre-existent mental health conditions.￭ The rapidly changing environment, risk of infection, increasing isolation and reduced access to support services has led to an increase in psychological distress.￭ People with pre-existent mental health conditions are vulnerable and at greater risk of relapse and deterioration in their condition.


Introduction
The first reported cases of novel human coronavirus  were in December 2019 in China and a global pandemic declared in March 2020 by the World Health Organisation (WHO) (Cucinotta & Vanelli, 2020;WHO, 2020a). Since 31st December 2019 and as of the 25th of March 2021, 123,636,852 cases of COVID-19 were reported worldwide, and this includes 2,721,891 deaths (European Centre for Disease Prevention and Control, 2021). In response to this global pandemic and the continuing growing number of COVID-19 cases, a range of public health measures and physical restrictions were implemented by governments worldwide. These measures primarily aim to reduce person-to-person contact (WHO, 2020b) and have included national/regional lockdowns, closure of non-essential services, selfquarantining and travel restrictions to reduce the transmission of COVID-19. These measures have had a demonstrable impact upon physical and mental health outcomes and individuals' ability to access health services (Garriga et al., 2020;Wang et al., 2020). In particular, people with mental health conditions are a more vulnerable group in comparison to the general population during COVID-19 (Benson et al., 2020) in terms of health awareness, life circumstances and generally being at a higher risk of contracting COVID-19 due to reduced physical outcomes (Lighter et al., 2020). The disruptions to mental health services in terms of support services and treatment have the potential to disproportionally affect individuals with pre-existent mental health conditions (Moreno et al., 2020). However, there is limited evidence of the impact of COVID-19 and its related restrictions on people with preexistent mental health conditions. In addition, issues around stigma and reduced autonomy produce barriers to accessing appropriate care especially during COVID-19 (Yao et al., 2020a). People with pre-existent mental health conditions have been disproportionately impacted during COVID-19, experiencing increased incidence and/or exacerbation of symptoms, along with symptoms that have emerged in response to COVID-19 (Hao et al., 2020). WHO (2020c) identify that social and personal challenges associated with COVID-19 such as grief, social isolation, economic pressures and health anxiety further exacerbate pre-existent mental health conditions. In addition, the communal nature of mental health inpatient and outpatient settings produces challenges around social distancing, adding to vulnerability (Benson et al., 2020;Dalila et al., 2020). Garriga et al. (2020) suggests that individuals with severe mental illness may be at more risk of death than the general population due to vulnerabilities associated with pre-existent physical health co-morbidities and inability to access healthcare services (Liu et al., 2017;Shen et al., 2011). Public health measures aimed at decreasing transmission of COVID-19 have the potential to increase the isolation of individuals with pre-existent mental health problems, raising the risk of reducing both physical and mental health outcomes (Hwang et al., 2020). Druss (2020) also cautions that physical distancing measures may reduce potential support provided from support networks, such as, family and friends if a person becomes unwell. These factors can lead to a deterioration of mental health conditions and although there is an increasing body of evidence, these are factors that require consideration. However, a broad examination of the nature and extent of current literature and mapping different characteristics would assist in planning services, support and modes of delivery during a global crisis. Furthermore, Pan et al. (2020) identify the need for further research to develop a greater understanding of the impact of COVID-19 on people with pre-existent mental health conditions. Further challenges experienced by mental health service users during COVID-19 include premature discharge from psychiatric units and cancellation of planned, in person mental health appointments (Chevance et al., 2020;Moreno et al., 2020). The WHO (2020c) report that COVID-19 has caused major disruption to core mental health services in 93% of countries worldwide. Notably, 70% of countries have implemented telemedicine approaches in response to the challenges of delivering face-to-face mental health services. However, variations exist in the provision and uptake of these approaches (WHO, 2020c) and evidence is limited regarding their use and effectiveness. The disruptions to mental health service provision may have impacted on a range of unintended consequences including relapse of symptoms, suicidality and increased social isolation (Chevance et al., 2020;Jefsen et al., 2020;Mehra et al., 2020). Frontline practitioners in mental health have a key role in supporting individuals with pre-existent mental health conditions in support of their recovery, especially during the COVID-19 pandemic. Mental health nurses are fundamental to this process in terms of providing support and care across the spectrum in a range of healthcare settings. However, it is important that the impact of COVID-19 and its related restrictions on people with pre-existent mental health conditions are better understood as a means of planning appropriate future support and services. This paper explores the evidence relating to the impact of the COVID-19 pandemic and its related restrictions for people with preexistent mental health conditions in order to map the evidence for mental health practitioners to enable the provision of safe effective care. The term mental health conditions will be used throughout this paper and the authors acknowledge the many variations in terminology relating to mental health that are used in the literature. These range from mental health problems to mental health disorders and mental health conditions, which are often used interchangeably and refer to a range of issues that can affect a person's thinking, feelings and behaviours e.g., depression, schizophrenia, or anxiety (Fadyl et al., 2020;Steel et al., 2014).

