Three years post-pandemic of SARS-CoV-2: Insights from a Bulgarian online survey

Three years post-pandemic of SARS-CoV-2: Insights from a Bulgarian online survey Emilia Naseva1,2 , Verginiya Ivanova2, Hristiana Batselova3, Latchezar Tomov2,4 , Daniel Georgiev2, Kaloyan Guevara5, Vasil Jenkov6, Tsvetelina Velikova2 1 Faculty of Public Health “Prof. Tzecomir Vodenitcharov, MD, DSc”, Medical University of Sofia, 15 Acad. Ivan Evstratiev Geshov, 1606 Sofia, Bulgaria 2 Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak str, 1407 Sofia, Bulgaria 3 Department of Epidemiology and Disaster Medicine, Medical University of Plovdiv, University Hospital “St George”, 15A Vasil Aprilov blvd, 4000 Plovdiv, Bulgaria 4 Department of Informatics, New Bulgarian University, 21 Montevideo str, 1618 Sofia, Bulgaria 5 Division of Adult Mental Health Care, Stavanger University Hospital, Jan Johnsens gate 12, 4011 Stavanger, Norway 6 New Bulgarian University, 21 Montevideo str, 1618 Sofia, Bulgaria Corresponding author: Emilia Naseva ([email protected]) Received 30 July 2025♦ Accepted 10 October 2025♦ Published 3 November 2025 Citation: Naseva E, Ivanova V, Batselova H, Tomov L, Georgiev D, Guevara K, Jenkov V, Velikova T (2025) Three years post-pandemic of SARS-CoV-2: Insights from a Bulgarian online survey. Pharmacia 72: 1–10. https://doi.org/10.3897/pharmacia.72.e167249 Abstract Beyond its medical implications, the COVID-19 pandemic precipitated widespread psychological distress, with numerous studies reporting increases in anxiety, depression, and other mental health issues across diverse populations worldwide. This study examined the evolution of perceptions, emotions, and coping strategies from the initial 2020 outbreak to the post-crisis period in 2023 through two identical online surveys conducted among Bulgarian citizens: “How do I feel during the COVID-19 pandemic?” (2020) and “How do I feel after the COVID-19 pandemic?” (2023). The surveys utilized standardized questionnaires with 24 core questions in 2020 (n = 1,020) and 27 questions in 2023 (n = 661), distributed through digital platforms including Facebook, LinkedIn, and e-mail. Results revealed significant improvements in mental health outcomes by 2023, including enhanced mood (p < 0.001), reduced feelings of sadness and helplessness (from 12.9% to 7.7% experiencing daily symptoms), decreased financial stress (severe stress declining from 11.4% to 5.3%), and reduced unhealthy habits. Additionally, belief in conspiracy theories regarding the virus’s origins and transmission methods decreased significantly. These findings underscore the importance of ongoing monitoring and targeted mental health interventions to address the diverse psychological needs following major global crises. Keywords Bulgaria, COVID-19, long-term impact, online survey, pandemic perception, post-pandemic, public health, SARS-CoV-2 Introduction The impact of crisis on mental health Throughout recorded history, humanity has faced numerous large-scale crises, including armed conflicts, economic collapses, natural disasters, and global health emergencies. “Nearly everyone will experience emotional and psychological distress in the immediate aftermath of a disaster or other large-scale traumatic event” (Gray et al. 2004). Each of these events has had a profound imCopyright Naseva E et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Pharmacia 72: 1–10 DOI 10.3897/pharmacia.72.e167249 Research Article Naseva E et al.: A post-pandemic Bulgarian online survey2 pact on societies, often leaving long-term consequences on individuals’ mental and emotional well-being. Among such crises, pandemics present a unique and far-reaching challenge, as they not only affect physical health and strain healthcare systems but also generate prolonged periods of uncertainty, fear, and social isolation. “Data from previous major emergencies and pandemics pointed to a likely peak in mental health problems, which was predicted to occur later than the initial peak in physical illness and also to endure for longer” (Gavin et al. 2021). The Coronavirus Disease 2019 (COVID-19) pandemic, caused by the novel coronavirus SARS-CoV-2, rapidly evolved into a global crisis affecting nearly every aspect of life. “Following its initial outbreak, it spread rapidly across the global community, prompting the World Health Organization to declare COVID-19 a global pandemic in March 2020” (Chen et al. 2021). Beyond its medical implications, the pandemic triggered widespread psychological distress, with numerous studies reporting increases in anxiety, depression, post-traumatic stress, and other mental health issues across diverse populations (Xie et al. 2022). Even after patients had recovered from the illness and were successfully discharged, an additional cause for concern was the emergence of unexpected complications (Grigorov et al. 2022). The abrupt changes in daily routines, enforced social distancing, lockdown measures, and the loss of lives and livelihoods contributed to what many experts have described as a parallel “mental health pandemic.” In this context, the role of psychosocial support has emerged as not only beneficial but also essential. The United Nations highlighted that the mental health of whole societies has been severely impacted by this disaster and must be addressed as a