Search for new and renewable sources of energy has made research reach the tiny little tots, microalgae for the production of biodiesel. But despite years of research on the topic, a definitive statement, declaring microalgae as an economically, environmentally, and socially sustainable resource is yet to be seen or heard of. With technological and scientific glitches being blamed for this delay in the progress of the production system, an assessment of the sustainability indices achieved so far by the microalgal biodiesel is important to be done so as to direct future research efforts in a more coordinated manner to achieve the sustainability mark. This article provides a review of the current economic, environmental, and social status of microalgal biodiesel and the strategies adopted to achieve them, with suggestions to address the challenges faced by the microalgal biodiesel production system. Living in an age where life revolves around energy in all forms, a crisis of sustainability is indeed indispensable. With the continued consumption of fossil fuels by the expanding populations, maintaining economic, environmental and social sustainability is a difficult proposition. Hence, strong abatement practices and policies to encourage research on renewable energy resources are being developed. It is in this context that energy in the form of biofuels is being produced from renewable resources of plant origin. Although various other alternatives like geothermal, wind and solar energy are being surveyed, bioenergy is looked at as a strong resource of energy in the coming years.In such a scenario, the presence of objectionable facts such as issues of food security and energy balance in the first- and second-generation biofuels and the desire for new, sustainable energy resources has brought into limelight, a garden pond nuisance, microalgae, as a promising renewable fuel feedstock. Reports of its high oil yields, dramatic GHG savings, faster growth rate, more harvesting cycles and higher carbon fixation rates, all devoid of any negative effects on farming are reasons of its sudden popularity .Research on microalgae as a source of energy were extensively carried out in the 1970s, in the United States, but shortage of adequate funding and shift of focus to other feedstocks and technologies gradually brought an end to the research program . HoweverThe term ‘sustainability’ has been rightfully defined by the World Commission on Environment and Development as “the development that satisfies the needs of the present generations without compromising the ability of the future generations to meet their own needs.” Sustainable development comprehends economic, social, and ecological standpoints of conservation and change  UNCED, .Despite the widespread use of the term, ‘sustainability,’ human beings fail to cater to the basic requirements for a sustainable society which is clearly reflected through their activities of environmental degradation, overconsumption, population growth and their quest for indefinite economic growth in a closed system.For achieving economic sustainability, low-cost production strategies with greater output to input ratio is imperative besides being available at affordable market rates. At times, the need to maximize returns from investments overlooks the environmental considerations giving rise to negative implications. Additionally, the demand for economic gains affects food production and availability, creating adverse impacts on the society. Hence, to balance between economic and environmental sustainability, higher productivity must be targeted.Environmental sustainability can be assessed through use of environment friendly, renewable sources of energy along with use of chemicals and machines during the production process with minimum negative environmental impact. These assessments are done with the help of some indicators which can either be global  or regional . Moreover, the government and private led directives, schemes and initiatives for spreading awareness and activity, also contribute toward environmental sustainability in a major way .Social sustainability can be ascertained through implementations of certification schemes, scorecards and regulations for mitigating the negative impacts such as child labor, minimum wage, compensation for lost land and resources etc . HoweverThe basic criteria and indicators for production of sustainable biofuels have been clearly stated by drop in fuels and various high-value products. In a bid to realize the sustainability index, extensive research efforts are being carried out by researchers, academicians and industrialists worldwide to improve the economic and environmental benefits from algal biodiesel through improvement in upstream and downstream processes. Despite such widespread research activities in the field, many questions still remain unanswered. What exactly is the sustainability index? How far are we from reaching the sustainability mark? Is the same sustainability index applicable to all nations and societies? Although the sustainability index is a concept as vague as, ‘to each his own,’ in this world of expanding problems and populations, to ensure continued efforts in the right direction and at the right pace, a sustainability check of the microalgal biodiesel production system is indispensable.Algae biodiesel industry is starting to take off. Algae projects see an emerging trend in the production of algal-based Biodiesel production is an energy intensive process. All the processes during biodiesel production, starting from procurement of raw materials to processing, manufacturing, storing and marketing, contribute toward the product’s economic feasibility. The decision to use a particular biodiesel initially depends on its cost competence. So research efforts to bring down the cost of microalgal biodiesel to comparable rates with conventional petroleum diesel are being focused on. Hence, for ensuring cost effectiveness of the microalgal biodiesel, few important strategies are generally followed, such as (i) increasing the amount of energy captured from the atmosphere, (ii) increasing the amount of energy harvested from the microalgal biomass, (iii) increasing the biomass yield of the resource, (iv) increasing the number of co-products produced, (v) decreasing the energy input during downstream processes, and (vi) increasing the ability of the product to be stored for a longer period of time.Missing Link Technology and Algae Venture Systems  in a paddle- wheel driven microalgal pond cultivation system , over th Systems , and use Systems . Interes Systems . Through2/day on a sustained basis, the energy-return-on-investment (EROI) for harvesting algae from ponds ideally would need to be >20, i.e., no more than 5% of the energy content of the algae should be spent during harvesting and the lipid extraction and conversion efficiency to biodiesel should be improved so as to ensure minimum expenses in the defined process , is limited, nevertheless production models with cost reduction calculations anticipating a competitive market for microalgal biodiesel, substitute the limitation . Microal process . Additio process . Photobi process  and the  process . In Tabl2 into the atmosphere which is sequestered back by microalgae for growth and product development. This technology called the BECCS has been rated as the most technologically and economically potential solution for mitigating the impact of GHG emissions, by the IPCC  are used for measuring these indicators. LCAs can highlight areas of concern and focus the future research efforts on aspects of the supply chain that carry the largest environmental burden .2 is majorly responsible for this problem. CO2 is naturally present in the atmosphere, but activities such as burning of forests, mining and burning coal increase their concentrations to dangerous levels in the atmosphere by converting the carbon stored in the solid state to gaseous state  as compared to what is emitted by low sulfur diesel fuel   . This ision BTU) . With pe2 from the atmosphere whereas reduced emissions signify a reduced inlet of CO2 into the atmosphere. Both have their own respective benefits, but with the OECD Environmental Outlook 2050 at the 2011 United Nations Climate Change Conference, suggesting achieving CO2 concentration targets at lower than 450 ppm by the Bioenergy for Carbon Capture and Storage Technology (BECCS), negative emissions should be critically pursued , a combination known by the abbreviation BECCS . This wofossil considers only the consumption of primary fossil energy throughout the fuel supply chain and thus measures how much fuel product is generated per unit investment of primary fossil resources. As such EROIfossil values provide a surrogate measure for the renewability of the biofuel. Accordingly, EROIfossil values more than unity are desirable, because more energy is produced via the biofuel than the fossil energy consumed throughout the supply chain , feasibility of microalgal biodiesel production with respect to energy security, can be ascertained if the amount of energy required to produce and process the microalgal biodiesel is found to be lower than the energy contained per dry weight of the alga . In curran unity . Various process  and soment plant . Some resil of 8 , but witsil of 8 .fossil and GHG emissions are indirectly proportional to each other with an increase in the value of one parameter bringing about a decrease in the other and vice versa. Hence strategies to reduce the GHG emissions from the microalgal biodiesel production process eventually raise the EROIfossil values, thus producing an environmentally sustainable biofuel. EROI is not an absolute indicator of sustainability, but it does help to indicate where a particular source fits in with regional, national