Aim
The aim of this scoping review was to locate, examine and describe literature on the impact of COVID-19 and its related restrictions on people with pre-existent mental health conditions. The purpose of this study was not to systematically appraise the literature but to map the literature and provide an overview of the evidence, concepts, and research studies in relation to the impact of COVID-19 and its related restrictions within the first year of COVID-19 (Pollock et al., 2021). The objective was to identify gaps, reveal the existing research evidence and use the results to plot the evidence by categorising the components of literature, such as methodology, population, methods, key findings, key messages, and limitations.

Method
As novel research findings regarding COVID-19 are being published daily, a scoping review design was chosen for this paper as it allows for a broad overview and assessment of emerging evidence, while providing a robust foundation for developing practice guidelines and future research (Peterson et al., 2017). Scoping reviews are used to ascertain literature on a given topic, focusing on the extant literature to identify both important conceptions and any gaps evident and publicising the results (Arksey & O'Malley, 2005;Levac et al., 2010;Pollock et al., 2021). It was deemed to be too early in the context of the pandemic evolution to conduct a more comprehensive systematic review. Although systematic approaches are used in scoping reviews to search and review the literature, there are some controversies around their depth (Peterson et al., 2017). However, as they are exploratory in nature, they do provide a wider conceptual range and a broad appreciation and knowledge synthesis of the existing literature (Anderson et al., 2008). This process supported the reviewers to focus on the review question, unlimited by methodological issues such as the design or quality of included papers (Arksey & O'Malley, 2005). This scoping review was guided by Arksey and O'Malley (2005) methods involving a five-step process: (a) identification of the research question, (b) identification of relevant studies, (c) study selection, (d) mapping the data, and (e) arranging, summarising, and communicating the outcomes. Although these steps are sequential, the process remains interactive where each step is revised and developed throughout the review duration. Tables and diagram illustrations are used to present the results of the review, in addition to narratives (Arksey & O'Malley, 2005;Munn et al., 2018).

Identification of the research question
This review plans to focus on the following question: what is the impact of the COVID-19 pandemic and its related restrictions on people with pre-existent mental health conditions? There will be three specific questions to map the evidence onto and these include: 1. What COVID-19 pandemic related factors have influenced the health outcomes of people with pre-existent mental health conditions? 2. What is the impact of the COVID-19 pandemic on the health of people with pre-existent mental health conditions? 3. What strategies and/or measures are recommended to support people with pre-existent mental health conditions during the COVID-19 pandemic?

Identification of relevant studies
A broad range of databases and keywords were utilised to ascertain a wider selection of literature (Arksey & O'Malley, 2005). The search process involved the use of subject headings (Title/Abstract) and Boolean operators to combine and expand searches. Appropriate 'wild cards' were also incorporated to account for plurals, and differences in spelling. Search strings for key words were identified, then searched individually and subsequently all search strings combined (Table 1). The systematic search process was applied across eight electronic databases (PsycINFO, Cochrane, Web of Science, MEDLINE, EMBASE, CINAHL, Scopus, Academic Search Complete) to identify relevant papers. Inclusion and exclusion criteria were formulated (Table 2) and applied to the search results.

Study selection
The electronic database searches produced an original set of 2566 papers. These papers were screened to identify duplicates (n = 562) and after duplications were removed 2004 papers remained. Initial screening of title and abstracts was then performed by two reviewers (OD, LM) and papers were judged relevant if their abstracts described the COVID-19 pandemic and included people with a pre-existent mental health condition and in light of this 1962 papers were excluded. The remaining 42 papers at full texts were reviewed and assessed against the inclusion and exclusion criteria (Table 2). Based on the inclusion criteria, 12 papers were excluded with the agreement of two reviewers (OD, LM) leaving 30 papers that met the criteria for this review. Conflicts between the reviewers were resolved, but a third reviewer (KM) was available if conflicts between the initial two reviewers remained unresolved. The selection process followed Tricco et al.'s (2018) Preferred Reporting Items for Scoping Reviews [PRISMA-Sc-R] (Supplementary File 1) and PRISMA flow diagram ( Fig. 1) to identify selection process and reasons for exclusion.

Mapping the data
Existing literature was mapped in terms of quantity, type, characteristics and sources of evidence in accordance with the aim of this scoping review (Daudt et al., 2013). In accordance with Arksey and O'Malley's (2005) process, mapping the data stage involved extracting summaries from each paper (n = 30) in relation to: author, year, title, country, aim and methodology, population and methods, summary of findings, key messages and limitations as presented in Table 3. Four authors (LM; OD; COD; KM) extracted and mapped the data from the included studies onto the data extraction table, while a fifth author (MM) checked the extracted data.
Arranging, summarising and communicating the outcomes Arksey and O'Malley's (2005) final stage summarises and communicates the outcomes of the review and to this end a narrative account of the findings is presented hereunder. The extent, nature and distribution of the studies included in the review are presented, as well as the geographical locations of the evidence. The review findings are collated, summarised and organised under the three key review questions identified in step one of the review process.