priority (Lindert et al. 2021). Psychosocial support and mental health in times of crisis In response to the increasing need for structured mental health interventions during emergencies, the United Nations Inter-Agency Standing Committee (IASC) introduced the framework of mental health and psychosocial support (MHPSS) (IASC 2021). This term encompasses “any type of local or external support aimed at protecting or promoting psychosocial well-being and/or preventing or treating mental health disorders” during crises. MHPSS approaches are multifaceted and context-sensitive, considering cultural, societal, and economic factors that shape individual and collective experiences of trauma. During pandemics like COVID-19, psychosocial support encompasses a wide range of services, including mental health counseling, emotional first aid, stress management training, public health communication, and community-based support networks. Crucially, MHPSS interventions focus not only on clinical symptoms but also on social factors, including family dynamics, workplace stress, education, and access to healthcare. This holistic approach is particularly important in mitigating long-term psychological effects and promoting community resilience. As mentioned in other studies, mental disorders are strongly connected with the fear of rejection in people’s social circles – family, friends, and colleagues – because of humans’ natural need for belonging to a certain group in order to be integrated and function properly as members of society (Dimitrova et al. 2020). According to the handbook, “sustainability can be enhanced when it is identified as a foundation of the approach from the beginning and considered throughout” (IASC 2021). Acknowledging the psychological burden of COVID-19, particularly in countries with limited access to mental healthcare, is a key step toward understanding the broader consequences of the pandemic. Vulnerable groups – including healthcare workers, the elderly, young people, and individuals with pre-existing mental health conditions – require targeted support to prevent further deterioration of their mental health. In Bulgaria, as in many other countries, the COVID-19 pandemic imposed new social norms and psychological stressors. Recognizing the need for empirical data to assess the long-term mental health consequences of the pandemic, a two-phase online survey was conducted to evaluate Bulgarian citizens’ mental health and psychosocial experiences during and after the crisis. The study aimed to capture the evolution of perceptions, emotions, and coping strategies from the initial shock of the 2020 outbreak to the post-crisis period in 2023. The primary aim of the study was to compare the results of two identical online surveys conducted 3 years apart: the first titled “How do I feel during the COVID-19 pandemic?” in 2020, and the second, “How do I feel after the COVID-19 pandemic?” in 2023. By analyzing changes in self-reported mental health status, levels of emotional distress, and perceived social support, the study sought to provide insights into the longer-term psychosocial impact of the pandemic in Bulgaria. Methods Two questionnaires were used: the pre-pandemic (conducted in 2020) “How do I feel during the COVID-19 pandemic?” and the post-pandemic (conducted in 2023) “How do I feel after the COVID-19 pandemic?”. Data collection for the first survey took place in May 2020, and its details are described elsewhere (Velikova et al. 2020). To ensure methodological consistency and comparability, the research team developed a standardized, anonymous questionnaire composed of 24 core questions from the initial 2020 survey. These questions covered areas such as emotional well-being, coping mechanisms, fears and concerns, social relationships, and perceived changes in lifestyle. Before its distribution, the survey underwent pilot testing with 20 individuals to evaluate the clarity, relevance, and comprehensibility of the questions. Based on participant feedback, three new questions were added to the 2023 survey, and minor adjustments were made to verb tenses and phrasing to reflect the retrospective nature of the follow-up study. The final 2023 version included 27 questions. Pharmacia 72: 1–10 3 Respondents in both surveys were informed about the aim of the research, their voluntary participation, and data confidentiality prior to completing the questionnaires, and they provided informed consent by clicking the “Continue” button. The survey was distributed electronically through widely used digital platforms, including Facebook, LinkedIn, Twitter, and e-mail mailing lists. Participants were Bulgarian citizens aged 18 and above. The design ensured that respondents could submit their answers only after completing all required fields, thereby maintaining the integrity and completeness of the dataset. The anonymity of the survey encouraged honest and unfiltered responses, which are essential in studies involving sensitive personal topics such as mental health. Statistical methods Results are presented as numbers and/or proportions. The Pearson chi-square test (Fisher’s exact test when applicable) was used to compare both surveys. Results were considered significant if p < 0.05 for two-sided tests. IBM SPSS Statistics v.29 was used. Results Demographics and occupation A