and global energy markets. In that context, a competitive EROI for algae biodiesel provides support for a national energy policy that replaces petroleum.EROIThe ability of a product to be sustained for use by the society and for the society, decides its social sustainability. This social dimension of microalgal biodiesel sustainability is decided by its ability to positively impact rural development, poverty reduction and inclusive growth . To judgIn the market of bioenergy, microalgal biodiesel is like a new born baby waiting to be nurtured and groomed. In such a scenario implementation of social certification schemes, rules, laws or acts for ensuring its social sustainability is too early to be true. Under such circumstances, with the Renewable Fuel Standard, 2007 in United States and Renewable Fuel Quality Directive, 2008 in European Union, mandating a substantial portion of renewable fuel in the transportation sector by 2040, countries all over the world are gearing up with microalgae as a source of biodiesel and encouraging its use by their people through grants to companies equipped for their production .2, an environmental pollutant, in the atmosphere  shows a support of 39,027 jobs and more than $ 2.1 billion in household income in the United States  . These jWith a rush for jobs by the skilled and educated masses, unemployment among the unskilled rises to alarming levels. In order to balance this difference, programs like Pathways out of Poverty (POP), a national workforce training program by the United States government’s ARRA of 2009 trains individuals living below or near poverty level with skills needed to enter the green job market, focusing primarily on the energy efficiency and renewable energy industries. The training programs focus on teaching basic literacy and job readiness skills in addition to providing supportive assistance with childcare and transportation to overcome barriers to employment .Microalgal biodiesel production has been initiated on a pilot scale at various places, but a discussion on their ability to profoundly displace petroleum diesel, has been mostly ignored. In today’s market condition, microalgal biodiesel is more expensive than petroleum diesel as the improved economics of production are inadequate for environmentally sustainable production let aside the oblivion of social sustainability. A retrospection of the different research studies on microalgal biodiesel production system highlights few major challenges in the production of biodiesel from microalgae eventually hindering its commercialization. A few essentials are explicitly addressed.1.The different stages of microalgal biodiesel production continue to be highly energy intensive impeding attainment of economic and environmental sustainability.2.2 with minimum negative impact on the environment and microalgal culture quality still appear to be challenging.A low-cost arrangement for water, nutrients and CO3.Maintaining a monoculture inside the raceway ponds continues to be difficult to achieve.4.Unsuitability of non-native algae to a new ecosystem creates risks of microalgal spills.5.Scaling up of microalgal culture is a big problem with high degrees of uncertainity about the replication of functional characteristics in the scaled up cultivation system.6.Huge variation in GHG emissions and EROI data from different research studies question the efficacy of the strategies being adopted.7.Lack of faster and efficient tools for screening of oleaginous microalgal strains slows down progress in the field.8.Lack of complete biochemical and molecular profiling of oleaginous microalgae restricts informations and innovations.9.Lack of detailing of the cultivation and operational parameters used in the microalgal biodiesel production system, hinders complete sustainable development of the production system.10.Routes for recuperating energy from the microalgal biomass left after oil extraction are required for attaining a net positive energy balance during the production of microalgal biodiesel.11.Lack of sufficient genetic and metabolic engineering in the field of microalgal biodiesel confines exploration of genes that control the production of lipid in microalgae.12.Wasted energy from captured photons during photosynthesis is a major challenge in mass algal cultivation.13.Uncertainities about policy support and competition from other fuels further adds to the plight.With a focus and determination to defy the pessimistic view of a group of research scientists who claim that microalgal biodiesel can never outcompete petroleum diesel, research organizations, institutions and individuals are working with hastened speed to address the challenges mentioned above. Although fortunately there has been some success in achieving some near-term goals as has been mentioned in the previous sections, there still remains enough work to be done in future, details of which have been mentioned below.1.With microalgal cultivation requiring huge inputs of nitrogen and phosphorous, recycling of nutrients with special emphasis on the quality and quantity of nutrients being recycled can be focused on.2.With reports of 100% nutrient recycling raising the cost of microalgal biodiesel by $2/Gal as compared to 0% recycle , alterna3.Co-products reduce the economic and environmental burdens of microalgal biodiesel but life cycle impact assessment studies to understand the type of co-products which when produced provide maximum benefit in attaining sustainability, can be done.4.Use of paddle-wheels in raceway ponds is where maximum allocation of capital is done. In order to reduce the cost burdens , alterna5.Combined heat and power treatment of the gaseous substances released from the hydrothermal system is used to generate electricity to power the entire cultivation system, but quantification and optimization of the process can be done to get the exact figures for future reference and research.6.Several resource and environmental challenges exist for scaling up of microalgal culture. To overcome this, complete detailing about the microalgal strain and the cultivation system can be done, as knowledge about the microalgal biology and biochemistry helps us understand the possible response of the microalga to a designed cultivation system with a temperature control mechanism in it as microalgae are extremely susceptible to temperature variations in open cultivation systems.7.With monoalgal culture being a difficult target to achieve in open raceway pond systems, cultivation of algal consortium can be practiced with an effort to maintain a functional specificity of accumulating lipids rather than a species specificity.8.With chances of microalgal spills due to cultivation of non-native microalgae in new ecosystems , mutagento delete genes that are unnecessary in culture but obligatory in nature.9.With different harvesting techniques being experimented with for finding out a faster and efficient technique with minimum energy expenses, bioflocculation and autoflocculation have been found to be most attractive options . So rese10.Outside blown in dust, being a major impediment to harvesting costs and a reason for light shading during microalgal cultivation, can be made to settle at the bottom of the pond through some innovative flocculating mechanisms so as to improve productivity in the cultivation systems.11.2 fixation can be considered as a crucial area of research.Photosynthesis being the starting point for energy capture and dissipation, the complex interplay between spectral range, light capture efficiency and CO12.Additionally, development of models of regulatory network in microalgae to assist in better gene and metabolic regulation for optimization of the storage of chemical energy in a particular form, for understanding the signaling mechanism in algal cells in more complex algal populations and for development of predator and pathogen resistance, can allow better biological control in large scale systems.13.Microalgal metabolism and growth rate being inversely proportional to their cell diameters, the surface-to-volume ratio of the microalgae can be considered to be an important parameter of research while searching for high biomass yielding microalgal strains.The scope of future research in the field of microalgal biodiesel production, does not limit itself to the few points mentioned here, but goes deep into an elaboration of the points highlighted. With some research projects in progress and few more planned for the future, an analysis of the entire scenario suggests that, today at this moment, the fundamentals are the problem. Lack of fundamental knowledge on the factors governing the variations in the entire algal biodiesel production process result in vague and inconclusive impact assessment reports.The question of whether microalgae will be a significant contributor to biodiesel production before 2030, generally depends upon the pace of innovations. Few people with a pessimistic view, are with the belief that with the current pace of microalgal biodiesel research scaling up to large quantities by 2030 will be a difficult target to achieve. However, more worrying is the fact that the pace of innovations might be slow enough to making it an uneconomic strategy to invest in at the commercial scale as compared to other opportunities.If companies fail to innovate, they die. But if they fail to rapidly develop cash-flowing solutions, they cannot attract capital, and they die that way too. Now, cooperative research projects, with companies collaborating with institutions to develop technologies, are an old idea. But planning a roadmap of innovations by using public funds for research and development leading to company formation is a new idea that can be proposed and pursued. The near-term stance for pervasive use of microalgal