Descriptive characteristics of papers included
The review evidence emanates from primary original research studies (n = 30). The methodologies of the studies are diverse and reflect quantitative, qualitative and mixed methods designs. A wide range of study populations are included in the review papers; however, the findings predominately represent the perceptions and experiences of people with pre-existent mental health conditions (including anxiety disorder, mood disorder, psychotic disorder, addiction, obsessive compulsive disorder, major depressive disorder, bipolar disorder, eating disorder, schizophrenia, and other severe mental illness). The general population and people without mental health conditions were also included in some studies, but in these cases, they were mainly used as control groups. The included papers (n = 30) span the globe representing: Italy (n = 9), United States (n = 5), China (n = 3), United States and Canada (n = 1), Germany (n = 2), Spain (n = 2), United Kingdom (n = 2), Canada (n = 2), Ireland (n = 1), Australia (n = 1), India (n = 1), and finally one global study (n = 1) which incorporated 12 different countries (Switzerland, USA, Spain, Italy, France, Germany, Iran, Turkey, Canada, Poland, Pakistan and Bosnia and Herzegovina).

Q1. What COVID-19 pandemic related factors have influenced the health outcomes of people with pre-existent mental health conditions?
Since the onset of the pandemic, the threat of infection and its' associated public health restrictions have influenced health outcomes service user OR client OR user OR consumer OR patient S4 S1 + S2 + S3 (The significance of the '+' symbol indicates that all search strings (S1, S2 and S3) were combined together in one search.).

Table 2
Inclusion and exclusion criteria. This was a retrospective single center study which should be considered when considering the generalisability of findings to other mental health services. Asmundson et al. (2020). Do pre-existing anxietyrelated and mood disorders differentially impact COVID-19 stress responses and coping.

United States and Canada
Aims to assess COVID-19-related stress, selfisolation stressors, and coping in people with a primary anxiety-related disorder diagnosis, a primary mood disorder diagnosis, and no mental health disorder. Comparison study using online surveys.
Participants with anxiety related disorders were found to be significantly more affected during COVID-19 than those with mood disorders. Participants with mood disorders were found to experience higher traumatic stress symptoms and socioeconomic consequent scales than those with no mental disorder. Participants with anxiety disorders experienced significantly greater selfisolation stressors. Participants with anxiety and mood disorders reported significantly higher levels of current anxiety and depression than those with no diagnosis.
COVID stress syndrome is more evident in selfisolated individuals with anxiety related disorders. Tailored COVD-19 related mental health interventions to meet the specific needs of people with pre-existing mental health conditions and address the domains of the COVID stress scale to target coping strategies is needed.
Mental health diagnosis was based on self-report rather than clinical evaluation which is a limitation of the study. In addition, participants were not questioned on potential comorbid conditions.
(continued on next page)  In times of uncertainty, mental health conditions were exacerbated but leveled off as time passed and restrictions eased indicating a readjustment and resilience. Although an overall trend of recovery was noted there will inevitably be a portion of the population who will experience an exacerbation of mental health conditions and it is important to identify and support those most vulnerable.
The study provided tablets and internet access to support participation. There was a large sample and comparison group.
The study was conducted in the early stages of Covid-19 as additional waves and lockdowns occurred and responses could change. Davide et al. (2020). The impact of the COVID-19 pandemic on patients with OCD: Effects of contamination symptoms and remission state before the quarantine in a preliminary naturalistic study.

Italy
Aims to evaluate the changes on OCD symptoms during the COVID-19 quarantine in a group of patients with OCD who had undergone psychiatric care at a specialised clinic for OCD before the quarantine period. Quantitative study using a survey.
Participants demonstrated an overall worsening of all symptoms associated with OCD during the COVID-19 quarantine period. Factors influencing OCD symptoms worsening included living with a relative in the same house during quarantine and having contamination symptoms before quarantine.
COVID-19 quarantine has a negative effect on symptoms associated with people with pre-existing OCD. Relapse prevention strategies should be implemented, particularly at the end of cognitive behavioural therapy to reduce the risk of relapse.
The small sample size and low statistical power prevented exploring the role of additional variables which should be taken into consideration when interpreting the generalisability of the findings.
Other symptoms such as anxiety and depression or personality comorbidity were not assessed. There was also lack of a control group for comparison. Di    73 participants with a preexisting mental health condition.
During the first 2 months of the pandemic, participants were interviewed to evaluating access to care, mental health, quality of life, and coping. Tools used -PHQ-9* and PROMIS*. Data gathered -April 2020.
Participants described themselves as more depressed (n = 32) or more anxious (n = 33) as a result of COVID-19.
Participants were more concerned about the risk of contracting the virus than the risks of isolation. The impact of social isolation is not a major concern at presentbut this data was only collected 32 days into the global pandemic. Older adults weighed fears of COVID-19 illness as greater than concerns from the distancing requirements.   The CPSS, HAM-D and HAM-A scores of the study group were significantly higher for people with schizophrenia than those of the control group. There were no statistically significant differences in the common inflammatory indicators between the isolation group and the control group.
Inpatients with pre-existing mental health conditions (schizophrenia) who have to socially isolation have higher levels of stress, anxiety, and depression.
There was a small sample size used in this study which limits the generalisability of the study findings.

Murphy et al. (2020).
Exploring the impact of COVID-19 and restrictions to daily living as a result of social distancing within veterans with pre-existing mental health difficulties.

