Global Statistics

All countries
41,598,141
Confirmed
Updated on October 22, 2020 2:25 pm
All countries
30,481,509
Recovered
Updated on October 22, 2020 2:25 pm
All countries
1,137,965
Deaths
Updated on October 22, 2020 2:25 pm

Global Statistics

All countries
41,598,141
Confirmed
Updated on October 22, 2020 2:25 pm
All countries
30,481,509
Recovered
Updated on October 22, 2020 2:25 pm
All countries
1,137,965
Deaths
Updated on October 22, 2020 2:25 pm

Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

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Summary

The coronavirus disease 2019 (COVID-19) pandemic is having a profound effect on all aspects of society, including mental health and physical health. We explore the psychological, social, and neuroscientific effects of COVID-19 and set out the immediate priorities and longer-term strategies for mental health science research. These priorities were informed by surveys of the public and an expert panel convened by the UK Academy of Medical Sciences and the mental health research charity, MQ: Transforming Mental Health, in the first weeks of the pandemic in the UK in March, 2020. We urge UK research funding agencies to work with researchers, people with lived experience, and others to establish a high level coordination group to ensure that these research priorities are addressed, and to allow new ones to be identified over time. The need to maintain high-quality research standards is imperative. International collaboration and a global perspective will be beneficial. An immediate priority is collecting high-quality data on the mental health effects of the COVID-19 pandemic across the whole population and vulnerable groups, and on brain function, cognition, and mental health of patients with COVID-19. There is an urgent need for research to address how mental health consequences for vulnerable groups can be mitigated under pandemic conditions, and on the impact of repeated media consumption and health messaging around COVID-19. Discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of the pandemic are required. Rising to this challenge will require integration across disciplines and sectors, and should be done together with people with lived experience. New funding will be required to meet these priorities, and it can be efficiently leveraged by the UK’s world-leading infrastructure. This Position Paper provides a strategy that may be both adapted for, and integrated with, research efforts in other countries.

Introduction

It is already evident that the direct and indirect psychological and social effects of the coronavirus disease 2019 (COVID-19) pandemic are pervasive and could affect mental health now and in the future. The pandemic is occurring against the backdrop of increased prevalence of mental health issues in the UK in recent years in some groups.

1

  • McManus S
  • Bebbington P
  • Jenkins R
  • Brugha T

Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014.

2

  • Ford T
  • Vizard T
  • Sadler K
  • et al.

Data resource profile: the mental health of children and young people surveys (MHCYP).

Furthermore, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, might infect the brain or trigger immune responses that have additional adverse effects on brain function and mental health in patients with COVID-19.

Research funders and researchers must deploy resources to understand the psychological, social, and neuroscientific effects of the COVID-19 pandemic. Mobilisation now will allow us to apply the learnings gained to any future periods of increased infection and lockdown, which will be particularly important for front-line workers and for vulnerable groups, and to future pandemics. We propose a framework for the prioritisation and coordination of essential, policy-relevant psychological, social, and neuroscientific research, to ensure that any investment is efficiently targeted to the crucial mental health science questions as the pandemic unfolds. We use the term mental health sciences to reflect the many different disciplines, including, but not limited to, psychology, psychiatry, clinical medicine, behavioural and social sciences, and neuroscience, that will need to work together in a multidisciplinary fashion together with people with lived experience of mental health issues or COVID-19 to address these research priorities.

The UK has powerful advantages in mounting a successful response to the pandemic, including strong existing research infrastructure and expertise, but the research community must act rapidly and collaboratively if it is to deal with the growing threats to mental health. A fragmented research response, characterised by small-scale and localised initiatives, will not yield the clear insights necessary to guide policy makers or the public. Rigorous scientific and ethical review of protocols and results remains the cornerstone of safeguarding patients and upholding research standards. Deploying a mental health science perspective

3

  • Holmes EA
  • Craske MG
  • Graybiel AM

Psychological treatments: a call for mental-health science.

to the pandemic will also inform population-level behaviour change initiatives aimed at reducing the spread of the virus. International comparisons will be especially helpful in this regard. In this Position Paper, we explore the psychological, social, and neuroscientific effects of COVID-19 and set out clear immediate priorities and longer-term strategies for each of these aspects.

We also surveyed the public and people with lived experience of mental ill-health (panel 1). The general population survey, done by Ipsos MORI,

4

The Academy of Medical Sciences

revealed widespread concerns about the effect of social isolation or social distancing on wellbeing; increased anxiety, depression, stress, and other negative feelings; and concern about the practical implications of the pandemic response, including financial difficulties. The prospect of becoming physically unwell with COVID-19 ranked lower than these issues related to the social and psychological response to the pandemic. The MQ: Transforming Mental Health stakeholder survey of people with lived experience of a mental health issue likewise highlighted general concerns about social isolation and increased feelings of anxiety and depression. More specifically, stakeholders frequently expressed concerns about exacerbation of pre-existing mental health issues, greater difficulty in accessing mental health support and services under pandemic conditions, and the effect of COVID-19 on the mental health of family members, especially children and older people. Both surveys are reported online.