biodiesel appears dreary, but biodiesel for vocation solicitations such as in aviation may be possible in the medium term.It’s honestly extremely turbulent at this moment with a large number of innovations going on at too many fronts, just to make stable forecasts about when microalgal biodiesel will become an affordable reality. It requires scientists to take too many high-risk decisions for a faster pace of innovations. However, it is very clear that counting microalgal biodiesel out, any time before 2030, is a complete no–no for the researchers. What is important to remember here is that, microalgal biodiesel is based on a system of systems, not a single technology. Hence, with patience and perseverance, that which looks daunting today will be a successfully achieved target, couple of years after.RP read the literature and drafted the manuscript. NM supervised and corrected the manuscript. Both authors have approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In a recent paper, we presented new evidence and provided new insights on the status of Cantabrian brown bear subpopulations, relevant for this species conservation. Namely, we revealed the likely phylogeographic relation between eastern Cantabrian subpopulation and the historical Pyrenean population. We have also detected an asymmetric flow of alleles and individuals from the eastern to the western subpopulation, including seven first-generation male migrants. Based on our results and on those of previous studies, we called the attention to the fact that Eastern Cantabrian brown bears might be taking advantage of increased connectivity to avoid higher human pressure and direct persecution in the areas occupied by the eastern Cantabrian subpopulation. In reply, Blanco et al (2020)  have cri Brown bear became extinct in Portugal in the XIX century, with the last report of a bear killing in 1843 . Both poWhile acknowledging the misuse of the expression “population decline”, we reply to Blanco et al , with thMajor criticisms of Blanco et al  to our pSource-sink theory has been extensively applied in the context of spatially structured populations ,15 and nrural exodus, which we feel to be a better comparison in this context. Besides, the use of the exodus concept is not new in the context of ecology and conservation biology. For example, the word has been used for explaining phylogeographic patterns relevant to conservation, as in the case of wildcats . Da(XLSX)Click here for additional data file.


Pain is prevalent in older people, especially in those with advanced dementia who have communication impairments. Although pain is recognised to be present in this population, it is often under-assessed and ineffectively managed. The assessment of pain in advanced dementia is extremely challenging and complex, particularly in institutional settings such as care homes. This study systematically reviews the literature to examine and characterise the evidence for the use of pain assessment tools in care homes with individuals living with advanced dementia. Relevant publications were sourced from electronic bibliometric medical databases including AMED, CINAHL Plus, Medline, PsycINFO, EMBASE, TRIP Pro, Google Scholar, and HINARI. The database search was supplemented by screening citations and reference lists, in addition to a grey literature searches. The search identified 2221 studies, among which 26 were included in the review. The majority of the studies were observational, which created a rich source of data to create four major themes. The findings were informed and shaped by working with key stakeholders to develop a conceptual model that can contribute to developing evidence-based practice. This highlights the importance of a comprehensive, multi-disciplinary approach to pain assessment in this population, which is beyond the use of tools. Pain in older adults is prevalent and often underestimated and under-treated, especially in institutional settings such as care homes. Individuals living with dementia are more at risk of pain being undetected, particularly as the condition progresses into the later stages. Individuals with advanced dementia who have limited ability or reliability to self-report pain makes the assessment even more challenging and complex ,2,3,4,5.In an ever-increasing older population, with a predicted increase in 8.2 million people over 65 living in the UK in 50 years’ time , the numTo identify what pain assessment tools have been used to assess pain in advanced dementia care in care home settings globally including their psychometric properties; andTo explore the implications of using pain assessment tools in practice through the medium of a narrative synthesis.A systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ,13. A prA comprehensive search strategy was used including combinations of three main blocks of terms including and relating to ‘Dementia’ and ‘Pain Assessment’ and ‘Care Homes’ using a combination of Medical Subject Headings (MeSH) and free-text terms wherever relevant and possible . ElectroStudies were included in the review if they met the following criteria:Population: Adults aged 65 or over, diagnosed with dementia including the primary subtypes of dementias  as diagnosed using any recognised criteria. If studies included a mixed population (early and later stages of dementia), studies were only included if at least 50% of the population included in the study had advanced dementia and in cases where this was unclear, it was excluded.Intervention: Studies that described a pain assessment tool used for assessing pain in individuals with advanced dementia including sub-groups of dementia in older adults residing in care home settings were considered. Studies that did not include at least one recognized pain assessment tool were excluded.Types of studies: All study designs were eligible for inclusion. Setting: Studies in care home settings including residential and nursing homes. Studies were included irrespective of country and language. Studies in secondary or tertiary care hospital setting were excluded.Only studies published in the English-language were included in this review.An Endnote library was used to combine and export the results of the searches from the different databases. Study selection was completed in two stages. First, NF independently screened titles and abstracts in order to identify eligible and relevant studies. A random sub-sample of 50% was screened by a second reviewer (SC/MH/SD) independently. As the rate of agreement was high, screening of the remaining titles and abstracts was continued by the primary researcher independently. Subsequently, full texts of the relevant studies were screened and reviewed in full by NF for eligibility and a random subset sample of 30% were screened independently by a second reviewer (SC/MH/SD). At both stages, any disagreements were resolved through discussions.Study characteristics: author, date and country;Participant characteristics: diagnosed with a dementia, living in a care home setting;Aims of the study;Sample size, age range;Methodology: study collection, data collection process, synthesis of results, risks of bias;Pain assessment tool/s used;Main findings; andRecommendations made.A data extraction form was devised in Microsoft Word and piloted on 20% of randomly selected studies. It was then checked by a second reviewer (MH) and a third reviewer (SD). Data for the remaining studies were extracted by one reviewer (NF) and double checked by JL and SD. The following descriptive data for the included studies were extracted: Assessment was carried out in the study selection to assess the strengths and weaknesses of each study. Due to the heterogeneous nature of the included studies, a single quality assessment tool was used—the Mixed Methods Appraisal Tool (MMAT)—to appraise quantitative, qualitative, and mixed method studies . Qualityn = 106), for title/abstract screening. After reviewing titles and abstracts, this was reduced to 159 for full text screening, after which a total of n = 23 individual studies were included. Three additional studies were identified through citation searches, searching the reference lists, and grey literature, with a total of n = 26 studies included in the narrative synthesis , which was expected as the review question explores observational scales used to assess pain in a population who cannot reliably verbalise their pain. In addition, there were two cross-sectional studies, one longitudinal study, five evaluation studies, and three cluster RCTs. n = 5), the United States of America (n = 4), Australia (n = 4), Norway (n = 4), Canada (n = 3), the UK (n = 2), Italy (n = 2), Poland (n = 1), and New Zealand (n = 1). The sample sizes also varied, ranging from 10 to 352, with a mean size of 117. An additional strength was that most of the studies used clinical staff as pain assessors who were familiar with the participants, which is fundamental to person-centred care and therefore a much more accurate assessment  used worldwide in care home settings for those with advanced dementia .The most frequently used tools are PACSLAC (including the three variations) and PAINAD, each used in the seven included studies. The choice of these tools recognises them as international scales with good psychometric qualities and clinical utility, developed by experienced dementia care clinicians for this population ,39,41,42A summary of the quality appraised studies included is shown in a data extraction form . Using tThe studies were generally of good quality, with the exception of two studies that were of low quality , using aIn the 26 studies, there were 17 pain assessment tools (including variations) identified as suitable for psychometric evaluation and were analysed for their reliability and validity . Not all the studies