United Kingdom
Aims to explore the effects of the COVID-19 lockdown on British Armed Forces veterans with pre-existing mental health conditions. Cross-sectional study using electronic surveys.
15.1% of participants reported that they had experienced a bereavement related to COVID-19. The most frequently endorsed mental health conditions were anxiety and depression, followed by problems with anger, PTSD, and alcohol misuse. Symptoms exacerbated by the pandemic and worsened included: anxiety and depression (69.3%), PTSD (65.0%), difficulties with anger (52.7%) and alcohol misuse (30.0%). There was a significant association between reporting lower levels of social support and increased stressors because of COVID-19 and an increase in the severity of symptoms.  Those with a pre-existing mental health condition were more likely to experience suicidal ideation and report higher levels of depressive symptoms. Participants with g a preexisting mental health condition were more likely to score above the anxiety cut off and reported higher levels of defeat, entrapment and loneliness, and report lower well-being scores.
Individuals from more socially disadvantaged backgrounds and those with pre-existing mental health conditions report the worst mental health outcomes. These groups need to be prioritised to ensure that they receive the support they require and access to services tailored to meet their needs during COVID-19. Loneliness may become more of an issue for people as the pandemic unfolds.  There was a small sample size used in this study, making it difficult to generalise the findings. Participants were from an area that did not experience a high rate of Covid-19 at the time of the study. The study was limited to veterans who accessed care through the Veterans Affairs (VA) which is seen as a wellresourced integrated healthcare system. Thus, the same barriers to mental health treatment as may be experienced as the civilian population.
(continued on next page) This study only comprised females discharged from inpatient treatment the year before and had a relatively high mean BMI.
Results may not be gereralisable to others with anorexia nervosa. All data was self-reported and there is a potential for bias (e.g., body weight). No Cronbach's alpha was reported in the study. The sample included adolescents and it was not always possible to distinguish results specific to adults with pre-existing mental health conditions. Skoda et al. (2020). Severely increased generalised anxiety, but not COVID-19related fear in individuals with mental illnesses: A population based crosssectional study in Germany.

Germany
Aims to explore the impact of COVID-19related fear, generalised anxiety, depressive symptoms, and distress on people suffering from a mental health condition. Cross-sectional study using an electronic survey.
Individuals with mental health conditions scored higher than healthy individuals on all scales (COVID-19-related fear p < 0.001, generalised anxiety p < 0.001, depressive symptoms p < 0.001 and perceived distress p < 0.001).
Pre-existing mental health conditions significantly affects generalised anxiety, depressive symptoms, and distress, while a somatic illness that increases the threat caused by the COVID-19 pandemic does not significantly increase these parameters.
Generalised anxiety, depressive symptoms, and distress are significantly enhanced in people suffering from pre-existing mental health conditions. The COVID-19 pandemic increases unspecific, pathological anxiety rather than a specific fear of the virus in people suffering from pre-existing mental health conditions.
Cronbach's Alpha -GAD-7 0.900, GAD-2 0.818, and PHQ-2 0.825 -all indicating good reliability. The overall survey had 12,028 participants and it was not always possible to distinguish results specific to persons with mental health conditions. Data collected early in the Covid-19 time period which may have influenced the findings of the study. for all people. Pandemic-related factors have influenced the determinants of health across the social, economic, environmental and personal aspects of life and wellbeing. However, the pandemic has had a greater impact on health outcomes for some populations over others (Burström & Tao, 2020). This review highlights the factors which have influenced health outcomes for people with pre-existent mental health conditions and reports on a wide range of conditions from depression, anxiety and obsessive-compulsive disorders to mood disorders, psychosis and other serious mental health conditions. The factors which have compounded health difficulties for people are charted in Table 4. The most commonly reported factor is the additional fear, worry and stress which COVID-19 pandemic created. People were fearful of contracting the virus and worried about spreading it to others, particularly to vulnerable family members Davide et al., 2020;Hao et al., 2020;Newby et al., 2020). This led to increased levels of distress, especially for people with pre-existent mental health conditions where symptoms centred on the fear of contamination and infection risk from others Newby et al., 2020). COVID-19 pandemic related restrictions for public health protection (such as lockdowns, quarantines and social distancing rules) contributed to increasing levels of social isolation and loneliness, with reduced opportunities for people to connect with family and friends Hamm et al., 2020;Hao et al., 2020;Newby et al., 2020;Plunkett et al., 2020). In some cases, this resulted in people relying more heavily on social media networking to connect with others, yet it was viewed that this increased usage was also negatively affecting mental health status . For the majority, social isolation was difficult and further compounded by reduced access to and withdrawal of face-to-face individual and group-based mental health services and supports Hao et al., 2020 ;Muruganandam et al., 2020). This led to difficulties with medication management as people were unable to attend medication clinics or collect medicines from pharmacies due to restrictions, thus further impacting on the management of pre-existent conditions and contributed to deteriorating mental health status Muruganandam et al., 2020). The loss of daily routines regarding eating habits, physical activity and communitybased activities also negatively impacted on peoples' physical and mental health Gobbi et al., 2020;Muruganandam et al., 2020;Newby et al., 2020;Schlegl et al., 2020). This impact was intensified if one was living away from home, living alone or unmarried . Within the review, lower employment levels and/or opportunities for work resulted in reduced income, increased financial worries and generally lowered socioeconomic status Franchini et al., 2020;Gao et al., 2020;Hao et al., 2020;Iasevoli et al., 2020;Muruganandam et al., 2020;Newby et al., 2020;O' Connor et al., 2020). It is reported that these pandemic related factors increase the predisposition of people with pre-existent mental health problems to relapse, exacerbation and/or deterioration in mental health status (Alonzi et al., 2020;Asmundson et al., 2020;Davide et al., 2020;González-Blanco et al., 2020;Hao et al., 2020;Muruganandam et al., 2020;Newby et al., 2020;Riblet et al., 2020).