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The Academy of Medical Sciences

These findings, combined with the published scientific literature, informed the development of our research priorities. The surveys represent a snapshot of the current situation, but they will need to be repeated more rigorously over the course of the pandemic, and the research priorities reviewed.

Panel 1

Methodology

This Position Paper summarises the priorities put forward by an interdisciplinary group of 24 world-leading experts, including people with lived experience of a mental health issue, from across the bio-psycho-social spectrum of expertise in mental health science in March and April, 2020. The experts were convened by the UK Academy of Medical Sciences and the mental health research charity, MQ: Transforming Mental Health. Members participated in an individual capacity, not as representatives of their organisations. A coordinating group of seven experts met daily over a period of two weeks to develop the research priorities, informed by input from the expert advisory group. Given the need to develop the research priorities rapidly to inform immediate funding priorities, extended evidence gathering and consultation was not possible. However, we are confident that the wide breadth of expertise on the expert group and their leading roles in their respective fields provide a wide-ranging and comprehensive view of the mental health and neuroscience research priorities now; priorities which should be reviewed and should evolve with the pandemic.

Lived experience of a mental health issue was incorporated by four mechanisms. First, three representatives with lived experience provided input as part of the expert advisory group. Second, an online survey collected data on people’s two biggest concerns about the mental health and wellbeing implications of the coronavirus disease 2019 (COVID-19) pandemic and the coping strategies used by patients. The survey was promoted via email to MQ’s supporter network and via social media. In total, 2198 people completed the survey, submitting 4350 concerns about the mental health effects of the COVID-19 pandemic and 1987 responses about what has helped to maintain mental health and wellbeing during the pandemic. A thematic analysis of the full dataset was done. Third, two questions were asked on Ipsos MORI’s online Omnibus survey to collect data on people’s concerns about the effect of COVID-19 on mental wellbeing and what is helping people’s mental wellbeing at this time. In total, 1099 interviews were completed with adults aged between 16 and 75 years from across England, Wales, and Scotland. Quotas were set and data were weighted to the offline population to ensure a nationally representative sample by gender, age, and region. Statistical analysis was done and any subgroup differences included are statistically significant at a 95% confidence interval unless stated otherwise. A summary report of the findings of both surveys and further methodological details can be found online.

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The Academy of Medical Sciences

The Ipsos MORI tabular data can be found on its website.

5

  • Ipsos MORI

Covid-19 and mental wellbeing.

Finally, the manuscript was peer-reviewed by a reviewer with lived experience of a mental health issue. We acknowledge the limitations of our surveys, including the representativeness of the MQ sample, the short timescale for input, and the representativeness of online populations. We also acknowledge the restricted evidence gathering and opportunity for wider consultation of people with lived experience. However, combined, these four mechanisms of collecting input from people with lived experience provide important insight into people’s concerns about the effect of COVID-19 on mental health and coping strategies within the very short timeframe.

A living systematic map

6

  • Lorenc T
  • Khouja C
  • Raine G
  • et al.

COVID-19: a living systematic map of the evidence.

is tracking emerging empirical studies, systematic reviews, and modelling on COVID-19. As of April 1, 2020, 643 records were identified in the databases MEDLINE and Embase. Only ten of these were on mental health effects of the pandemic.

7

  • Qiu J
  • Shen B
  • Zhao M
  • Wang Z
  • Xie B
  • Xu Y

A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations.

8

  • Lai J
  • Ma S
  • Wang Y
  • et al.

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.

9

  • Wang C
  • Pan R
  • Wan X
  • et al.

Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.

10

  • Liu S
  • Yang L
  • Zhang C
  • et al.

Online mental health services in China during the COVID-19 outbreak.

11

  • Bo H-X
  • Li W
  • Yang Y
  • et al.

Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China.

12

  • Xiao H
  • Zhang Y
  • Kong D
  • Li S
  • Yang N

The effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (COVID-19) in January and February 2020 in China.

13

  • Li S
  • Wang Y
  • Xue J
  • Zhao N
  • Zhu T

The impact of COVID-19 epidemic declaration on psychological consequences: a study on active Weibo users.

14

  • Brooks SK
  • Webster RK
  • Smith LE
  • et al.

The psychological impact of quarantine and how to reduce it: rapid review of the evidence.

15

  • Li Z
  • Ge J
  • Yang M
  • et al.

Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control.

16

  • Huang JZ
  • Han MF
  • Luo TD
  • Ren AK
  • Zhou XP

Mental health survey of 230 medical staff in a tertiary infectious disease hospital for COVID-19.

Psychology and individual factors: researching the effect of COVID-19 on mental health

In this section, we focus on the psychological processes and effects in individual people related to COVID-19, such as cognition, emotion, and behaviour, that affect mental health (table 1).

Table 1Psychology and individual factors: the effect of COVID-19 on mental health

COVID-19=coronavirus disease 2019.

 What is the effect of COVID-19 on risk of anxiety, depression, and other outcomes, such as self-harm and suicide?

Although a rise in symptoms of anxiety and coping responses to stress are expected during these extraordinary circumstances, there is a risk that prevalence of clinically relevant numbers of people with anxiety, depression, and engaging in harmful behaviours (such as suicide and self-harm) will increase. Of note, however, is that a rise in suicide is not inevitable, especially with national mitigation efforts.