included psychometric testing of the tools and so could not contribute to this data. Additionally, there was considerable gaps in the data, with further validity and reliability testing required. The tools that scored the highest were the PACSLAC, the Abbey Pain Scale, and the Mahoney Pain Scale each scoring 15/20. However, the score implies that the overall scores were moderate and could be improved. All scales require further testing to improve and refine them including complete validation and reliability studies and larger samples. Additionally, the authors leading the evaluation of the Mahoney Pain Scale had a personal interest in developing the scale. Due to the heterogeneous nature of the included studies, a narrative synthesis approach is appropriate to summarise the current state of knowledge in relation to the review question . This apA narrative synthesis of the literature included taking an iterative approach to develop themes. This involved a preliminary synthesis, followed by identifying primary themes exploring relationships, similarities, and differences within and between studies .A preliminary synthesis was developed using the tabulation of pain assessment tools, grouping studies, and looking for patterns in relation to the review question, and thematic-analysis of good quality primary data. This enabled identification of recurrent and key themes and concepts across studies.However, no one tool is recommended, which contributes to the lack of consistent use of such tools in practice. A common reason is that there is no ‘gold standard’ pain assessment tool for this population . This isThe review findings were informed and shaped by involving diverse stakeholders at the stage of synthesis and conceptual development. Stakeholder contributions included a Care Providers Forum, composed of commissioners and care home providers. Experts in the field were consulted for feedback on the Conceptual Model  and the The evidence-based Conceptual Model and Pain Decision-Making Model were therefore informed by the literature included in this review and shaped by key stakeholders from various academic, clinical, and public domains.Four primary patterns, or themes, emerged from the literature: behavioural indicators of pain, staff training and education, affective symptoms of pain, and the multi-dimensional aspects of pain. These are summarised below in relation to the literature findings.The detection of pain in individuals with advanced dementia presents unique challenges associated with the reduced ability to comprehend information and reliably communicate pain. In this group, behavioural indicators provide more reliable signs of pain than using the ‘gold standard’ of pain assessment, which is self-reporting. A number of pain assessment tools have been developed that include behavioural indicators of pain, which apply to people with dementia. These pain tools are predominantly based on guidance published by on the American Geriatrics Society categorisation of six domains for pain assessment, as listed below:Facial expressions such as grimacing;Verbalisations and vocalisations such as groaning;Body movements, such as rocking;Changes in interpersonal interactions such as aggression;Changes in activity patterns and routines such as sleep; andChanges in mental state such as confusion.The six behavioural domains of pain :Facial Despite the most recent update of these guidelines being in 2009, they remain relevant to current approaches to assessing pain in this population. They are recognised as the basis to observational pain assessment tools, as reflected in more recent studies and guidelines ,6,46. HoNational guidelines on pain management in older people promote the use of standardised assessment tools using pain-related behaviours . ProceduA study by Cohen-Mansfield (2008) showed that when pain is identified using observational assessment tools, it leads to an increase in the administration of analgesia, which results in a reduction in pain. This was a pioneering study in its focus on a population with advanced dementia in a care home setting. It had important clinical implications in demonstrating the clinical utility of observational tools in this population. It found an absence of correspondence between self-reporting (when applicable) and observational measures of pain, suggesting that self-reporting can be open to personal bias and environmental factors. Behavioural assessment of pain is therefore less susceptible to confounding variables. The findings are also reflected in a more recent study by Malara et al. (2016), which states that self-reporting alone is insufficient to assess pain in this population. Cohen-Manfield’s study was also weighted in favour of the PACSLAC tool, which is associated with the researchers and so may reveal a bias towards this tool. Additionally, the PACSLAC-D is supported in a RCT study by Pieper et al. (2018), finding the importance of behavioural identifiers for pain assessment in advanced dementia. Cohen-Manfield’s study also demonstrated that the identification of pain can impact positively on the social engagement of individuals with their environments and therefore contribute to their quality of life. Such factors would need to be further explored within a qualitative study approach. The results of this study present a standardised methodology that caregivers could utilise to detect pain and enable more effective treatment. However, a limitation of such tools is that localisation or type of pain cannot be determined and this was suggested as an area for future research. Behaviour indicators are explored further by Husebo (2009), suggesting that pain behaviours can help with the assessment of pain intensity, but assessment can be impacted by variables such as interpretation of the behaviours including who is doing the assessment. Pain assessment tools and guidelines follow general principles and need to be used in conjunction with critical thinking, clinical judgement, and experience . The stuSuch challenges of using pain behaviours as part of pain assessment in this population is explored in a European survey on the use of pain assessment tools, practices, guidelines, and policies . Carers There appears to be discrepancies in the literature regarding whether assessing pain from behaviours is dependent on the level or standing of the assessor. A study by Nowak et al. (2018) in Poland considered the characteristics of pain and the variables that may impact on using the recommended observational pain tools. This includes the estimation of pain being dependent on the knowledge of caregivers. It compares a previous study that showed that less than 15% of individuals suffering with moderate to severe cognitive impairment were treated for pain, compared to the current study, which showed a higher percentage. This is suggested to correlate with enhanced efforts in Poland regarding the education of staff on pain diagnosis and treatment. However, the small sample size should be considered in relation to the generalisation of the findings. In addition, other variables and reasons for administration of analgesia need to be considered. The study contributes to the findings of this review that pain related behavioural disturbances can be misinterpretated as symptoms of dementia and the consequent inappropriate prescription of psychotrophic medication. Even when these individuals scored high on the Abbey Pain Scale, they were not receiving adequate analgesia. This also highlights a lack in staff training and awareness of the different indications and signs for pain in individuals who cannot verbalise or express their pain reliably. This is consistent with conclusions drawn in a feasibility study by Zwakhalen et al. (2012). Although there were high compliance rates in using the pain assessment observational scale, pain prevalence was 22%, which is low compared to other studies, and pain relieving interventions were not frequently applied. The identification of pain using an observation tool therefore did not necessarily result in an increase in interventions. n = 22) and time span (six weeks) so restricts external validity and suggests that further research with an extended length and larger participant number is needed. However, this is acknowledged as a limitation and consequently presents this work as a preliminary study with emphasis on the testing feasibility and piloting of the procedure. The method includes the Medical Research Council framework for the evaluation of complex interventions, strengthening the multifactorial nature of such interventions. A pre-intervention interview was conducted to enable the gathering of key information such as pain policy and staff knowledge of the individual participants. Two further evaluation interviews were conducted to gather staff experiences on assessing pain; repeated measurements increase confidence in the findings and provide a stronger study design. The study contributes valuable findings to the argument that providing staff with pain assessment tools alone is not sufficient to change practice. The tools may not differentiate between pain and other constructs such as distress or panic, and they do not contribute to specific clinical decisions regarding how to reduce or treat pain. This study used qualitative information drawn from staff questionnaires on using the scales. Staff identified difficulties in interpreting pain cues and believed that a score could be increased by factors such as distress or panic, although primary data from the interviews were limited, so reduces the credibility. The study was also limited by a small sample size , and is shown to result in inappropriate prescription of psychotropic medication or inappropriate admissions to mental health inpatient units . Nowak eVillanueva et al. (2003) recognises