total of 1,020 respondents were recruited during the pandemic and an additional 661 respondents after the pandemic. Their characteristics are presented in Table 1. Both groups were similar in terms of sex, with a predominance of females (83.8% during the pandemic and 82.2% post-pandemic). They differed significantly in their age groups (p < 0.001). During the pandemic, the majority of respondents were between 21 and 40 years old (71.4%), while after the pandemic, the most prevalent age group was 41–60 years old (58%). Age differences significantly influenced the likelihood of having children: respondents after the pandemic reported having offspring more often (71% compared to 61.8% during the pandemic; p < 0.001). The proportion of those whose children were younger than 7 years old was similar in both groups (36.8% during the pandemic and 35% post-pandemic; p > 0.05). Children of school age were more often reported by post-pandemic respondents (28.1% compared to 18.3% during the pandemic; p < 0.001). The post-pandemic group also more often reported having children above 18 years old (17.8% vs. 13.4%; p = 0.014). Respondents in both surveys were asked if they had a job. A significant difference was observed in the answers (p < 0.001). A significantly higher proportion of respondents after the pandemic reported going to their workplaces in person (56.3% compared to 36.3% during the pandemic). The proportion of “home office” workers was similar (21.2% during the pandemic and 21.6% after the pandemic), as was the proportion on maternity or sick leave (12.5% and 11.5%, respectively). A reduction was observed among those who did not have a job due to the pandemic, as well as those who had been unemployed before the pandemic (7.3% to 0.8% and 10.2% to 2.6%, respectively). Nearly the same proportion of respondents had jobs related to medicine and COVID-19 (27.8% and 26.3%; p > 0.05). Table 1. Demographic characteristics of the respondents. Questions Answers During the pandemic After the pandemic p n % n % Sex Male 156 15.3% 116 17.5% 0.195 Female 855 83.8% 544 82.2% Other 5 0.5% 0 0.0% Prefer not to disclose 4 0.4% 2 0.3% Age group < 21 years old 34 3.3% 0 0.0% <0.001 21–40 years old 728 71.4% 0 0.0% 41–60 years old 242 23.7% 384 58.0% 61+ years old 16 1.6% 278 42.0% Do you have children? Yes 630 61.8% 470 71.0% <0.001 No 390 38.2% 192 29.0% Children under 7 years old? Yes 375 36.8% 232 35.0% 0.473 No 645 63.2% 430 65.0% Children of school age? Yes 187 18.3% 186 28.1% <0.001 No 833 81.7% 476 71.9% Children above 18 years old? Yes 137 13.4% 118 17.8% 0.014 No 883 86.6% 544 82.2% Do you have a job? Yes, I go to my workplace 370 36.3% 373 56.3% <0.001 Yes, at home (home office) 216 21.2% 143 21.6% No, I do not have a job due to the pandemic 74 7.3% 5 0.8% No, and I did not have a job before the pandemic 104 10.2% 17 2.6% Maternity or sick leave 128 12.5% 76 11.5% Other 128 12.5% 48 7.3% Is your job related to medicine and COVID-19 patients? Yes 284 27.8% 174 26.3% 0.483 No 736 72.2% 488 73.7% Naseva E et al.: A post-pandemic Bulgarian online survey4 Psychological well-being A significant increase was observed in the proportion of respondents who rarely associated flu-like symptoms (fever, cough, etc.) with COVID-19 (from 41.3% to 50.3%), as shown in Table 2. However, the proportion of respondents who actively associated these symptoms with COVID-19 also increased (from 29.8% to 37.2%). In contrast, a decrease in the proportion of respondents who tried not to think about this was noted (from 28.9% to 12.5%). In general, a significant change was observed (p < 0.001). A significant decrease was recorded in the proportion of respondents who followed information channels about the pandemic either all the time or for a limited amount Table 2. Psychological well-being of the respondents. Questions Answers During the pandemic After the pandemic p n%n% If you do not feel well and experience symptoms like fever, cough, etc., do you associate them with COVID-19? Usually yes 304 29.8 246 37.2 <0.001 No, rarely 421 41.3 333 50.3 I try not to think about this 295 28.9 83 12.5 Do you follow the information channels about the pandemic (TV, social media, etc.)? / 2023 Do you continue to follow... Yes, but limited 572 56.1 343 51.8 <0.001 Yes, all the time 246 24.1 66 10.0 No, I avoid such information 202 19.8 253 38.2 Do you find yourself experiencing feelings of sadness, helplessness, despair, or hopelessness more often than before? Yes, every day 132 12.9 51 7.7 <0.001 Yes, sometimes 422 41.4 240 36.3 Rarely or not at all 466 45.7 371 56.0 Do you find yourself becoming more irritable and getting angry more easily than before? Yes 389 38.1 170 25.7 <0.001 No 436 42.7 341 51.5 I am not sure 195 19.1 151 22.8 Do you have a strong fear that you or someone close to you could become ill? Yes, I feel a very strong fear 82 8.0 65 9.8 0.001 Yes, but sometimes 237 23.2 165 24.9 Yes, but I try not to think about it 382 37.5 186 28.1 Very rare or never 319 31.3 246 37.2 Do you experience stress due to current or potential financial problems related to the pandemic? No 456 44.7 437 66.0 <0.001 Yes, a mild stress 448 43.9 190 28.7 Yes, severe stress 116 11.4 35 5.3 Have your family relationships changed? In what direction? Yes, towards unity 223 21.9 109 16.5 0.035 Yes, to misunderstanding 87 8.5 54 8.2 I