17

Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry (in press).

The potential fallout of an economic downturn on mental health is likely to be profound on those directly affected and their caregivers. The severe acute respiratory syndrome epidemic in 2003 was associated with a 30% increase in suicide in those aged 65 years and older; around 50% of recovered patients remained anxious; and 29% of health-care workers experienced probable emotional distress.

18

  • Yip PS
  • Cheung YT
  • Chau PH
  • Law YW

The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong.

19

  • Tsang HW
  • Scudds RJ
  • Chan EY

Psychosocial impact of SARS.

20

  • Nickell LA
  • Crighton EJ
  • Tracy CS
  • et al.

Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution.

Patients who survived severe and life-threatening illness were at risk of post-traumatic stress disorder and depression.

19

  • Tsang HW
  • Scudds RJ
  • Chan EY

Psychosocial impact of SARS.

20

  • Nickell LA
  • Crighton EJ
  • Tracy CS
  • et al.

Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution.

Many of the anticipated consequences of quarantine

14

  • Brooks SK
  • Webster RK
  • Smith LE
  • et al.

The psychological impact of quarantine and how to reduce it: rapid review of the evidence.

and associated social and physical distancing measures are themselves key risk factors for mental health issues. These include suicide and self-harm, alcohol and substance misuse, gambling, domestic and child abuse, and psychosocial risks (such as social disconnection, lack of meaning or anomie, entrapment, cyberbullying, feeling a burden, financial stress, bereavement, loss, unemployment, homelessness, and relationship breakdown).

21

  • O’Connor RC
  • Nock MK

The psychology of suicidal behaviour.

22

  • John A
  • Glendenning AC
  • Marchant A
  • et al.

Self-harm, suicidal behaviours, and cyberbullying in children and young people: systematic review.

23

  • Turecki G
  • Brent DA
  • Gunnell D
  • et al.

Suicide and suicide risk.

A major adverse consequence of the COVID-19 pandemic is likely to be increased social isolation and loneliness (as reflected in our surveys),

4

The Academy of Medical Sciences

which are strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan.

24

  • Elovainio M
  • Hakulinen C
  • Pulkki-Råback L
  • et al.

Contribution of risk factors to excess mortality in isolated and lonely individuals: an analysis of data from the UK Biobank cohort study.

25

  • Matthews T
  • Danese A
  • Caspi A
  • et al.

Lonely young adults in modern Britain: findings from an epidemiological cohort study.

Tracking loneliness and intervening early are important priorities. Crucially, reducing sustained feelings of loneliness and promoting belongingness are candidate mechanisms to protect against suicide, self-harm, and emotional problems.

26

  • O’Connor RC
  • Kirtley OJ

The integrated motivational-volitional model of suicidal behaviour.

27

  • Stack S

Suicide: media impacts in war and peace, 1910–1920.

Social isolation and loneliness are distinct and might represent different risk pathways.

To inform management of COVID-19, it is vital to understand the socioeconomic effect of the policies used to manage the pandemic, which will inevitably have serious effects on mental health by increasing unemployment, financial insecurity, and poverty.

28

  • Barr B
  • Taylor-Robinson D
  • Scott-Samuel A
  • McKee M
  • Stuckler D

Suicides associated with the 2008-10 economic recession in England: time trend analysis.

29

  • Frasquilho D
  • Matos MG
  • Salonna F
  • et al.

Mental health outcomes in times of economic recession: a systematic literature review.

Involvement of people with lived experience and rapid qualitative research with diverse people and communities will help to identify ways in which this negative effect might be alleviated. Achieving the right balance between infection control and mitigation of these negative socioeconomic effects must be considered.

30

  • Prieto L
  • Sacristán JA

Problems and solutions in calculating quality-adjusted life years (QALYs).

The immediate research priorities are to monitor and report rates of anxiety, depression, self-harm, suicide, and other mental health issues both to understand mechanisms and crucially to inform interventions. This should be adopted across the general population and vulnerable groups, including front-line workers. Monitoring must go beyond NHS record linkage to capture the real incidence in the community, because self-harm might become more hidden. We must harness existing datasets and ongoing longitudinal studies, and establish new cohorts with new ways of recording including detailed psychological factors.

26

  • O’Connor RC
  • Kirtley OJ

The integrated motivational-volitional model of suicidal behaviour.

31

  • Holmes EA
  • Ghaderi A
  • Harmer CJ
  • et al.

The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science.

Techniques assessing moment to moment changes in psychological risk factors should be embraced.

Given the unique circumstances of COVID-19, data will be vital to determine causal mechanisms associated with poor mental health,

31

  • Holmes EA
  • Ghaderi A
  • Harmer CJ
  • et al.

The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science.

32

  • Kazdin AE

Mediators and mechanisms of change in psychotherapy research.

including loneliness and entrapment. To optimise effectiveness of psychological treatments, they need to be mechanistically informed—that is, targeting factors which are both causally associated with poor mental health and modifiable by an intervention.

31

  • Holmes EA
  • Ghaderi A
  • Harmer CJ
  • et al.

The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science.

A one-size-fits-all response will not suffice because the effectiveness of interventions can vary across groups.