the need to routinely assess pain in dementia as a clinical necessity. The approach is a person-centred, holistic one, which includes the consideration of pain behaviours as well as the impact pain has on the activities of daily living, social behaviour, and sleep patterns. The study goes on to explore the close association between pain and agitation, especially in the later stages of dementia and identified verbal agitation as the most consistently associated with pain. Pain is sometimes treated as agitation using antipsychotic medication. This study suggests that pain, agitation, and psychiatric symptoms are closely linked or simultaneously interpreted by care home staff, and that further research is required to better understand the relationship between these factors. The study has strong clinical applicability; identifying the value of care staff (rather than researchers) as assessors when using pain scales in the clinical setting, with good inter-rater reliability.n = 199), although this is compromised by a low response rate. It also uses a combination of pain assessment tools, which can account for the complexities involved in pain assessment. Van Kooten et al. (2017) studied pain and its pharmacological treatment in relation to dementia sub-type and severity. The study highlights the need to focus pain management on tailored approaches and regular adjustment to individual needs. It considers different types of pain in this population, as determined through findings of a physical examination and information from medical records. It presents greater external validity as it has a larger sample size , which explored the use of opioids in care homes with the prevalence of pain in this population remaining high. Additionally, Van Kooten et al. (2017) highlight confounding variables that impact on pain assessment; pain complaints are often associated with comorbid depressive symptoms and attention should be paid to this coexistence of depressive symptoms when assessing and treating pain. This was the first study on pain type and its pharmacological treatment in relation to dementia severity. The findings build upon a previous study by Cohen-Mansfield (2008) that promoted a much wider use of analgesics in this population. Van Kooten et al. (2017) used MOBID-2 to reflect clinical practice, as this uses standardised movement during morning care and considers the use of a combination of pain measurements. However, this strength is compromised by the use of the researcher, rather than clinical staff, to judge the residents’ understanding of the pain scales and ability to communicate pain, which may introduce an element of bias. On the other hand, Jordan et al. (2011) explored the use of PAINAD and DisDAT for detecting pain in this population, with PAINAD not having been previously explored in a UK population with severe dementia. PAINAD has 92% sensitivity, suggesting that if a person with severe dementia is in pain, this tool is likely to detect it. However, the researcher also discusses the high levels of false positives (33%), so other potential causes of behavioural changes should be explored. This tool, and other similar observational tools, should therefore not be regarded as definitive in the detection of pain in this population. Psycho-social distress can be difficult to distinguish from pain, and this further highlights the complicated nature of pain assessment and how there are several variables and influences that need to be considered.Additionally, there is a lack of consensus in the literature about which behaviour signs are valid indicators of pain and differentiating this with psychological symptoms such as fear or anxiety . This haPain assessment in advanced dementia is therefore a highly complex process involving a multitude of factors that can impact the findings. Pain, being a subjective experience, means that a person-centred approach to pain assessment is essential. In addition, person-centred approaches are important when working with individuals with dementia . In the Malara et al. (2015) identified a close relationship between pain and behavioural and psychological symptoms in residents with dementia. Pain is often communicated in behaviours that can be challenging and complex. It found chronic pain to be almost double in residents with dementia, and lack of a well-defined pain assessment tool and documentation to be obstacles to successful pain management. The study recommends the use of observational pain assessment tools, in combination with self-reporting, in a multi-dimensional assessment of pain. The assessments carried out by carers is a strength of the study, although it does not fully explore the relationship of the carer to the individual or how other professionals could contribute valuable input to the assessment. This was further explored in a cluster RCT by Rostad et al. (2018). The study found no overall effect of regular pain assessment when using an observational pain assessment tool on the pain scores or use of analgesia for individuals with severe dementia. The study methodology had a number of strengths including the randomisation of clusters (a cluster being a care home) and the raters being blinded, thus reducing bias. There were 16 clusters across four nursing homes in four counties in Norway. In addition, it was carried out in real-life conditions, with data collected by carers or nurses who would be involved in nursing home practice and who would know the individuals. This led to a discussion around the value of input and information that can be provided by such key practitioners and carers in this setting, as discussed earlier in this review. Assessing pain in older people is very complex, with considerations of co-morbidities, polypharmacy, and complex causes of pain. Further complexities are considered when assessing pain in individuals with severe dementia, and the importance of knowing the individual can be a key factor in assisting with this process. A standardised pain assessment tool cannot directly lead to clinical decision-making around pain, rather, it can contribute to and complement clinical judgement and knowledge applied by the staff. The pre-requisite to person-centred care in dementia is knowing the person including familiarity with the person’s patterns of behaviour and pain tolerance, and so pain assessment needs to be multi-dimensional and multi-disciplinary. This could be extended to the consideration of demographic information of both the staff/raters and the participants. Rostad et al. (2018) considered this as a limitation; information such as cultural background, professional qualification and training as well as the experience of the staff who completed the assessments should be considered as having an impact on interpretations and subjective assessment when using the assessment tool. Additionally, it came through in the literature that most of the studies had limited or no minority representation or consideration of culture and ethnicity and how this interacts with pain expression and interpretation ,40. A recent study by Ersek et al. (2020) used a multi-dimensional approach to pain assessment to characterise pain experiences in this population. It identified an improvement in pain management in this group, with most residents having mild and intermittent pain and the majority receiving at least one pain therapy in the last week. The study used a rigorous, multidimensional evaluation, which contributes to the strength of its findings. However the sample was small, and the evaluations were carried out by clinicians who did not provide on-going care to the residents enrolled on the study. Additionally, the study found only 3% of the participants had documented non-drug pain therapy. The study identified factors that may affect this low rate including some nondrug therapies being inappropriate to this group (such as CBT or mindfulness), there may be lack of availability, or perceptions that such interventions are ineffective or time consuming in this group. Further research is needed to explore such barriers to contribute to reductions in medication use. Pieper et al. (2018) supports the use of a stepwise, multidisciplinary approach to reduce pain in this population. It has strong external validity, with a large sample size, and six month cluster RCT study, with low risk of bias. Intervention involved a tailored approach, focusing on physical and psychosocial unmet needs, although this placed increased time pressures and the training needs on staff.The assessment of pain in advanced dementia is extremely challenging and complex, often resulting in under-treatment and poor pain management within the care home setting. This review reflects the growing awareness of the importance of detecting pain in this population with close associations with quality of life ,44. The Pain perception and interpretation is highly subjective and can be influenced by a number of variables. This was explored by narrative synthesis, finding key challenges, and barriers, which can affect clinical decision-making around pain in this setting and how such barriers may be addressed. These include the role of the pain assessor, when and how pain assessments are conducted, the training provided to staff to use pain tools, and if/how clinical decisions are then informed around pain management.First, there was variation across studies regarding the chosen primary pain assessor(s); differences between using a researcher or a key carer/nursing staff from the home, or a combination . This reSocial heterogeneity was also evident in the literature. Across the studies, demographic detail provided was basic; frequently limited to age and gender ,22,27 anA large number of observational pain assessment tools have been developed and evaluated. A systematic review