don‘t think they have changed 605 59.3 434 65.6 I am not sure 105 10.3 65 9.8 Do you miss your family and friends? / Do you meet your family and friends more frequently? Yes, although we keep in touch online /we were in touch online during the pandemic 718 70.4 310 46.8 <0.001 Yes, although we haven‘t stopped meeting each other 112 11.0 247 37.3 No, we keep in touch online only 190 18.6 105 15.9 Do you have someone to talk to if something is bothering you? Yes 866 84.9 572 86.4 0.393 No 154 15.1 90 13.6 Do you feel you have a professional need for psychological support for you and your family during/after the pandemic? Yes 212 20.8 130 19.6 0.568 No 808 79.2 532 80.4 Did you increase any unhealthy habits during the pandemic? Yes 706 69.2 370 55.9 <0.001 No 314 30.8 292 44.1 Alcohol consumption Yes 149 14.6 64 9.7 0.003 No 871 85.4 598 90.3 Cigarette smoking Yes 184 18.0 74 11.2 <0.001 No 836 82.0 588 88.8 Drug use Yes 15 1.5 3 0.5 0.048 No 1005 98.5 659 99.5 Overeating Yes 313 30.7 144 21.8 <0.001 No 707 69.3 518 78.2 Lack of physical activity Yes 572 56.1 298 45.0 <0.001 No 448 43.9 364 55.0 Other Yes 19 1.9 8 1.2 0.297 No 1001 98.1 654 98.8 Are you spending more time on your hobbies? Have you taken up new hobbies or increased activities such as reading or other pastimes? No 479 47.0 220 33.2 <0.001 Yes 398 39.0 294 44.4 I am not sure 143 14.0 148 22.4 Pharmacia 72: 1–10 5 Questions Answers During the pandemic After the pandemic p n%n% Does it scare you that there is no specific treatment and prevention? / Does it scare you that there is still no specific treatment, despite ongoing drug trials? Yes 492 48.2 233 35.2 <0.001 No 370 36.3 332 50.2 I am not sure 158 15.5 97 14.7 Are you tired of staying at home more? / Were you tired of staying at home more often? Yes, but I‘m coping with it 502 49.2 313 47.3 <0.001 Yes, and I don‘t handle it 85 8.3 31 4.7 No, but I don‘t know how long 188 18.4 61 9.2 No, not at all 245 24.0 257 38.8 Do you want to become infected so the pandemic “passes” more quickly? / Was there a point when you stopped protecting yourself from the virus so the pandemic would “pass” more quickly? Yes 40 3.9 108 16.3 <0.001 I am not sure 208 20.4 97 14.7 No 772 75.7 457 69.0 Have you had sleep disturbances in recent weeks? Yes 228 22.4 113 17.1 0.021 Yes, worsened from before 142 13.9 88 13.3 No 650 63.7 461 69.6 of time (from 56.1% to 51.8% for all the time and from 24.1% to 10% for a limited amount of time), along with an increase in the proportion of those who avoided such information (from 19.8% to 38.2%) (p < 0.001). A significant improvement in mood was observed (p < 0.001). The proportion of respondents who felt sadness, helplessness, despair, or hopelessness decreased (from 12.9% to 7.7% every day and from 41.4% to 36.3% sometimes), while the proportion of those who rarely or did not experience such feelings increased (from 45.7% to 56%). Respondents were asked if they had become more irritable or prone to anger. A significant decrease was observed in the proportion of respondents who answered “yes” (from 38.1% to 25.7%), along with an increase in those answering “no” (from 42.7% to 51.5%) (p < 0.001). The fear that respondents themselves or someone close to them might contract the disease decreased significantly in the post-pandemic period (p = 0.001). An increase was observed in the proportion of those who experienced such fear very rarely or never (from 31.3% to 37.2%). Stress related to current or future financial problems due to the pandemic decreased significantly (p < 0.001), from 43.9% to 28.7% for mid-level stress and from 11.4% to 5.3% for severe stress. An increase was observed in the proportion of respondents who reported no stress (from 44.7% to 66%). During the pandemic, 59.3% of respondents reported that their family relationships remained unchanged, while 65.6% in the second survey reported the same (p = 0.035). A decrease was observed in the proportion of individuals whose relationships shifted toward unity (from 21.9% to 16.5%). The proportion of worsened relationships remained relatively the same (8.5% and 8.2%, respectively). Respondents were asked during the pandemic, “Do you miss your family and friends?” and this question was modified after the pandemic to “Do you meet your family and friends more frequently?” A significant change was observed toward an increase in in-person meetings (from 11% to 37.3%) and a decrease in online contacts (from 70.4% to 46.8%). Nearly the same proportion of respondents remained separated, maintaining online contact only (18.6% and 15.9%, respectively). The majority of respondents in both surveys reported having someone to talk to if something was bothering them (84.9% and 86.4%, respectively). No significant change was observed in response to the question “Do you feel you have a professional need for psychological support for you and your family during/ after the pandemic?” About one-fifth in both surveys responded positively (20.8% and 19.6%, respectively). Post-pandemic respondents were asked whether they had sought psychological help. One in ten (10.4%) confirmed, and almost the same proportion were considering such help (9.7%). A significant decline in unhealthy habits that spread during the pandemic was observed (p < 0.001). During the pandemic, 69.2% of respondents reported an increase