26

  • O’Connor RC
  • Kirtley OJ

The integrated motivational-volitional model of suicidal behaviour.

33

  • Carl E
  • Witcraft SM
  • Kauffman BY
  • et al.

Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials.

34

  • Hawton K
  • Witt KG
  • Salisbury TLT
  • et al.

Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis.

35

  • Cuijpers P
  • Cristea IA
  • Karyotaki E
  • Reijnders M
  • Hollon SD

Component studies of psychological treatments of adult depression: a systematic review and meta-analysis.

36

  • Spinhoven P
  • Cuijpers P
  • Hollon S

Cognitive-behavioural therapy and personalized treatment: an introduction to the special issue.

Digital psychological interventions that are mechanistically informed, alongside better understanding of the buffering effects of social relationships during stressful events, are required in the long term. The digital response is crucial,

37

  • Torok M
  • Han J
  • Baker S
  • et al.

Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.

38

  • Garrido S
  • Millington C
  • Cheers D
  • et al.

What works and what doesn’t work? A systematic review of digital mental health interventions for depression and anxiety in young people.

39

  • Lattie EG
  • Adkins EC
  • Winquist N
  • Stiles-Shields C
  • Wafford QE
  • Graham AK

Digital mental health interventions for depression, anxiety and enhancement of psychological well-being among college students: systematic review.

not only because of social isolation measures but also because less than a third of people who die by suicide have been in contact with mental health services in the 12 months before death.

40

Healthcare quality improvement partnership
National confidential inquiry into suicide and homicide by people with mental illness.

Digital interventions for anxiety, depression, self-harm, and suicide include information provision, connectivity and triage, automated and blended therapeutic interventions (such as apps and online programmes), telephone calls and messages to reach those with poorer digital resources (digital poverty),

41

  • Greer B
  • Robotham D
  • Simblett S
  • Curtis H
  • Griffiths H
  • Wykes T

Digital exclusion among mental health service users: qualitative investigation.

suicide risk assessments, chatlines and forums, and technologies that can be used to monitor risk either passively or actively. The digital landscape extends beyond apps and requires an evidence base. Artificial intelligence-driven adaptive trials could help to evaluate effectiveness, while digital phenotyping could be helpful to ascertain early warning signs for mental ill-health.

42

  • Huckvale K
  • Venkatesh S
  • Christensen H

Toward clinical digital phenotyping: a timely opportunity to consider purpose, quality, and safety.

Looking beyond digital interventions (as not everyone has access to them), and ascertaining what other mechanistically based psychological interventions are effective and for whom is important.

31

  • Holmes EA
  • Ghaderi A
  • Harmer CJ
  • et al.

The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science.

43

  • O’Connor RC
  • Portzky G

Looking to the future: a synthesis of new developments and challenges in suicide research and prevention.

Risks and buffers for loneliness should be a focal target in interventions to protect wellbeing. The longer-term consequences of COVID-19 for the younger and older generations (and other groups at high risk, including workers, those with existing mental health conditions, and caregivers) are also unknown and must be a priority.

 How do individuals build optimal structures for a mentally healthy life that works for them in the wake of COVID-19 and social and physical distancing?

The optimal structure of a mentally healthy life for individuals in the wake of COVID-19 needs to be mapped out. Structure will vary as a function of background and individual circumstances. Changes in sleep and lifestyle behaviours influence our mental health and stress response. Understanding the effective, individualised ways of coping in such a situation is of paramount importance.

44

  • Lazarus RS
  • Folkman S

Stress, appraisal, and coping.

45

  • Folkman S

Stress, health, and coping: synthesis, commentary, and future directions.

46

  • Folkman S
  • Moskowitz JT

Coping: pitfalls and promise.

The social and personal resources (eg, seeing family and getting sufficient sleep) available to individuals can be important resilience-related factors for mitigating mental health difficulties under particularly stressful circumstances.

47

  • Sehmi R
  • Maughan B
  • Matthews T
  • Arseneault L

No man is an island: social resources, stress and mental health at mid-life.

We need research to foster positive social resources, resilience, and altruism.

The immediate research priorities are to understand how front-line health and social care staff and their families can be supported to optimise coping strategies to mitigate symptoms of stress, and facilitate the implementation of preventive interventions in the future.

14

  • Brooks SK
  • Webster RK
  • Smith LE
  • et al.

The psychological impact of quarantine and how to reduce it: rapid review of the evidence.

48

  • Duan L
  • Zhu G

Psychological interventions for people affected by the COVID-19 epidemic.

During the COVID-19 pandemic, it is important that health and social care workers are supported to stay in work, the health, personal, social, and economic benefits of which are vast. Personalised psychological approaches are likely to be a key component to address complex mental health conditions, coping mechanisms, and prevention.

31

  • Holmes EA
  • Ghaderi A
  • Harmer CJ
  • et al.

The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science.

Given the association between sleep disturbance and mental health,

49

  • Alvaro PK
  • Roberts RM
  • Harris JK

A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression.

and the effect of sleep disturbance on the risk of suicide,

50

  • O’Connor DB
  • Gartland N
  • O’Connor RC

Stress, cortisol and suicide risk.

research on mitigating the effect of such changes on mental health and stress response is required.