of systematic reviews in 2014 explored pain assessment tools in adults with dementia  and founThe current review identified 17 tools used in advanced dementia worldwide in this setting, which were suitable for psychometric evaluation . The AssThe review findings suggest that the overall quality of all the scales could be improved through further testing and in larger samples. There remains no ‘gold’ standard for assessing pain in this population, in recognition of the fact that the use of self-report is not always being possible or reliable in the more advanced stages of dementia. The review findings conclude that a standardised, systematic approach to pain assessment may not be appropriate in advanced dementia care, but this should rather compliment the clinical judgement and experience of the staff including their knowledge of the individual. Such familiarity with the individual during pain assessment is crucial and has been termed as the ‘silver’ standard . Making The reviewed studies used different research methods and objectives, therefore making comparisons between studies difficult. However, this provided a rich diversity of information and offered a comprehensive summary of pain assessment and management for those with advanced dementia in a care home setting, as represented in the Conceptual Model . This hiGiven that the studies were conducted in a variety of countries raises questions around cultural and organisational differences between care homes. This would need further exploration in future studies. Additionally, there is variation in situational characteristics across the studies, which may also affect generalisability. Moreover, pain assessment outcomes could potentially be affected by the time of day, the length of the assessment, the immediate environment, how the individual is positioned, or who is present. However, the impact of such factors is difficult to assess without appropriate levels of information provided by individual studies and many of these variables cannot be controlled. Due to the nature of the studies, the level of detail in terms of situational characteristics was limited to the pain assessments being conducted during standardized activities, primarily during care. The time of day may vary, depending on the presentation of the individual, which highlights the benefit of combining a standardized pain assessment with a person-centred approach. Consideration of the clinical application and relevance of the pain assessment as well as the situational characteristics of pain assessment should also be accounted for . This alRigorous search methods were employed in order to provide a comprehensive search of relevant studies to the review question. A Narrative Synthesis Framework  was applPatterns emerging between studies were identified using tabulation and concept mapping as visual methods to construct themes, groupings, and relationships between the studies, which is a methodological strength of this review. A limitation is that there was heterogeneity, which made comparing some study findings difficult, although this is discussed in relation to the review question and does suggest further research is required to investigate by locality, social, and ethnic groups. Another strength of this review is that key researchers in the field were contacted to source unpublished literature, or studies that had not yet been published, although no further studies that met the inclusion criteria were identified. Additionally, a key methodology strength was involving the stakeholder in conceptual development, which meant that the model is relevant to the population in practice. The search was restricted to the English language, so primary papers in other languages would have been excluded, but with no geographical restriction. The search included papers from a wide variety of countries, but a lack of data from low-income countries was apparent. This may be due to the language restriction. The present review highlights a number of key points from a practice perspective, which resonate on a global scale. First, there is an extensive number of observational pain assessment scales available; without evidence to recommend one particular scale or ‘gold standard’ pain assessment, which would support organisational decision-making. Second, a multidisciplinary approach to pain assessment in this population is essential, which is both structured and person-centred. Third, assessing pain in advanced dementia is extremely complex and challenging. It requires more than an assessment tool; the value of professional judgement, training, and experience together with familiarity with the individual in pain is crucial in the pain management of this population.There needs to be efficient and standardised methods of eliciting and centralising pain related information for this group in the care home setting. This would provide the basis for making decisions about pain management and treatment. It therefore requires a conceptual shift in care home practices, incorporating the benefits of both standardised and person-centred approaches. The process would also require regular training to staff regarding the use of protocols, guidance, and pain assessment tools, framed by a multi-disciplinary approach. This in turn could reduce the levels of work-related carer stress . To be able to achieve this in the care home setting is a challenge due to the complexities of the care needs of this population, the high staff turnover as well as cost restrictions . An evidThere is also growing interest and evidential support for use of the ePAT ,25. FaciThe assessment of pain in individuals with advanced dementia is complex and challenging for care home staff to manage. This review highlights the current state of the evidence base in this area including the gaps in knowledge and the implications for practice.This review shows the importance of a comprehensive approach to pain assessment in care homes for this population, which is beyond the use of assessment tools. A holistic, multi-disciplinary approach is essential, which is both structured and person-centred. Pain tools complement clinical information and clinical judgement together with familiarity with the individual. The pain assessment process needs to be on-going and supported by staff training. There is a profound lack of specific guidelines to assist with decision-making in this setting to support this very vulnerable population. Therefore, there needs to be further research to consider the perspective of the individual, who is central to the process.


The concept of social isolation is currently understood as a measure of epidemiological containment that aims to reduce the speed of spread of the disease, enabling health services to prepare their resources to cope with the likely increase in demand, while also seeking to provide additional protection to groups considered to be at higher risk.The present narrative review aims to compile and synthesize the literature related to social isolation produced during the COVID-19 pandemic in 2020.This study is a narrative review of the literature on social isolation in the context of the COVID-19 pandemic.73 publications were included for full-text reading and were classified into the following categories: levels of social isolation, economic effects, family relationships, health system, mental health of the population, and use of technology.It is necessary to plan an escalation of responses to the consequences of the pandemic, especially in view of the increased demand on the health sector and social services. The negative effects of social isolation can be prevented by public policies that offer a response to the economic recession, maintenance of social work, encouragement of quality care in mental health services, and community support for vulnerable families. Thus, in order to contain the overwhelming dissemination, certain technical safety precautions have been adopted to take a more stringent approach to public health protection. Such containment measures have been adopted in all countries involved4and include mandatory use of face masks, implementation of social distancing, cancellation of events , strict travel restrictions, closure schools/universities and most of the workplaces . On the other hand, some countries were slow to carry out epidemic control measures, suffering the consequences of vacillation by central authorities.5The COVID-19 pandemic started in December 2019 in Wuhan (China), with the emergence of a specific coronavirus, known as SARS-CoV-2. Worldwide spread of the virus reached pandemic severity in March 2020, as declared by the World Health Organization.6Although social isolation is effective as a public health measure to contain viral spread, in psychological terms it can arouse fears, uncertainties, and despair.8Additionally, the impact on the economy and health systems, changes to family relationships, and migration to unprecedented levels of technology use are all happening simultaneously. The pandemic constitutes an urgent situation and demands a range of quick and effective responses from people. Therefore, rapid and systematic efforts are being made in research and clinical settings, mainly in the academic environment and on the so-called “front line”, as demonstrated by the increasing numbers of publications on the subject over recent months. One of the goals of these efforts is to employ different methods to understand the effects of this new external situation on the internal situation, while other targets of investigation include the emergence or worsening of psychiatric symptoms. Prompt dissemination of the findings should contribute knowledge on how to better care for people in general.9Social isolation includes measures such as avoiding contact with family and friends, preference