Q2. What is the impact of the COVID-19 pandemic on the health of people with pre-existent mental health conditions?
This scoping review confirms that people with pre-existent mental health conditions experience increasing difficulties and challenges due to the COVID-19 pandemic and its related public health restrictions. Exacerbation and deterioration of symptoms associated with the preexistent mental health conditions were the most commonly reported effect in all studies (Alonzi et al., 2020;Asmundson et al., 2020;Baenas et al., 2020;Benatti et al., 2020;Daly & Robinson, 2020;Davide et al., 2020;Di Nicola et al., 2020;Fiorillo et al., 2020;Gao et al., 2020;Gentile et al., 2020;Gobbi et al., 2020;González-Blanco et al., 2020;Hao et al., 2020;Muruganandam et al., 2020;Newby et al., 2020;O' Connor et al., 2020;Pinkham et al., 2020;Plunkett et al., 2020;Riblet et al., 2020;Schlegl et al., 2020;Skoda et al., 2020). An increase in selfharming behaviour and suicidality  were also reported. However, a small number of studies (n = 3) acknowledged the challenges experienced as a result of COVID-19 but proposed that the impact on mental health conditions in the early stages of imposed public health restrictions were minimal. For example, no patient reported mood disorder re-occurrence , people with pre-existent serious mental illness were not reporting a worsening of symptoms or affective experiences (Pinkham et al., 2020) and participants in a study by Hamm et al. (2020) did not report depression but found that anxiety increased when measured on anxiety scales. However, this scoping review does illuminate the idea that individuals with deteriorating symptoms associated with their mental health condition were more susceptible to COVID-19, as they experienced poorer health outcomes . Increased incidences of cognitive impairment and lower literacy levels in this population means that some may have difficulty adhering to public health guidelines and restrictions Newby et al., 2020). A lack of awareness and understanding about COVID-19, including symptoms, mode of transmission and precautionary measures needed, contributes to this susceptibility  and increases the risk of individual and community transmission. Nonetheless, there was some evidence within the review of resilience among people with pre-existent mental health conditions. Many studies reported that this population were more likely to have past experiences of the negative detriments of health (e.g., isolation, fear, unemployment), factors which are now similar to those associated with the pandemic. Therefore, it is posited that this population may have more resilience and developed coping strategies in such contexts (Daly & Robinson, 2020; González-Blanco  Hamm et al., 2020;Pinkham et al., 2020;Plunkett et al., 2020;Riblet et al., 2020;Schlegl et al., 2020).
Q3. What strategies and/or measures are recommended to support people with pre-existent mental health conditions during the COVID-19 pandemic? Table 5 summarises the key strategies and/or measures recommended to support people with pre-existent mental health conditions during the COVID-19 pandemic. A key recommendation which consistently emerged within the review was the need for increased monitoring, early intervention and proactive planning of alternative healthcare strategies, which are accessible for all people with pre-existent mental health conditions during a pandemic Baenas et al., 2020;Burrai et al., 2020;Daly & Robinson, 2020;González-Blanco et al., 2020;Iasevoli et al., 2020;Muruganandam et al., 2020;Newby et al., 2020;Plunkett et al., 2020;Riblet et al., 2020). However, the challenges of providing adequate supports in such unprecedented circumstances were also highlighted. The provision of remote/distance mental health services and supports via technology-enhanced platforms/resources was a key recommendation (Alonzi et al., 2020;Aragona et al., 2020;Asmundson et al., 2020;Baenas et al., 2020;Burrai et al., 2020;Daly and Robinson, 2020;Davide et al., 2020;Franchini et al., 2020;Gentile et al., 2020;Hao et al., 2020;Newby et al., 2020;O' Connor et al., 2020;Plunkett et al., 2020;Riblet et al., 2020). There was evidence of such technology-enhanced services in some studies, and in other cases they were either not available or needed to be enhanced. Nonetheless, Muruganandam et al. (2020) drew attention to the importance of strategically planning and allocating adequate resources to ensure the success of such support strategies, such as finances, capital and staffing levels. Also, of note within the review, was the varied terminology used to describe the technology-enhanced approach to the provision of remote/ distance health care, the diverse terms may be open to different interpretations by different people, including healthcare providers and service-users (Table 6). Reviewing medication management support strategies during the pandemic was also recommended. Home delivery of medicines from clinics and pharmacies and support around the administration of medicines is advocated, particularly with long-acting injectable medicines . The need for greater accessibility to point-of-care COVID-19 testing at mental health care facilities, and protocol development for the management of people with severe mental health conditions who become infectious and require isolation, were also identified as requiring urgent consideration Muruganandam et al., 2020).