in these bad habits, which decreased to 55.9% in the post-pandemic period and remained at 55.9% thereafter. The most prevalent bad habit was a lack of physical activity, which was common among 56.1% of participants during the pandemic and 45% in the post-pandemic survey (p < 0.001). Other negative habits that decreased significantly were overeating (30.7% and 21.87%, respectively; p < 0.001), cigarette smoking (18% and 11.2%, respectively; p < 0.001), alcohol consumption (14.6% and 9.7%, respectively; p = 0.004), and drug use (1.5% and 0.5%, respectively; p = 0.048). After the pandemic, respondents started spending significantly more time on their hobbies (39% and 44.4%, respectively); however, there was an increase in the proportion of those who were uncertain about changes in their engagement with hobbies (p < 0.001). Respondents were asked during the pandemic, “Does it scare you that there is no specific treatment and prevention?” and this question was modified afterward to “Does it scare you that there is still no specific treatment, even though there are drug trials?” A significant decrease was observed in the proportion of respondents who reported being scared (from 48.2% to 35.2%), along with an in- Naseva E et al.: A post-pandemic Bulgarian online survey6 crease in the number of respondents who claimed not to be scared (from 36.3% to 50.2%) (p < 0.001). In the post-pandemic period, a significantly greater proportion of respondents reported that they had wished to “get” the virus themselves in order for the pandemic to “pass” more quickly (from 3.9% to 16.3%) (p < 0.001). During the same period, significantly fewer respondents reported suffering from sleep disturbances (from 22.4% to 17.1%) (p = 0.021). Myths about the pandemic The belief that the virus was artificially engineered decreased significantly from 2020 to 2023, while the number of people who did not believe in this conspiracy theory increased (p < 0.001). The perception that the virus was spread via 5G or other methods to enhance its transmission also showed a clear reduction in belief from 2020 to 2023, with a larger proportion of respondents in 2023 rejecting this idea (p < 0.001). Both surveys indicated that respondents felt well-informed about the COVID-19 pandemic and anti-epidemic measures (Table 3). After the pandemic Three additional questions were added to the post-pandemic survey. Fig. 1 presents the responses to the question, “Did you get sick from COVID-19?” Almost half of the respondents (45.5%) had a test result confirming infection, and 22.4% indicated that they had contracted COVID-19 more than once. In total, more than two-thirds had confirmed COVID-19 infection (67.9%). About 18.2% believed they had not contracted COVID-19, and the remaining 13.9% were unsure. Another post-pandemic question concerned vaccination against COVID-19. The majority of respondents (82.5%) received the vaccine, while another 0.8% were considering it, and 16.8% did not receive a vaccine (Fig. 2). Discussion The COVID-19 pandemic, caused by the novel coronavirus SARS-CoV-2, rapidly evolved into a global crisis affecting nearly every aspect of life, precipitating widespread psychological distress (Sampogna et al. 2021). Beyond its medical implications, numerous studies have reported increases in anxiety, depression, post-traumatic stress, and other mental health issues across diverse populations. The abrupt changes in daily routines, enforced social distancing, lockdown measures, and the loss of lives and livelihoods contributed to what many experts described as a parallel “mental health pandemic” (Bower et al. 2023; Chen et al. 2021). In this context, psychosocial support has emerged not only as beneficial but also as essential. While pandemics are not unprecedented in human history, COVID-19 represents the first to unfold within the context of globalization, digital connectivity, and widespread commodification – structural characteristics of contemporary society that have both accelerated viral transmission and intensified its psychological toll (Sawika et al. 2022). These are among the main features of modern society that have contributed to the spread of the pandemic and, at the same time, to its profound impact on the mental health of the general population. Even in the early aftermath of the WHO declaring a global pandemic in March 2020, there was awareness that the impact of the pandemic and the measures necessary to curtail it would inevitably result in psychological morbidity. Table 3. Beliefs and self-reported awareness about SARSCoV-2 over time. Questions Answers During the pandemic After the pandemic p n % n % Do you think SARS-CoV-2 was artificially created? Yes 411 40.3 198 29.9 <0.001 No 343 33.6 290 43.8 I am not sure 266 26.1 174 26.3 Do you think SARS-CoV-2 is spreading via 5G and other methods that increase its transmission? Yes 41 4.0 11 1.7 <0.001 No 854 83.7 629 95.0 I am not sure 125 12.3 22 3.3 Do you feel well informed about the COVID-19 pandemic and anti-epidemic measures? Yes 756 74.1 493 74.5 0.758 Yes, but not enough 208 20.4 138 20.8 No, not at all 56 5.5 31 4.7 Figure 2. Post-pandemic question: “Did you get vaccinated (with one, two, or three doses)?” Figure 1. Post-pandemic question: “Did you get sick from COVID-19?” Pharmacia 72: 1–10 7 Our study, conducted 3 years after