for home delivery of essential items, and reduction of social coexistence, which when it does take place, should observe a minimum distance of two meters between people.Against this background, this study aims to review the literature related to social isolation produced during the COVID-19 pandemic in 2020. It is expected that analysis of this scientific production and its synthesis in this article will provide a concise and well-founded source to be read by professionals involved in the care of people in isolation.This study is a narrative review of the literature on social isolation in the context of the COVID-19 pandemic. The descriptors “pandemic”, “COVID-19” and “social isolation” were used to search the CAPES Periódicos (a Brazilian database), PubMed, SciELO, and Google Scholar databases. All studies published during 2020 in Portuguese or English up to May 31, 2020 were included in the analysis, in addition to brief communications and theoretical reflections. After reading the search results, three publications that did not mention social isolation during the COVID-19 pandemic were excluded. Data were compiled into analytical categories defined by the authors a posteriori, to better understand aspects related to isolation in the context of the pandemic, covering them in depth.After a careful perusal of the abstracts identified, 73 publications were included for full-text reading and were classified into the following categories: levels of social isolation, economic effects, family relationships, health system, mental health of the population, and use of technology.In this category we integrate issues related to levels of social isolation, economic effects, and health systems.11However, different strategies for centralized and decentralized social distancing exist. Centralized strategies refer to governments granting tax relief and tax holidays; whereas a decentralized strategy is restricted to conscious isolation (neighbors of affected children isolate themselves from those infected) and self-isolation .12These different degrees of social distance are crucial to reducing the peak rate of contamination. Data show that moderate social distance  can reduce the impact of the outbreak by 47% for centralized isolation and by 31% for decentralized isolation. Countries that decided to implement a reactive response to the pandemic with immediate adoption of isolation measures showed less damage from infection.12Non-pharmaceutical isolation policies, such as social distancing, have been proven to be the only possible response to stop the spread of the virus when it comes to a pandemic.10The laxity of social isolation strategies needs to take into account that, although some people remain voluntarily or habitually at a social distance, others seek high levels of social reengagement as soon as possible.13There seems to be a need for distinct measures aimed at high-risk groups to decrease mortality in this population; such measures require mobility restrictions  and increased support to meet communication and medical care needs.10Different countries follow different combinations of social distance. For example, in Sweden, only moderate social distancing has been implemented. This strategy targets the possibility of developing the population’s immunity, but it can generate high mortality and saturation of the health system, since there are no specific measures for the vulnerable population. Italy and Spain implemented uniform strict social distancing, but even so, this strategy was unable to stop the pandemic from advancing, perhaps because of the physical proximity between generations of elderly and young people or because it was executed late. In Germany, where different isolation measures were adopted for vulnerable people, the mortality rate was lower.14; while in Jordan it caused chaos in the population.15Social isolation was not seen as a positive measure in some countries. For example, in Hubei, China, the population revolted against the isolation imposed by the government16Data obtained in a Chinese province with 1925 participants showed that the measures of social isolation implemented by local governments must take into account the theory of planned behavior, which identifies three factors related to the desire to isolate oneself in the face of a pandemic emergency: attitudes (degree to which a person has an unfavorable assessment of the behavior in question), subjective norms , and perceived control . The attitude factor was the most relevant, referring to the degree to which the person has a favorable or unfavorable assessment of social isolation.17The economic effects of the pandemic are evident: closing workplaces (whether for the employee or the owner of the establishment), closing schools (which may require comprehensive childcare on the part of families or hiring someone extra to assist in this role), and the threat to housing security with non-payment of rent or real estate loans,3increasing the risk of homelessness.11A survey of 27 participants in the UK found that social isolation caused a fall in pay and even loss of income.13Nevertheless, in spite of the predominantly negative scenario, the long stay at home can reconfigure our consumption habits, making people more sustainable, frugal, and responsible in terms of use of resources and of finding ways of reusing them creatively.5One relevant issue of the pandemic is the great economic impact on families’ incomes, because of restrictions on establishments’ operations. Other social vulnerabilities are unleashed as a consequence.3Government actions can be decisive in coping with these issues5; there must be joint efforts by the government, the private sector, and individuals to reduce the economic impact of the pandemic. Some possible measures are suspension of taxes and establishment of universal basic income for the most vulnerable populations.19The pandemic always affects the most vulnerable people the most violently: street people, slum dwellers, and others. These individuals are isolated in extremely unhealthy conditions, in which basic health care is practically impossible; in this regard, there was also increasing work informality in several countries.20In this context, it is possible that substance use may increase among the population.3Additionally, there are concerns about scarcity of supplies, which have led to irrational hoarding behaviors, and concerns about the significant financial losses also cause damage to psychological well-being.21The pandemic is causing a period of economic recession in many countries, causing a complex pattern of health crises with worsening mental health, and increasing the number of homicides and suicides; it is known that low income also increases psychosocial stress.22Many countries are using a combination of containment and mitigation activities with the intention of delaying large outbreaks of patients and leveling demand for hospital beds, while protecting the most vulnerable from infection, including the elderly and those with comorbidities.23Health systems in several countries are suffering due to the excess demand caused by the pandemic. Effective planning to reconfigure services in the face of escalating demand is vital when dealing with this situation. Implementation of social isolation is also therefore important to avoid overburdening the health system. Planning should be based on the assumption that the majority of the population can contract the virus with little or no long-term effects, while using vital secondary health care resources to treat the small percentage of people who become seriously ill.In this category we integrate issues related to family relationships, violence, and mental health.25During home quarantine, family members spend most of the time together, which can cause or exacerbate tensions. Additionally, closing schools can increase stress for parents with school-aged children, who now have to support their children’s academic activities in addition to their children’s recreational activities and their other domestic and work chores.3Changes in family relationships and routines due to social isolation have an impact on mental health and psychological well-being.26A very recent note published in The Guardian reported increased incidence of violence in several different countries, with rises of 40 to 50% in Brazil and 25% in the United Kingdom and 20% in the first days of the confinement period in Spain.27Furthermore, social isolation from the pandemic may increase the risk of child abuse; this risk assessment is based on the increase in child abuse during school holidays, which also worsens during natural disasters, such as hurricanes.28New Zealand’s experience has shown that family violence  can increase during and after large-scale disasters or crises.29there is also a greater risk of violence against women in this pandemic period, during which victims are usually confined with the perpetrators of violence and often do not report the aggressions suffered. There is a growing rate of cases and therefore specialized support services such as shelters and health and assistance services (economic support packages) should be implemented as a matter of urgency. “ISA.bot” (a robot programmed to inform and welcome in cases of domestic or online violence that was launched in late 2019) has been updated in Messenger and Google Assistant to assist with safety and provide guidance for women.29According to ONU Mulheres (the Brazilian chapter of UN Women)30In the face of these situations of violence, it is therefore important to think critically about the idealized representations of home and family; enabling listening places for people; asking people directly - on repeated occasions - if they feel safe at home; and offering protected and resourceful health services. The