Discussion
This review captures the first year of the COVID-19 pandemic and maps the evidence of the impact of COVID-19 on people with preexistent mental health conditions, along with its related restrictions. Interestingly to note, the majority of the included research studies in this paper collected their study data in March/April (n = 11) and March/ May (n = 6), approximately 1-3 months after COVID-19 was declared a global pandemic by the WHO in March 2020. The other included studies collected their study data in April/May (n = 4), March/June (n = 2), January/April (n = 3), February/March (n = 2), April/June (n = 1), June/July (n = 1). The key findings from this review highlight the vulnerability of people with pre-existent mental health conditions. In particular, it provides clear evidence that the COVID-19 pandemic can exacerbate symptoms in people with pre-existent mental health conditions and subsequently place them at an increased risk of psychological distress and potential risk of relapse. Vulnerability can be heightened for certain groups such as those with obsessive compulsive disorder who have checking, hoarding, and washing compulsions or those living or receiving care in congregated settings (Connolly, 2020). In addition, COVID-19 restrictions jeopardise normal daily routines, social rhythm and thereby increases stress levels, which further accelerates cortisol levels, leading to exacerbation of generalised anxiety disorder, depressive symptoms, chronic insomnia (Dong & Bouey, 2020) and suicidal ideation (Goyal et al., 2020). This overall dysregulation of the stress system exacerbates pre-existent mental health conditions (Steenblock et al., 2020) and of note within the wider literature is that older people have a high risk of severe COVID-19 illness and mental-health-related consequences due to the pre-existence of cognitive decline Webb, 2020). Compounding this are issues around access to services and support (Chevance et al., 2020;Garriga et al., 2020;Hao et al., 2020), literacy levels (Melamed et al., 2020;Muruganandam et al., 2020;Newby et al., 2020), awareness (Garfin et al., 2020;Muruganandam et al., 2020;Zhoa & Zhou, 2020) and accessibility Baenas et al., 2020;Burrai et al., 2020;Daly & Robinson, 2020;González-Blanco et al., 2020;Iasevoli et al., 2020;Muruganandam et al., 2020;Newby et al., 2020;Plunkett et al., 2020;Riblet et al., 2020). These issues need to be addressed as it is everyone's right to have equal access to healthcare that is of the highest standard (Rajkumar, 2020).
A small number of studies Hamm et al., 2020;Pinkham et al., 2020) reported on the impact on mental health conditions as minimal while acknowledging the challenges experienced as a result of COVID-19. This, however, needs to be considered in the context that these studies were conducted in the early stages of COVID-19 (March/June 2020) and the full impact of the restrictive measures and Table 5 Recommended strategies and/or measures during the COVID-19 pandemic. Provide point-of-care COVID-19 testing within mental health services. Hao et al. (2020) Provide medication management support strategies, particularly regarding long-acting injectable medicines. Hao et al. (2020)  the following waves were not captured and may impact on later studies. It is possible that the negative effects may take time to arise as COVID-19 lockdown persists, thus highlighting the need for longitudinal studies to determine whether mental health stability in people with pre-existing mental health conditions is likely to continue or if trajectories decline as COVID-19 evolves. Furthermore, it is evident from this review that the way in which people are accessing information about COVID-19 can potentially have an impact on their mental health. For example, while the media can publicise accurate up-to-date data on COVID-19 with speed and subsequently raise awareness about individual's health behaviours, it also has the potential to trigger and increase anxieties and communicate misinformation (Garfin et al., 2020;Zhoa & Zhou, 2020). This is also relevant for vaccinations and other public health messages (WHO, 2020d). Loomba et al. (2021) quantified how exposure to online misinformation around COVID-19 vaccinations affects intent to vaccinate and found that exposure to online misinformation about COVID-19 was more strongly associated with declines in vaccination intent, threatening the goal of herd immunity. Misinformation can further complicate COVID-19 response efforts and decrease the publics' trust in organisations leading out on the response to COVID-19 (WHO, 2020d; WHO, 2020e). Zhong et al. (2020) highlighted a link between social media and depression and secondary trauma, which also produced health behaviour changes, but interestingly no association was found between health behaviour change and mental health conditions. Excessive social media has been found to lead to mental health issues indicating that taking a break from social media may be conducive to promoting positive mental health well-being . Young adults may need to be targeted as they use social media more and tend to utilise disasterrelated information via social media platforms (Piotrowski, 2015). Mheidly and Fares (2020) caution the difficulties posed in relation to monitoring all published posts on social media during COVID-19. In response to this, the WHO has worked closely with more than 50 digital companies and social media platforms such as Facebook, TikTok, WhatsApp, Google, Instagram, YouTube and Twitter to discourage the spread of misinformation in relation to COVID-19 and a number of initiatives were introduced subsequently e.g., WHO developed a 'Myth busters' page and social listening with artificial intelligence, and Google created an 'SOS' alert on COVID-19 accessible in many languages (WHO, 2020d;WHO, 2020e).
Resilience among people with pre-existent mental health conditions during COVID-19 was evident Daly & Robinson, 2020;Pinkham et al., 2020). Individuals with mental health conditions often demonstrate resilience in managing and adapting to challenges faced, demonstrating the importance of understanding the varied responses to the pandemic. Two key aspects to resilience factors are optimism and meaningful social support (Ayed et al., 2019;Plomecka et al., 2020;Li et al., 2021), with optimism lending itself to more flexible adaptive emotion-focused coping strategies. For example, positive reinterpretation of a situation (Lazarus & Folkman, 1984) and meaningful social support can provide a protective buffer effect on mental health in stressful situations (Eisman et al., 2015;Li et al., 2021). Furthermore, within the literature, resilience has been shown to positively predict subjective well-being through the mediating role of hope (Satici, 2016), with lower symptoms of depression and anxiety associated with resilience characteristics (Skrove et al., 2012). Killgore et al. (2020) assessed psychological resilience during COVID-19 and found lower resilience scores were associated with more severe depression and anxiety in the general population. In addition, predictors of good state resilience in people with pre-existing mental health conditions during COVID-19 were reported as having pursued hobbies or conducted home tasks and having a good level of organisation in the family (Verdolini et al., 2021). This review provided evidence of the strategies recommended to support people with pre-existent mental health conditions during COVID-19, in particular, remote/distant service provision was highlighted.
Pre-COVID-19 there was a concerted push towards the development and implementation of remote/distance services in supporting people with pre-existent physical and mental health conditions in an attempt to reduce their burden of care. Hubley et al. (2016), despite evidence that online services can be an effective and conventional method to improving access to mental health service provision, where access may have been limited previously (Salmoiraghi & Hussain, 2015;Bashshur et al., 2016;Wherton et al., 2020). However, with the arrival of COVID-19, adoption of telehealth is reported globally (Figueroa & Aguilera, 2020;Liu, Yang, et al., 2020;Sheridan Rains et al., 2020;WHO, 2020c;Wosik et al., 2020). This move to remote/distance service provision highlights the increased need for monitoring and tailored care due to COVID-19 and the increased vulnerabilities people have (Figueroa & Aguilera, 2020). For example, the importance of point of care COVID-19 testing and isolation protocols, particularly in, in-patient facilities are needed (Benson et al., 2020;Hao et al., 2020;Li, 2020;Muruganandam et al., 2020). People with pre-existent mental health conditions in inpatient facilities are at an increased risk of exposure to COVID-19 due to difficulties assessing medical systems, frequent patient turnover, limited space and staff (Benson et al., 2020). In addition, the need for medication support and emergency care support is further emphasised (Capuzzi et al., 2020;Hao et al., 2020).