the pandemic started, provides valuable insights into the longer-term psychosocial consequences of the COVID-19 crisis, comparing self-reported mental health status, emotional distress, and perceived social support from 2020 to 2023. This is a critical moment for advancing mental health research as we strive to understand the mental health needs of the population and advocate for adequate resourcing to deliver quality mental healthcare in the post-pandemic period (Gavin et al. 2021). One of our key findings indicates a significant improvement in general perceptions related to COVID-19, with a notable decrease in the proportion of respondents who associated flu-like symptoms with the virus or avoided thinking about it. This shift suggests a normalization of public perceptions and a reduction in the initial fear and uncertainty that characterized the early stages of the pandemic. This aligns with broader evidence that, although psychological distress was initially elevated, societies gradually adapted to the new reality (Sampogna et al. 2021). Several concerns have been reported among the general population, ranging from threats to personal and family safety to difficulties in receiving a prompt diagnosis of the infection, the use of containment measures that limit personal mobility, and the lack of effective treatments. The availability of vaccines has improved the situation significantly but has also been associated with a variety of partially unexpected complications, as well as generating new inequities (Privor-Dumm et al. 2023). Regarding the demographic questions about children, it was shown that the presence of children significantly influenced pandemic-related stress, coping mechanisms, and mental health outcomes. Parents faced unique challenges during COVID-19, including managing children’s remote schooling, balancing work-from-home with childcare responsibilities, concerns about children’s health and development, and increased family tensions from prolonged confinement (Whaley and Pfefferbaum 2023). The age of children is particularly relevant because different developmental stages presented distinct challenges – caring for toddlers versus managing teenagers’ educational and social needs required different coping strategies and generated varying stress levels (Aviles et al. 2024). Nevertheless, in their systematic review, Ng and Ng (2022) demonstrated that both children’s and parents’ mental health is at risk, and there is a critical need for tailored governmental interventions targeting children with internalizing and externalizing behaviors, particularly implementing health promotion and prevention strategies for lower socioeconomic status families who face heightened mental health risks in post-pandemic recovery policies. Furthermore, our results demonstrate a significant improvement in mood, with a decrease in reported feelings of sadness, helplessness, despair, and hopelessness from 2020 to 2023. This suggests a recovery in emotional well-being over time, moving away from the heightened distress observed during the initial phases of the pandemic. This positive trend is further supported by the significant decrease in respondents reporting increased irritability and anger. These findings are consistent with emerging literature suggesting that the acute phase of mental health challenges may subside as the immediate threat diminishes, although long-term effects can still persist among specific vulnerable groups (Bouza et al. 2023; National Academies of Sciences, Engineering, and Medicine 2023). The observation of this positive trend could be attributed to post-traumatic growth (Aulov et al. 2023). Lewis et al. (2022) demonstrated factors associated with post-traumatic growth: perceived social support, perceptions of the pandemic as traumatic, and higher psychological well-being. In line with this, Lazarus and Folkman’s (1984) transactional theory of stress and coping has profoundly shaped pandemic-related psychological research, serving as the foundational framework for understanding how individuals cope with COVID-19 stressors (Biggs et al. 2017). Therefore, although the COVID-19 pandemic has had adverse effects on psychological well-being, it may concurrently offer pathways for beneficial change. Furthermore, we support the position paper by Moreno et al. (2020) on how mental healthcare should change as a consequence of the pandemic. They recommend that mental health delivery systems require sustainable, expert-designed adaptations that reduce healthcare disparities, with continuous outcome assessment determining which practices to expand or eliminate (Moreno et al. 2020). The fear of contracting the virus or of a close one becoming infected significantly decreased in the post-pandemic period. This reduction in health-related anxiety likely contributes to the overall improvement in psychological well-being. This finding contrasts with initial concerns during the early pandemic that chronic anxiety and stress would lead to sustained mental health issues, as reported by Chen et al. (2021) and Lindert et al. (2021). Our study also reveals a significant decrease in stress related to current or future financial problems linked to the pandemic, with a substantial increase in the proportion of respondents reporting no stress in this regard. This is a significant