authors point out the need for governments around the world to allow these services to remain open.31comparable to other natural disasters such as earthquakes or tsunamis.32Specifically, social isolation decreases face-to-face connections and workaday social interactions, which is considered a relevant stressor.34Increased loneliness and reduced social interactions are well-defined risk factors for mental disorders, including schizophrenia and major depression.35It had already been stated that loneliness itself has become a modern epidemic; now, with the COVID-19 pandemic, loneliness has increased and is compounded by financial insecurity and the possibility of the death of a friend or family member.36From a psychopathological point of view, the pandemic is being considered a new trauma by mental health professionals,41After about two months of pandemic, one survey showed an increase in symptoms of depression (16.5%), anxiety (28.8%), and stress (28.8%) in the general population8and, in particular, in health professionals.42Additionally, there were also increases in suicide rates linked to the psychological impact of COVID-19 in South Korea43and in India.44A study with 643 Canadian mothers of children aged 0 to 8 years in quarantine revealed that prevalence rates of maternal depressive symptoms and anxiety increased significantly with the age of the children.28Some studies indicate increases in stress disorders, such as Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD), and in emotional disorders such as depression, suicide and sleep disorders.11The effects of isolation also include PTSD symptoms, confusion, and anger.40Fear of contamination affects psychological well-being, because of the rapid spread and since there is considerable ignorance of the nature of the virus.46There is also fear for the future, which generates uncertainty and a lot of insecurity, also linked to the rise of fake news about the pandemic.38Uncertainty about contamination and death or about infecting family and friends can also cause dysphoric mental states.41Additionally, the effects of social isolation have had an impact on increased substance use. People being treated for a variety of conditions, such as alcoholism and other substance abuse, may experience additional complications from social isolation.47in addition to interventions based on arts and life skills.38It has also been suggested that sources of information about the pandemic be limited, and a regular routine be maintained, mainly in terms of sleeping and eating, and that help should be requested when needed.35It is important to ensure that basic supplies  are accessible, to reinforce a sense of altruism,6and to pay attention to one’s own needs, feelings, and thoughts.25Individual coping strategies include different activities that provoke pleasant mood and improve quality of life to overcome existential adversities, such as hobbies, physical exercise, reading, films, meditation, prayers, home maintenance, strengthening (or not) family bonds, studying, and listening to music,18Additionally, increased use of technology to access online gaming platforms has also been observed,48and there have been increases in online gambling.3One of the measures employed to make isolation feasible is implementation of remote working, with online activities and revision of priorities (activities that do not require travel). There is an incentive to engage in intentional activities during this period to minimize the effect of isolation, for which use of technology is essential.49Other examples include Google’s and Facebook’s initiatives for tracking infected people.50On the other hand, ethical issues are raised by health surveillance and it is considered a dilemma of safety versus privacy.New health surveillance technologies have evolved with the pandemic, using machine-learning analysis for data collection, selection, and interpretation. For example, digital contact tracking is performed by analyzing people’s virtual accesses, identifying potentially infected people, tracking their contacts, and assessing social distancing.52In the Brazilian scenario, formal psychological care remains online54or, when proven necessary, in person.55There is also an offer of psychological help through structured letters.56However, it is necessary to consider that a portion of the population has limited access to the internet, which limits the possibility of offering them support at this time. Furthermore, even if there is access, it is possible that there may also be difficulties with using smartphones or computers, as with the elderly25and it is therefore recommended that psychological services be provided via telephone in these cases.54With regard to psychological care in the midst of a pandemic, a number of different modalities are offered. There are psychological listening channels via phone call or online platforms.37The review conducted in this study identified several forms of impairment of people’s mental health. Most people have symptoms of distress, in addition to the fact that patients with pre-existing mental disorders are at risk of their clinical condition worsening due to suspension or reduction of activities at health centers. The psychological damage resulting from isolation stands out. It has been referred to as the “parallel pandemic” and will need specific coping strategies.35In Brazil, there was a great decrease in the flow of patients seen at mental health care centers run by the Unified Health System (SUS) due to the impact of social distance measures. One example of this situation is the fall in numbers of people presenting at Psychosocial Care Centers (CAPS) due to the lack of mobility, with a consequent report of increased stress, anxiety, and disorganization of routines, with changes in eating and sleeping.17In this context, psychoeducational interventions are revealed as important strategies, such as booklets and informative materials in general,57monitoring fake news, providing alternative support and service channels, and stimulating research to target prevention and mental health care policies.25Modification of the form of care delivery to mental health patients is a consequence of the reality of social distance.58suggest that three main factors should be included in government mental health strategies during COVID-19: 1) multidisciplinary mental health teams; 2) clear communication about the outbreak of COVID-19 and; 3) establishment of safe psychological counseling services (via electronic devices or applications). Additionally, protocols for managing stress, trauma, depression, and risky behavior need to be developed and available to guide professionals, covering areas relevant to the individual and collective mental health of the population.25Xiang et al.59point to awareness of pitfalls to combating the COVID-19 crisis, such as fear of the unknown, personal embarrassment (of adopting prevention strategies), and risk of neglect. A challenge during this period is to identify emergence or worsening of psychiatric disorders, which can be “invisible” and not easily detected by population screening. In this sense, the use of technology can facilitate access by isolated individuals to some types of health care, in addition to facilitating maintenance of work relationships and leisure activities.Redelmeier & Shafir60For the population, it is essential to seek wellness strategies, identify triggers that cause psychological distress, keep in touch with the support network of family and friends (even if online), practice physical exercise, relieve stress, and avoid overexposure to media information related to the pandemic. It is necessary to reconcile leisure and work or study schedules with the quarantine. Public awareness campaigns should focus on ways to make quarantine easier and frictionless, rather than repeating reasons for staying indoors.It is of note that only five Brazilian publications were identified in this review: three referring to economic effects and two on the use of technology as a way of adapting to this scenario. It is thus clear that the country is trying to adapt to the situation of isolation, but is very concerned with the economic effects, to the detriment of real health care of the population, as seen in European and North American countries.This study has some limitations, inherent to its objective of conducting a review of recent literature on the effects of social isolation in the COVID-19 pandemic. Studies on the consequences of other recent epidemics (such as SARS in 2003 and African Ebola in 2014) were not considered. In order to obtain the greatest diversity of publications in a short period, letters to the editor and other review studies were included in this review.Despite the recentness of the phenomenon of the COVID-19 pandemic, scientists are studying the theme in increasing depth, in a multidisciplinary and focused manner, in the search for better understanding of the current situation and its consequences, to facilitate responses to the pandemic and its repercussions. Greater support and a greater incentives for scientific production is expected, since only solid knowledge can explain and develop services that meet the demands and deliver comprehensive care to the population. Given this, it is necessary to plan an escalation of responses to the consequences of the pandemic, especially in view of the increased demand on the health sector and social services. The negative effects of social isolation can be prevented by public policies that offer a response to the economic recession, maintenance of social work, encouragement of quality care in mental health services, and community support for vulnerable families. Such measures, in the long run, will be decisive for the health for the population, especially its mental health.