This pandemic has accelerated the implementation of remote and distance services and supports which are valid measures for people with pre-existent physical and mental health conditions (Mencap Report, 2020). Thus, this momentum should be evaluated to advance our understanding of engagement with online services in supporting vulnerable populations emerging with new ways of delivering mental healthcare services (Galea et al., 2020;Sheridan Rains et al., 2020). Engagement with online services can be viewed as a positive attribute to healthcare and can be expected to outlast this COVID-19 pandemic (Sheridan Rains et al., 2020). However, online services are not without their concerns and challenges (Lowenstein et al., 2017;Naidoo & Cartwright, 2020), one potentially being confidentiality breaches depending on where the client is, as the virtual consultation takes place. Fear of breach of privacy and confidentiality surrounding the area of data storage and usage prevails (HEMHA, 2019). Healthcare services must be aware of the ethical, legal, practical and therapeutic risks associated with technology (Naidoo & Cartwright, 2020). Strategies to minimise such privacy and confidentiality breaches from occurring need to be initiated through appropriate security standards in compliance with national/international regulations (HEMHA, 2019). For service users who may have concerns and anxieties around breaches in confidentiality, other alternative modes such as email, text and face to face blended approaches could be considered (Naidoo & Cartwright, 2020). Types of software being used, how data is stored, encryption of data and gaining patient consent to engage in this way are also important considerations with online modalities. Lowenstein et al. (2017) suggest such considerations help alleviate concerns about technology, lessening patient worries and hopefully preventing them from deferring their care. A re-envisioning of current healthcare models is timely to benefit those most vulnerable, mitigating against the further pandemic of mental health problems resulting from COVID-19 (Galea et al., 2020). However, it is evident from this review that there are variations in the terminology used when referring to the provision of remote mental healthcare services/approaches/supports via the use of technology enhanced resources (Table 5).
When incorporating new strategies in supporting people with preexistent mental health conditions during the COVID-19 pandemic, it is important to remember that it is everyone's right to have equal access to healthcare that is of the highest standard (Rajkumar, 2020). However, some groups are identified as having limited access to services such as the older person with mental health problems , rural populations (Benavides-Vaello et al., 2013), individuals from lower socioeconomic divisions (Yao et al., 2020b) and those from ethnic minority populations . For example, in rural areas access to mental health service provision is impacted by geographical isolation, low socio-economic status of the population, cultural differences and language barriers (Yellowlees et al., 2008). This lack of access is further compounded when services are moved online, making digital exclusion real and complex (Sheridan Rains et al., 2020). Lack of technological access and/or experience and lack of resources further impedes mental health problems compounding this digital exclusion (Sheridan Rains et al., 2020). Such exclusions unfortunately, exclude the voice of those unable to participate and it should be noted when considering and reviewing online services or publications regarding online services. Learning from previous pandemics demonstrates how negative psychological and socio-economic influences can continue to persist (Lee et al., 2007;Mak et al., 2009). Recognising the increase in mental health problems associated with COVID-19, it must be acknowledged that the risk of social adversities and existing inequalities may rise further (Sheridan Rains et al., 2020). While acknowledging that during the COVID-19 pandemic telemedicine and teletherapy have contributed greatly to the delivery of mental healthcare globally (WHO, 2020c), we must also note the disparity that exists between countries where 80% of high-income countries deployed these services compared with 50% of low-income counties (WHO, 2020c). Thus, highlighting the importance of exploring unique cultural contexts when interpreting research findings from different countries as they are not directly comparable. Prior to this pandemic, Power (2019) reported that one in ten service users in the United States used telehealth where 75% reported that they were unaware of telehealth options or how to access them. In recognising the value of online digital support, we must also recognise the inequalities in technology access and digital literacy which continue to exist.
Further research on ways of overcoming digital literacy gaps is required and is timely to help sustain the delivery of services post COVID-19. Through identifying barriers to online services for both staff and service users, such as, technological limitations of various devices, regulatory, authorised, linguistic barriers, and cultural misunderstanding, services can be developed in the future (Damschroder et al., 2009;Sheridan Rains et al., 2020;Shore et al., 2020). For example, language barriers and cultural differences can potentially result in errors in medical communication and further increase anxieties and stress for service users (Bowen, 2000;Meuter et al., 2015). In addition, misunderstanding with terms of communication can lead to non-compliance or the service user refusing treatment (Meuter et al., 2015). This is further exacerbated in an online format as it is difficult to read nonverbal communication if the service user does not have their camera on. Measures such as being user friendly is advocated for scaling up the delivery of services as increased uptake is reliant on people's ability to use technology such as smartphone features, downloading apps and having good connectivity (Anderson et al., 2016;Figueroa & Aguilera, 2020). Improved technology is one part of improving engagement with online services, however, this needs to be accompanied by guidance and training for both staff and service users to support compliance (Figueroa & Aguilera, 2020). For example, strategies such as outreach programmes providing training for people with low-tech skills by healthcare staff may facilitate service users' usability and understanding of digital tools (Grossman et al., 2019). Post COVID-19 the need remains for delivery of services to support people with pre-existent physical and mental health conditions. Online/remote delivery of services must be considered now as a viable mode of delivery. For successful implementation of digital online services, a clear roadmap is essential, incorporating systems that are affordable, manageable, and suitable for a widespread group of individuals with variations in languages, age, and digital literacy levels (Lal, 2019). Insights gained through living and working through COVID-19 is vital to inform and support the successful implantation of e-mental health in the future.
A frequently raised concern within the literature was the exacerbation of pre-existent mental health conditions and difficulties in accessing mental health support and services. Thereby, we need to prioritise the voices of service users and their families within the research agenda and to coordinate existing research infrastructure through shared protocols and research measures in a collaborative manner (Holmes et al., 2020). In addition, while there is some evidence of short-term success for remote service delivery (Naslund et al., 2017;Jimenez-Molina et al., 2019;Liu, Yang, et al., 2020), challenges and drawbacks also exist in the use of remote therapies, especially in people who might be in most need. Issues of note involve access to and knowledge of technology, internet access, data allowance costs, and privacy and data security (Naslund et al., 2017;Jimenez-Molina et al., 2019). In addition, there is a risk that people may disengage from treatment, and their loneliness could increase without this in-person contact. Furthermore, telehealth and digital services should not replace face-to-face treatment, particularly for those requiring intensive mental health treatment and support (Moreno et al., 2020). Thereby, ongoing research that involves and captures the voices and experience of people with pre-existent mental health conditions are a necessity to guide and support care delivery and management in times of difficulty, uncertainty, and pandemics.