finding, as economic difficulties have been identified as a major contributor to psychological distress during the pandemic. The observed improvement in perceived financial stress in our Bulgarian sample suggests a potential economic recovery or adjustment to new economic realities in the country. This stands in contrast to earlier predictions that economic hardships, which have previously been shown to contribute to suicide risk, would lead to increased suicide rates following the COVID-19 pandemic (Chen et al. 2021). However, Oprea et al. (2020) investigated economic resilience across seven Eastern European countries following the 2008 crisis. They found that manufacturing sector size, services, public administration, entrepreneurship, and tertiary education are key determinants of regional economic resilience, with Bulgaria and Slovenia demonstrating the strongest resistance, while recovery patterns varied significantly across countries and regions. Our results also emphasize the observed resilience in our country, and we can also speculate on the broader concept of stress resilience development, especially in times of crisis, and how people “evolved” during and after the pandemic. Naseva E et al.: A post-pandemic Bulgarian online survey8 Additionally, our findings suggest that by 2023, many Bulgarian workers may have returned to traditional in-person work arrangements, potentially reflecting organizational policies that favor office presence, industry-specific requirements that do not accommodate remote work, or cultural preferences for face-to-face collaboration. This finding contradicts the popular narrative of a lasting “remote work revolution” and may indicate that the shift to online work was more temporary than anticipated, at least in the Bulgarian context. Regarding social relationships, while family relationships largely remained unchanged, a notable decrease was observed in those who reported a sense of unity within their family. However, a significant positive change was seen in how respondents interacted with family and friends, transitioning from predominantly online communication to more frequent in-person meetings in the post-pandemic period. This trend reflects a reestablishment of pre-pandemic social behaviors and a potential reduction in perceived social isolation, which was a significant concern during lockdowns and a risk factor for developing post-traumatic stress disorder (PTSD). The implementation of strict quarantine and lockdown measures disrupted established social networks. Prolonged exposure to loneliness has been identified as a key contributor to PTSD symptomatology. Overall, the pandemic profoundly affected the mental health of the population due to the widespread disruption of the social, economic, and psychological fabric of the global community (Chen et al. 2021). Despite the observed improvements in various aspects of psychological well-being, our study found no significant change in the perceived need for professional psychological support. Approximately one-fifth of respondents in both surveys continued to express a need for such support, with a notable proportion in the post-pandemic sample actively seeking or considering mental healthcare. This sustained need for professional support, even as general distress subsides, underscores the importance of continued access to mental health services and acknowledges that for some individuals, the psychological impact of the pandemic may be more enduring. Data from previous public health crises and pandemics, as reported by Gavin et al. (2021), pointed to a likely peak in mental health problems that was predicted to occur after the initial wave of physical illness and may persist well beyond the resolution of the acute crisis. Moreover, Hancheva and Bikovska (2025), who studied peripartum women, found that self-perceived social support was a protective factor against COVID-19-related depression and anxiety. The same authors also reported that reduced time spent on social media was associated with better psychological health. Furthermore, our study observed a significant decline in unhealthy habits that became more prevalent during the pandemic, such as physical inactivity, overeating, cigarette smoking, and alcohol consumption. This suggests a return to healthier lifestyle choices as pandemic restrictions eased and daily routines normalized. In contrast, respondents in the post-pandemic period reported significantly increased engagement in hobbies, indicating a shift toward more adaptive coping mechanisms and activities promoting well-being. Interestingly, the proportion of respondents who expressed a desire to be infected with the virus in order for the pandemic to “pass” more quickly significantly increased in the post-pandemic period. While seemingly counterintuitive, this might reflect growing frustration with prolonged uncertainty and a desire for resolution or a perception that the health risks associated with COVID-19 had diminished over time. Moreover, a significant decrease in self-reported sleep disturbances was observed in the post-pandemic period, which is another positive indicator of improved overall well-being. Insomnia was among the reported mental health burdens during the pandemic, as reported by Chen et al. (2021). Finally, our study revealed that 16.8% of