The longer-term strategic research programmes are to develop novel interventions to protect mental wellbeing, including those based on positive mechanistically based components (ie, causal, modifiable factors), such as altruism and prosocial behaviour. This could include increased opportunities to elicit community support,

51

  • Dawson KS
  • Bryant RA
  • Harper M
  • et al.

Problem Management Plus (PM+): a WHO transdiagnostic psychological intervention for common mental health problems.

52

  • Hogan BE
  • Linden W
  • Najarian B

Social support interventions: do they work?.

exercise,

53

  • Ashdown-Franks G
  • Firth J
  • Carney R
  • et al.

Exercise as medicine for mental and substance use disorders: a meta-review of the benefits for neuropsychiatric and cognitive outcomes.

social activities,

54

  • Solomonov N
  • Bress JN
  • Sirey JA
  • et al.

Engagement in socially and interpersonally rewarding activities as a predictor of outcome in “Engage” behavioral activation therapy for late-life depression.

training in assertiveness and conflict resolution,

55

  • Meunier S
  • Roberge C
  • Coulombe S
  • Houle J

Feeling better at work! Mental health self-management strategies for workers with depressive and anxiety symptoms.

and group interventions that provide support through peers.

56

  • Taubman DS
  • Parikh SV
  • Christensen H
  • Scott J

Using school-based interventions for depression education and prevention.

The inclusion of altruism in UK Government health messages has likely had a positive effect on wellbeing compared with compulsory orders to stay at home.

14

  • Brooks SK
  • Webster RK
  • Smith LE
  • et al.

The psychological impact of quarantine and how to reduce it: rapid review of the evidence.

Key research questions include “What positive mechanistically based psychological interventions can be developed for mental wellbeing derived from theories of altruism and prosocial behaviour?” and “What can be learned from the large-scale roll-out of volunteer-based psychological interventions that will optimise the benefits to individuals and society?”

Working from home, loss of employment, and social and physical distancing have abruptly interrupted many social opportunities important to physical and psychological health. It is important to research the mental health dimension of online life and investigate how changes in engagement with gaming and online platforms might inform interventions aimed at improving mental health. We must rapidly learn from successful existing strategies to maintain and build social resources and resilience and promote good mental health in specific populations moving forward.

Social and population factors: the effect of COVID-19 on mental health

Population-level factors, such as the effect of social distancing measures (more recently being redescribed as physical distancing)

57

  • Wasserman D
  • Rutger van der G
  • Wise J

Terms ‘physical distancing’ and ‘emotional closeness’ should be used and not ‘social distancing’ when defeating the Covid-19 pandemic.

and other necessary public health measures, affect mental health within a syndemics approach (table 2). By syndemics we mean intersecting global trends among demographics (eg, ageing, rising inequality) and health conditions (eg, chronic diseases and obesity) that yield resultant comorbidities. These interacting health effects and societal forces that fuel them combine to form syndemics, or complex knots of health determinants.

58

  • Swinburn BA
  • Kraak VI
  • Allender S
  • et al.

The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report.

Research priorities around COVID-19 require us to embrace complexity by deploying multidimensional perspectives.

Table 2Social and population factors: the effect of COVID-19 on mental health

COVID-19=coronavirus disease 2019.

 What are the mental health consequences of the COVID-19 lockdown and social isolation for vulnerable groups, and how can these be mitigated under pandemic conditions?

We do not yet know the acute or long-term consequences of the COVID-19 lockdown and social isolation on mental health. Although worries and uncertainties about a pandemic are common, for some they can cause undue distress and impairment to social and occupational functioning.

14

  • Brooks SK
  • Webster RK
  • Smith LE
  • et al.

The psychological impact of quarantine and how to reduce it: rapid review of the evidence.

59

  • Rubin GJ
  • Potts HWW
  • Michie S

The impact of communications about swine flu (influenza A H1N1v) on public responses to the outbreak: results from 36 national telephone surveys in the UK.

60

  • Lau JTF
  • Griffiths S
  • Choi KC
  • Tsui HY

Avoidance behaviors and negative psychological responses in the general population in the initial stage of the H1N1 pandemic in Hong Kong.

Across society, a sense of loss can stem from losing direct social contacts, and also range from loss of loved ones, to loss of employment, educational opportunities, recreation, freedoms, and supports. Existing evidence suggests some measures taken to control the pandemic might have a disproportionate effect on those most vulnerable (panel 2).

Panel 2

Populations of interest, including vulnerable groups

Although the whole population is affected by the coronavirus disease 2019 pandemic, specific sections of the population will experience it differently.

Children, young people, and families will be affected by school closures. They might also be affected by exposure to substance misuse, gambling, domestic violence and child maltreatment, absence of free school meals, accommodation issues and overcrowding, parental employment, and change and disruption of social networks.

Older adults and those with multimorbidities might be particularly affected by issues including isolation, loneliness, end of life care, and bereavement, which may be exacerbated by the so-called digital divide.

People with existing mental health issues, including those with severe mental illnesses, might be particularly affected by relapse, disruptions to services, isolation, the possible exacerbation of symptoms in response to pandemic-related information and behaviours, and changes in mental health law.