Study limitations
The limitations of this study are mainly related to the methodology employed for the review. Due to the evolving nature of COVID-19, research studies and new knowledge are being published daily worldwide. Therefore, the timeframe of this study is a limitation, as the search strategy was conducted up to and including the 31st December 2020, literature published after this time was not included. However, to the authors' knowledge this is the first scoping review that has focused on the impact of COVID-19 and its related restrictions on people with preexisting mental health conditions within the first year of COVID-19 which is a strength of the study. In addition, a quality appraisal of the included literature was not conducted as this is not generally a requirement for a scoping review and was not the purpose of this review (Pollock et al., 2021). Furthermore, only English language papers were reviewed.

Conclusion
Individuals with pre-existent mental health conditions are a vulnerable group of people and are even more so during the COVID-19 pandemic due to the nature of their illness, life circumstances and their requirements for mental health support services. Exacerbation of preexisting mental health conditions, lack of adequate resources in service provision and difficulties in accessing mental health support/services during the pandemic are reported. There is a strong emphasis in the literature on the importance of providing technologically enhanced remote/distance mental health services during the pandemic. However, there is evidence that access, uptake and usage of such remote services is not necessarily fair and equitable for all. Further research is needed in this area, particularly regarding the experiences of people with preexistent mental health conditions, in order to guide and support effective care delivery and management support during times of difficulty and uncertainty related to living life during a worldwide pandemic.

CRediT authorship contribution statement
All authors meet the criteria for authorship as outlined below. All entitled to authorship are listed as authors. No other authors were involved with this paper.

Declaration of financial support
This research is not part of a funded project.

Declaration of competing interest
None.