participants did not intend to get vaccinated. In contrast with our findings, Salama (2023) found that only 1% of pharmacy students in Jordan were not vaccinated. However, our study aimed to analyze the general population, which might differ from pharmaceutical students. Furthermore, Shen et al. (2025) found a decline in vaccine intention among the general population in the USA, comparing 2020 and 2022–2023. Strengths and limitations of the study Our study has a few limitations. First, it is an online survey that is prone to self-reporting bias. Furthermore, the second survey did not include the same individuals for pairwise comparisons. However, online data collection was the most appropriate research strategy during the pandemic. Moreover, online studies are mostly anonymous and do not allow researchers to study the same participants. The study also has several strengths worth noting. We ensured three key methodological advantages that enhance its scientific rigor and contribution to pandemic mental health research. First, the longitudinal design with consistent methodology employed an identical survey instrument administered 3 years apart (2020 and 2023), enabling direct comparison of psychological responses from the acute pandemic phase to the post-crisis period and providing robust evidence for tracking genuine changes in mental health outcomes over time rather than relying on cross-sectional snapshots. Second, the research achieved substantial participation, with 1,020 respondents during the pandemic and 661 in the post-pandemic phase, totaling 1,681 participants. This enhances the statistical power of the findings and increases their generalizability to the broader Bulgarian adult population. Third, the rigorous survey development and validation process included thorough pilot testing with 20 individuals before distribution to ensure clarity, relevance, and comprehensibility of questions, while the anonymous electronic format encouraged honest responses on sensitive mental health Pharmacia 72: 1–10 9 topics. The requirement to complete all fields maintained data integrity and completeness, collectively strengthening the reliability and validity of the finding. Conclusion In conclusion, our Bulgarian online survey provides a nuanced overview of the evolving psychosocial impact of the COVID-19 pandemic. Notably, the initial levels of fear, anxiety, and stress among respondents in 2020 decreased significantly by 2023. Moreover, a clear trend toward improved mood, reduced unhealthy habits, and increased social interaction was observed. However, the sustained need for professional psychological support highlights the complex and potentially long-lasting effects of such a global health crisis on mental well-being. These findings underscore the importance of ongoing monitoring and targeted, population-specific mental health interventions to address the diverse needs of the population in the aftermath of major crises. Additional information Conflict of interest The authors have declared that no competing interests exist. Ethical statements The authors declared that no clinical trials were used in the present study. The authors declared that no experiments on humans or human tissues were performed for the present study. The authors declared that no informed consent was obtained from the humans, donors or donors’ representatives participating in the study. The authors declared that no experiments on animals were performed for the present study. The authors declared that no commercially available immortalised human and animal cell lines were used in the present study. Use of AI No use of AI was reported. Funding This study is financed by the European Union-NextGenerationEU, through the National Recovery and Resilience Plan of the Republic of Bulgaria, project No BG-RRP-2.004-0008. Author contributions Conceptualization, T.V, and H.B.; methodology, E.N.; software, L.T.; validation, E.N., K.G. and V.J., formal analysis, L.T.; investigation, D.G.; resources, V.I.; data curation, E.N.; writing – original draft preparation, T.V. and E.N.; writing – review and editing, L.T., K.G., V.J.; visualization, E.N.; supervision, T.V.; project administration, T.V.; funding acquisition, T.V. All authors have read and agreed to the published version of the manuscript. Author ORCIDs Emilia Naseva https://orcid.org/0000-0002-1282-8441 Verginiya Ivanova https://orcid.org/0009-0009-6874-8342 Hristiana Batselova https://orcid.org/0000-0002-6201-848X Latchezar Tomov https://orcid.org/0000-0003-1902-6473 Daniel Georgiev https://orcid.org/0000-0002-3358-1206 Kaloyan Guevara https://orcid.org/0009-0005-6310-7600 Vasil Jenkov https://orcid.org/0009-0006-9239-9611 Tsvetelina Velikova https://orcid.org/0000-0002-0593-1272 Data availability All of the data that support the findings of this study are available in the main text. References Aviles AI, Betar SK, Cline SM, Tian Z, Jacobvitz DB, Nicholson JS (2024) Parenting young children during COVID-19: Parenting stress trajectories, parental mental health, and child problem behaviors. Journal of Family Psychology 38(2): 296–308. https://doi.org/10.1037/fam0001181 Aulov SS, Triplett KN, Tedeschi RG, Calhoun LG (2023) Posttraumatic growth. In: Friedman HS (Ed.) Encyclopedia of Mental Health (3rd ed.). 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