Clinical and research psychologists around the world are experiencing various challenges due to the COVID-19 pandemic. Quarantine, mobility restrictions and health risks associated with the new SARS-CoV-2 virus have disrupted studies, which has impacted data collection, project coordination and monitoring efforts. Researchers have had to shift and adapt their fields of research. Consequently, various studies regarding COVID-19 have emerged. In Panama, a multidisciplinary research group, the Panama Aging Research Initiative (PARI), has been studying the characteristics associated with aging among the Panamanian population for the last 10 years. Due to the COVID-19 pandemic, enrollment and assessment of elderly participants came to a halt being as they are most vulnerable to COVID-19. As the team became involved in pandemic-related studies, it faced an unfamiliar challenge: to collect data from hospitalized patients who had tested positive to SARS-CoV-2. This opinion article aims to present our experience with COVID-19 patients and critically explore the role of clinical researchers in emergency situations as they balance between the individual, scientific and social benefits of research.

In Panama, in April 2020, the PARI group began a seroprevalence antibody study in three different groups, namely healthcare workers, healthy controls recruited from a blood donor clinic and SARS-CoV-2 positive hospitalized patients from public hospitals (11). The research instruments included an initial informed consent, an interview to obtain sociodemographic information, previous diseases and COVID-19 related symptoms and the collection of a blood sample. Data collection in the current health emergency, specifically from positive hospitalized patients posed a series of adversities. As it was the beginning of the pandemic, different situations hindered research conditions; knowledge on the virus was scarce, there was a high mortality rate and there were no approved treatments. Additionally, as in many countries, we faced situations such as limited personal protection equipment and poor conditions in hospital facilities.

In this high uncertainty, high risk context, we also faced limitations regarding participant selection. Patients' level of illness varied. Some patients were delirious, cognitively impaired or experiencing psychological distress affecting their ability to talk. This required a careful evaluation of which participants were eligible to be offered participation in the study. We had to seek the balance between being just and offering the study to everyone, but also recognizing whether or not some people in a situation of vulnerability can be contemplated as research participants.

Second, as we addressed the COVID-19 patients, we were faced with realities that included educational, cultural and language barriers. Such challenges are common to many studies in Panama. One of the main difficulties was a low literacy level. Even though literacy rates in the last 12 years have increased in 50% and currently adult literacy rates are ~95.4%, the mean number of years of schooling is 10 (12) and education quality has been reported to be deficient (13). Moreover, some of the patients belonged to indigenous groups, therefore we had to take into consideration culturally appropriate materials.

Third, some of the other patients who understood the study and signed the informed consent viewed their participation as an opportunity to talk about the deficiencies they experienced at the hospital, such as the conditions of the rooms, bathrooms, food and the understaffed hospital wards. Although these situations are not research limitations per se, they can contribute to the psychological burden patients sustain.

Fourth, one of the biggest challenges we confronted conducting our study was the impact of COVID-19 on mental health. As we collected data, we had to consider that a large portion of SARS-CoV-2 positive participants were under extreme stress and fear. Topics such as loneliness, uncertainty, confusion, anger, sadness, anxiety, and stress were often discussed among patients. Literature has shown that symptoms of psychological distress, are associated to hospitalizations (14, 15). Isolation and quarantine where patients are not allowed to receive visitors often augment these psychological and psychiatric symptoms (14, 16). In addition to this, healthcare professionals have to deal with an overload of patients and work, often limiting the time they can spend with each patient aggravating the loneliness and despair patients experience.

Lastly, a recurring fear manifested by most patients, independent of their disease severity, was that of their own death. Moreover, others had witnessed other patients in their rooms dying; and a patient even had to intervene in a suicide attempt. Lastly some of the interviewed patients had been admitted to the hospital with a family member, and while hospitalized, their loved one passed away. Psychological distress regarding death in hospitalization situations and associated to pandemics and epidemics has been previously studied (14–17). From mourning to fear of dying, death is an extremely relevant topic that must be taken into account when approaching hospitalized patients. Studies have shown that in patients who recover from life threatening diseases, the experience of being hospitalized is associated with post-traumatic stress disorder and can be highly intensified by grief (15, 18). Having all this in mind, we had to rapidly assess if answering questions that were related to participant's health contemplated in our study, would emotionally and psychologically harm them.

As patients discussed the anguish they had experienced after contracting the virus, some of them evidenced the coping mechanisms they had developed through their convalescence. Some mentioned they had turned to faith and were constantly praying and thanking God for being alive and this helped them maintain optimistic. Others, turned to their roommates looking for comfort in their new friendship. Evidence suggests that, as witnessed, often patients look for external mechanisms such as spirituality and religion, gratitude, and social support to help them cope with burdensome situations (16, 19).

Conducting research during public health emergencies demands an adequate balance of social, scientific and individual benefits. Researcher's roles in clinical settings during COVID-19 require a comprehensive understanding of ethical principles and an empathic engagement with participants (6). Ethical considerations are fundamental from the conception and planification of the study, to the actual field work of data collection, publishing and sharing of results (2). As we conducted our study, we constantly asked ourselves, how do we draw the line between benefits for science, participants and knowledge?

At an individual level, we had a duty to always seek benefits for participants. A critical analysis had to be made regarding possible psychological or social harms of the study, as well as acknowledging and empathizing with patients' vulnerable states. Additionally, we needed to make sure they understood the study and made a voluntary decision to participate.

At a scientific level, due to the complexity, novelty and unexpectedness of COVID-19, we as other researchers around the world, have urgently responded by rapidly generating data while maintaining scientific validity and replicability. Researchers and work groups have had to generate multiple therapeutic strategies, prevention mechanisms and diagnostic tests to tackle this new disease. Moreover, the COVID-19 pandemic has exposed the importance of research's social benefits. Knowledge cannot be limited to a laboratory or to a publication. It is mandatory that research in this health emergency has practical applications that rapidly reaches all countries affected by the virus. In the case of the PARI COVID-19 study, over the last months there has been an important increase in the use of the antibody test.

As a multidisciplinary group we have engaged in multiple areas of science. Our previous experience in research with elderly population, aided us in conducting the COVID-19 project as it gave us tools to work and assess vulnerable groups. In our aging study, some participants have physical and cognitive impairments, frailty, a limited functional status as well as low literacy levels and/or economic limitations. Therefore, as researchers we are obliged to acknowledge their vulnerability and carefully ensure all ethical processes are taken into account.

The current study has shown us the immense need to address the long term psychological and social effects of the COVID-19 pandemic. Even though more than 80% of patients will recover from the virus, the pandemic will continue to have a detrimental mental health burden on various population groups (20). Therefore, as clinical and psychology researchers, we recommend the following:

It's time to move beyond the initial critical sanitary response to a sustainable global effort toward resilience.

DO conceived and wrote the manuscript. GB, AV, AP-L, and MC read, reviewed and equally contributed to the intellectual content, and format of the manuscript. All authors 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.