Front-line health-care workers might be affected by fears of contamination, moral injury, disruption of normal supportive structures, work stress, and retention issues.

People with learning difficulties and neurodevelopmental disorders might be affected by changes and disruption to support and routines, isolation, and loneliness.

Society might experience increased social cohesion and communitarianism, but also be negatively affected by increased health inequalities, increased food bank use, increased race-based attacks, and other trauma. Rural communities might also be affected differently to urban communities.

Socially excluded groups, including prisoners, the homeless, and refugees, might require a tailored response.

People on low incomes face job and financial insecurity, cramped housing, and poor access to the internet and technology.

Vulnerable groups include those with pre-existing mental or physical health issues (including those with severe mental illnesses), recovered individuals, and those who become mentally unwell (eg, in response to anxiety and loneliness surrounding the pandemic; panel 2).

14

  • Brooks SK
  • Webster RK
  • Smith LE
  • et al.

The psychological impact of quarantine and how to reduce it: rapid review of the evidence.

61

  • Wang J
  • Lloyd-Evans B
  • Giacco D
  • et al.

Social isolation in mental health: a conceptual and methodological review.

62

  • Cacioppo JT
  • Hughes ME
  • Waite LJ
  • Hawkley LC
  • Thisted RA

Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses.

Therefore, loss of access to mental health support, alongside loss of positive activities, might increase vulnerability during COVID-19 lockdown. Increased feelings of anxiety and depression in response to the outbreak have been highlighted already.

63

  • Yao H
  • Chen J-H
  • Xu Y-F

Patients with mental health disorders in the COVID-19 epidemic.

Health workers who come in close contact with the virus and are exposed to traumatic events, such as death and dying, while making highly challenging decisions, are particularly at risk of stress responses.

15

  • Li Z
  • Ge J
  • Yang M
  • et al.

Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control.

The pandemic intersects with rising mental health issues in childhood and adolescence.

2

  • Ford T
  • Vizard T
  • Sadler K
  • et al.

Data resource profile: the mental health of children and young people surveys (MHCYP).

64

  • Collishaw S

Annual research review: secular trends in child and adolescent mental health.

65

  • Sellers R
  • Warne N
  • Pickles A
  • Maughan B
  • Thapar A
  • Collishaw S

Cross-cohort change in adolescent outcomes for children with mental health problems.

Ascertaining and mitigating the effects of school closures for youth seeking care is urgent and essential, given that school is often the first place children and adolescents seek help,

64

  • Collishaw S

Annual research review: secular trends in child and adolescent mental health.

66

  • Fazel M
  • Hoagwood K
  • Stephan S
  • Ford T

Mental health interventions in schools in high-income countries.

as is considering vulnerabilities, such as special educational needs and developmental disorders, and finding therapeutic levers.

67

  • Schoneveld EA
  • Lichtwarck-Aschoff A
  • Granic I

Preventing childhood anxiety disorders: is an applied game as effective as a cognitive behavioral therapy-based program?.

For the older population, promoting good mental health is important during self-isolation, which can be compounded by lifestyle restrictions, exacerbated loneliness, comorbidities (such as dementia), and feelings of worry and guilt for using resources.

68

  • Armitage R
  • Nellums LB

COVID-19 and the consequences of isolating the elderly.

There is an acute need to identify, in consultation with people with lived experience, remotely delivered interventions that support those at risk of abuse.

69

  • Robotham D
  • Sweeney A
  • Perôt C

Survivors’ priority themes and questions for research.

70

  • Sweeney A
  • Beresford P
  • Nettle M
  • Faulkner A
  • Rose D

This is survivor research.

The immediate research priorities are to reduce mental health issues and support wellbeing in vulnerable groups in particular. A coordinating mechanism for pandemic mental health interventions is required for the agile identification of interventions that can be repurposed, alongside the identification of intervention gaps that will require bespoke de novo design, and the evaluation and roll-out of remotely delivered interventions. By the term intervention, we mean interventions of all sorts that make a difference to mental health, including population-level policy, occupational guidelines, and psychological interventions.

We need to gather high-quality data rapidly to ascertain the effects of lockdown and social isolation over time. Innovative research is needed to establish ways to mitigate and manage mental health risks and inform interventions under pandemic conditions.

Research to support vulnerable groups needs to consider cross-cutting themes (such as the physical absence of schools and clinics) to create methods to provide connectivity and support; promote rapid innovation in mental health services that can be remotely signposted and delivered (including online clinics and community support); identify and evaluate means to support those at risk of abuse within the home (eg, online outreach); and swiftly provide interventions to promote mental wellbeing in front-line health workers. By identifying cross-cutting research themes, interventions to help specific vulnerable populations should be leveraged to help other vulnerable groups.

With regard to the longer-term priorities, health services research must reliably and iteratively inform remotely delivered mental health resources, such as digital clinics, to efficiently manage mental health issues in an adaptive and flexible manner.

71

  • Wind TR
  • Rijkeboer M
  • Andersson G
  • Riper H

The COVID-19 pandemic: the ‘black swan’ for mental health care and a turning point for e-health.

