COVID-19 Webinar 3: Mental health and COVID-19 research
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health have launched a series of weekly webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
Chair: Niall Boyce, Lancet Psychiatry
Panellists:
Mark van Ommeren. WHO, Switzerland
Emily Holmes, Uppsala University and Karolinska Institutet, Sweden
Edward Bullmore, Cambridge University, UK
Lola Kola, WHO Collaborating Center, Ibadan, Nigeria
Charlene Sunkel, Global Peer Support Network, South Africa
Niall Boyce opened the meeting thanking the speakers.
Mark van Ommeren, WHO
The challenges in research at present are first, gaining access to COVID19 patients to conduct research in an ethical way. Second, distinguishing between mental health conditions and the wider mental health impacts of the response to COVID19. The latter has led to reports of increases in sadness and anxiety: it is hard to distinguish between mental health conditions and more general anxiety and this can lead to unusual findings. From a research perspective the first priority is how the mental health community can contribute to the overall COVID19 response to control the disease. This means how to address anxiety and fear to ensure people follow public health information. While improving mental health is good in itself, public health decision makers want us to show how we (as mental health professionals) can contribute to better a public health response.
Niall Boyce, Lancet Psychiatry
So the two have to work together – the public health response and mental health response.
Emily Holmes, Uppsala University and Karolinska Institutet, Sweden
Thank you to my fellow authors of a new report that proposes research priorities in the COVID19 pandemic. There are immediate priorities and longer term priorities. Mental health is on a continuum and lots of reactions are a natural response to stress. Therefore the first point is the need to monitor and understand the data: to understand what people are finding difficult and what is helping people cope.
A second point is understanding how to help vulnerable groups with existing mental health conditions to access services in a new way. Third, on a social level, media exposure can fuel anxiety and impact health behaviour messaging. Therefore there needs to be multiple disciplines to work together e.g. behavioural science and social science, and researchers need to work with people with lived experience.
Edward Bullmore, Cambridge University, UK
There are effects of the COVID19 infection on mental health and effects of the social response to the infection on mental health. The impact of the media and social isolation are social responses to the infection. The impact of the infection is not well known: there are still an awful lot of things we don’t know. Two things we do know now: the neurological presentations are surprisingly frequent and other coronaviruses have demonstrated a coronavirus can enter the nervous system. Neurological presentations include reports of headaches and loss of sense of smell, through to delirium, stroke or seizure. A new report in the New England Journal of Medicine documents several ICU patients with agitation and confusion i.e. impaired cognitive function. There are five cases of Guillain-Barré syndrome in relation to COVID: this is an auto-immune disorder triggered by infections. We don’t know what causes these neurological presentations, as patients also have other impacts such as strokes or infections. It is possible the virus gets into the brain and infects the brain although evidence is very slim (only one case report from China so far only).
We don’t know a long list of things – see report – and we need better data, so more clinical data sets of large cohorts to follow up over time. We need to build the capacity to look at COVID19 patients’ brain tissue post-mortem. In the longer term, there is a lot to do to understand the neurological presentations (why they are occurring, what are the biomarkers and the clinical tests to demonstrate how infection is impacting the brain) and interventions. There is a lot of interest in repurposing drugs that could be used particularly to treat COVID19 where it impacts on the brain and on mental health biologically. There is growing interest in the field in Neuro COVID – the mental health implications are unknown but it is wise to think about those now.
Dr. Lola Kola, WHO Collaborating Center, Ibadan, Nigeria
COVID-19 challenges the very fabric of our societies, and has disrupted our health systems. Research into health systems and implementation will help improve health interventions. In Africa, there are very limited services, though there are several initiatives, we know that there are implementation problems. Task shifting is a successful strategy, however, we need to study task shifting: this intervention will only have a positive impact if other parts of the health system are working, In Africa, COVID19 intersects with highly fragmented, under resourced health systems. We need strategies now as alternatives to face to face care as the latter is grossly inadequate. In a Lancet World Report by Paul Webster (ie, a news article), he said physicians are embracing virtual care like never before. In Africa there will always be reasons the patient and therapist cannot be in the same room – therefore this is an opportunity to overcome implementation barriers using mobile phones and other technology. We need to think out of the box on implementation strategies. African countries are on par with Europe/America countries on mobile phone technology.
Niall Boyce
So the emphasis needs to be on digital mental health as a focus for research and potential benefit for the longer term.
Charlene Sunkel, Global Peer Support Network
People with lived experience should be at the centre of the research agenda. They can inform research and give direction on what questions need to be answered. The lived experience community also plays a role in data collection; the design and modification of interventions; and lived experience researchers can help generate new evidence.