This requires a coordinating mechanism to prioritise and streamline efforts, working with service users to optimise signposting and delivery and define therapeutic targets that matter from a user perspective (eg, loss, loneliness). Such a mechanism requires a range of disciplines, including psychology, digital science, and social sciences.

31

  • Holmes EA
  • Ghaderi A
  • Harmer CJ
  • et al.

The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science.

72

  • Milton AL
  • Holmes EA

Of mice and mental health: facilitating dialogue and seeing further.

International collaboration will ensure the necessary research skills and expertise. Research should harness internet-based social media and gaming using existing platforms and be cognisant of the so-called digital divide, which leaves 15% of Britons without internet access.

73

  • Blank G
  • Dutton WH
  • Lefkowitz J

OxIS 2019: Digital divides in Britain are narrowing but deepening.

Research for population-level interventions will require rapid evolution of approaches, starting with testing whether existing digital interventions can be repurposed, such as physical activity, sleep, and stress management programmes, as well as targeted approaches for the prevention and treatment of established mental health symptoms (eg, anxiety and worry).

31

  • Holmes EA
  • Ghaderi A
  • Harmer CJ
  • et al.

The Lancet Psychiatry Commission on psychological treatments research in tomorrow’s science.

74

  • Hirsch CR
  • Krahé C
  • Whyte J
  • et al.

Interpretation training to target repetitive negative thinking in generalized anxiety disorder and depression.

Tailoring of such universal interventions will need to be informed by experimental and social science (eg, for loneliness, befriending, and physical activity).

75

  • Holt-Lunstad J
  • Robles TF
  • Sbarra DA
  • Julianne Holt-Lunstad N

Advancing social connection as a public health priority in the United States.

76

Agency for Healthcare Research and Quality
Addressing social isolation to improve the health of older adults: a rapid review.

The effectiveness of arts-based interventions also needs to be assessed

77

  • Fancourt D
  • Finn S

What is the evidence on the role of the arts in improving health and well-being? A scoping review.

as do other generative activities that boost positive coping and resilience throughout society, from community-based activities, to life-skills classes, to exercising outdoors.

4

The Academy of Medical Sciences

The effectiveness of all interventions requires rigorous evaluation and implementation to avoid recommending a plethora of apps with no evidence base.

78

  • Anthes E

Pocket psychiatry: mobile mental-health apps have exploded onto the market, but few have been thoroughly tested.

Interventions at the population level should be repurposed, developed, and tested in a virtuous loop to create the necessary evidence base.

 What is the effect of repeated media consumption about COVID-19 through traditional media and social media on mental health, and how can wellbeing be promoted?

People seek trusted information via the media, which can provide swift, critical guidance regarding the pandemic. Media consumption can be adaptive and positive for mental health. However, reports of infectious diseases often use risk-elevating messages, which can amplify public anxiety.

79

  • Sell TK
  • Boddie C
  • McGinty EE
  • et al.

Media messages and perception of risk for Ebola virus infection, United States.

Social media can be a source of rapidly disseminated misinformation,

80

  • Wang Y
  • McKee M
  • Torbica A
  • Stuckler D

Systematic literature review on the spread of health-related misinformation on social media.

amplifying perceptions of risk.

81

  • Ng YJ
  • Yang ZJ
  • Vishwanath A

To fear or not to fear? Applying the social amplification of risk framework on two environmental health risks in Singapore.

Repeated media exposure to information about an infectious disease particularly can exacerbate stress responses, amplify worry, and impair functioning.

82

  • Thompson RR
  • Garfin DR
  • Holman EA
  • Silver RC

Distress, worry, and functioning following a global health crisis: a national study of Americans’ responses to Ebola.

Anxiety and uncertainty can drive additional media consumption and further distress, creating a cycle that can be difficult to break.

83

  • Thompson RR
  • Jones NM
  • Holman EA
  • Silver RC

Media exposure to mass violence events can fuel a cycle of distress.

Media-fuelled distress can promote behaviours that negatively affect the health-care system (eg, visits to emergency departments and hoarding of face masks), with downstream mental and physical health consequences.

84

  • Garfin DR
  • Silver RC
  • Holman EA

The novel coronavirus (COVID-2019) outbreak: amplification of public health consequences by media exposure.

The immediate research priority is to better understand the role of repeated media consumption around COVID-19 in amplifying distress and mental ill-health in various groups, and the optimal patterns of consumption to promote wellbeing. Research is needed to inform future approaches, including strategies to help individuals to stay informed by authoritative sources, prevent over-exposure to media, and mitigate and help manage the effect of viewing images with traumatic content.

Longer-term research priorities should inform evidence-based guidelines for media around pandemic reporting (eg, clearly identifying authoritative sources, limiting graphic footage, and encouraging social media companies to flag or correct disinformation and rumours). Research should also help to develop strategies to mitigate an individual’s risk of exposure to misinformation and amplification of anxiety by minimising sharing of misinformation, and promoting strategies for managing the emotional consequences. Adaptive and positive uses of traditional media and social media, such as influencers, should be understood and harnessed. Understanding the effect of pandemic media on various vulnerable groups is essential.

 What are the best methods for promoting successful adherence to behavioural advice about COVID-19 while enabling mental wellbeing and minimising distress?