Empowerment and support are very important so that people with lived experience can meaningfully participate and share experiences during this time. COVID19 is a global event of such magnitude that most people never experienced something like it before. This global pandemic will affect people in ways the world is not particularly prepared for. Before COVID19 mental health services were underfunded and under-resourced. People with lived experience have experience of navigating these services. We are already seeing a rise in mental health conditions. People in mental health facilities or care homes are particularly vulnerable and often neglected. Peer support work could play such an essential component in the COVID19 response. Research in this field is particularly important.
Niall Boyce
In the time of a pandemic, can you discuss the trade off between quality and speed?
Mark Van Ommeren
We have written a paper on relevance or excellence – we need both, and there is a trade off to be had. Research has to be good enough to do something with the findings but must be relevant. The paper by Emily and others shows there are so many different things to study. The ones needed immediately are behavioural science and public health messaging (risk communication must be empathic). Much of the infection is happening in places where people with mental health conditions are, as demonstrated in a recent NBC report on psychiatric institutions. It is very likely that more people will get infected in such institutions. We need to look at what we can do right now to make sure that the hundreds of institutions not yet affected are better protected from COVID19: it is a very simple question to ask what to do about that issue.
Emily Holmes
Our paper proposes a focus on the needs - and action on the needs - of vulnerable groups including those in confinement. Confinement can mean risk of domestic violence and abuse.
Niall Boyce
Could COVID19 reverse some of the gains made for people living with mental health problems?
Charlene Sunkel
We need to push more for equality of health. There are fears for those living with mental health conditions that they may have problems accessing their chronic medication - including myself. There is so little focus on paying attention to how it affects people with mental health conditions. However, there are some positive aspects of being in lock down for some people. If you have an anxiety disorder, you don’t have to try and socialise; others are benefiting from a period of introspection. There is a range of experiences when designing interventions – and interventions need to look at the specific needs and challenges as identified by people with lived experience.
Niall Boyce
How can we deliver services in a sustainable way?
Lola Kola
We need to carry along the policy makers. When doing health systems research we need to engage with them so there is buy-in to what we are doing. We need to pay attention to health information systems, keep sharing information and keep the issue on the agenda of funding bodies.
Niall Boyce
Reflecting on how best to communicate with the public, Ed has written for a popular audience. There is the potential for alarming messages to emerge.
How can we frame and communicate messages around research without adding to stress and anxiety?
Ed Bullmore
We know it is a viral infection, but it is still a very new and evolving thing which we are trying to understand and deal with. Yet it is incredibly important to talk about it, and to work out what we need to do that is urgent, but not contribute to small scale and random studies.
We all need to talk about mental health in this phase during the acute crisis. It's hugely important to convey to the public that this is a marathon not a sprint. Some mental health outcomes are not visible, when economic impacts really bite and we start to see the full extent of the impact in developing economics, then our understanding of the mental health impacts will evolve.
We need to take people with us, and none of us can claim to be an expert. We need to clearly state what we know, and what we are concerned about, and what we don’t know; and we need to keep doing this for some time, for many months and years to come, because impacts will be delayed.
We also shouldn't forget about the upside psychologically, for example altruism or stepping up to take on new responsibilities. It is possible the experience of COVID19 could bring us together and make us kinder. The altruistic impulses to deal with stress by engaging and helping people will be part of the resilience tool box to help people come through it.
Talking about the situation and making sure it's on the agenda is really important; taking the public along with us on this journey of discovery; and avoiding it all being doom and gloom. Mental health should not only focus on negative impacts on the brain and mind, we need to share positive outcomes cropping up, to engage people with the story.
Niall Boyce
Emily, are you able to talk to the interaction between COVID19 and displaced populations?
Emily Holmes
For people who are refugees, being in confinement may bring back traumatic memories. We need to learn from and involve their lived experience in finding solutions. These solutions need to include what we already know - for example, the vast majority of refugees have access to phone technology, but we do need more research on how best to support people.
Niall Boyce
How would you convince governments to invest in mental health and research?
Mark Van Ommeren
The impact of COVID19 on peoples’ mental health is vast, and if functioning vibrant societies are to recover mental health has to be addressed. For that it needs to be underpinned by research.
Emily Holmes
There’s no health without mental health, listen to your people and include people with lived experience, do this for now but also take a longer term perspective not just a short term perspective. This is important for our societies across the world and critically, science and research have solutions at hand. There are solutions and we need to learn about what is helping people in order to help many more.
Lola Kola
Governments need evidence. Policymakers should be involved during research and pay attention to health systems.
Charlene Sunkel
The economic benefits of prioritising research in this field will far outweigh the cost of not generating evidence now. We must ensure that mental health systems and community based systems are geared to effectively deal with the mental health and wellbeing of people.
Niall Boyce
Thank you to our panelists. To those of you who are interested in working with young people and/ or mental health in the workplace; Wellcome has announced a new call that asks people to nominate one approach that they think might be the most promising for preventing and addressing anxiety and depression among young people in the workplace. There is more information on the Wellcome website, or email mentalhealth@wellcome.ac.uk.