Behavioural change—such as the three personal protective behaviours of handwashing, not touching the T-zone of the face, and tissue use, and social or physical distancing required to control the pandemic—necessitates ensuring people know what to do, are motivated to do it, and have the skills and opportunity to enact the changed behaviours.

85

  • Michie S
  • West R
  • Amlot R
  • Rubin J

Slowing down the COVID-19 outbreak: changing behaviour by understanding it.

86

  • Michie S
  • van Stralen MM
  • West R

The behaviour change wheel: a new method for characterising and designing behaviour change interventions.

Messaging is key for good knowledge,

86

  • Michie S
  • van Stralen MM
  • West R

The behaviour change wheel: a new method for characterising and designing behaviour change interventions.

but public health messaging needs to draw on behavioural science if it is to be effective and avoid unintended consequences. We know that the more concerned people are in pandemics, the more likely they are to adhere to advice.

59

  • Rubin GJ
  • Potts HWW
  • Michie S

The impact of communications about swine flu (influenza A H1N1v) on public responses to the outbreak: results from 36 national telephone surveys in the UK.

However, increasing concern experienced by the public might heighten distress, which could undermine adherence or exacerbate existing mental health issues. Anxiety can be fuelled by uncertainty and by fears of risk of harm to self or others. For example, feelings of paranoia

87

  • Freeman D
  • Garety PA
  • Bebbington PE
  • et al.

Psychological investigation of the structure of paranoia in a non-clinical population.

can be heavily influenced by anxiety, and symptoms of obsessive compulsive disorder

88

  • Torres AR
  • Fontenelle LF
  • Shavitt RG
  • Hoexter MQ
  • Pittenger C
  • Miguel EC

Epidemiology, comorbidity, and burden of OCD.

can be associated with fear of contagion and rigid handwashing.

89

  • Abramowitz JS
  • McKay D
  • Storch EA

The Wiley handbook of obsessive compulsive disorders.

Increasing people’s confidence and clarity in what they need to do fosters adherence to health behaviours,

90

  • Peters GJY
  • Ruiter RAC
  • Kok G

Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory.

and can help people to manage psychological distress.

Immediate research on COVID-19 health messaging is urgently required to both optimise health behaviour change and to reduce unintended mental health issues, which will be required in the event of a second wave of infection. Research should prioritise message content, format, and delivery modes and behavioural change alongside risk communication, and consider how this might need to vary for diverse groups. A virtuous cycle that tracks perceptions of and responses to public health messages during this pandemic will enable iterative improvements. It must be informed by mental health science

3

  • Holmes EA
  • Craske MG
  • Graybiel AM

Psychological treatments: a call for mental-health science.

to close the knowledge-to-implementation gap (eg, between effective behaviour messages and maladaptive consequences).

Longer-term research priorities are to create an evidence base of lessons learned to plan for future pandemics—that is, detailing how to foster a rapid and coordinated response regarding health messaging from governments

91

Public Health England
A Century of public health marketing: enduring public health challenges and revolutions in communication.

and simultaneously to develop effective systems embedded in communities to reach out and access the most vulnerable groups in our society, including how to motivate and enable people to prepare psychologically and plan practically for possible future scenarios, and how to promote people’s care and concern for others, fostering a sense of collective solidarity and altruism. The optimal messaging should be tailored (including digitally) to different social groups to connect diverse segments of the population to appropriate mental health information resources.

Neuroscience: effects of the virus on brain health and mental health

Almost nothing is known with certainty about the effect of SARS-CoV-2 infection on the human nervous system. SARS-CoV-2 is a zoonotic virus and a review from 2005 suggested that about half of zoonotic virus epidemics have been caused by neurotropic viruses that invade the CNS.

92

  • Olival KJ
  • Daszak P

The ecology of emerging neurotropic viruses.

The closely related coronaviruses responsible for the severe acute respiratory syndrome epidemic in 2003 and the so-called Middle East respiratory syndrome in 2012 are biologically neurotropic and clinically neurotoxic, causing mental health and neurological disorders.

93

  • Li YC
  • Bai WZ
  • Hirano N
  • Hayashida T
  • Hashikawa T

Coronavirus infection of rat dorsal root ganglia: ultrastructural characterization of viral replication, transfer, and the early response of satellite cells.

94

  • Xu J
  • Zhong S
  • Liu J
  • et al.

Detection of severe acute respiratory syndrome coronavirus in the brain: potential role of the chemokine mig in pathogenesis.

95

  • Li K
  • Wohlford-Lenane C
  • Perlman S
  • et al.

Middle East respiratory syndrome coronavirus causes multiple organ damage and lethal disease in mice transgenic for human dipeptidyl peptidase 4.

SARS-Cov-2 has a similar receptor-binding domain structure to SARS-CoV and probably shares its neurotropism and neurotoxicity (panel 3).

96

  • Lu R
  • Zhao X
  • Li J
  • et al.

Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding.

Panel 3

Neuroscience: effects of the virus on brain health and mental health

Immediate actions

  • Build a neuropsychological database of UK coronavirus disease 2019 cases (standardised, longitudinally repeated, data at scale) which is clinically and geographically inclusive

  • Expand facilities for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected tissue handling

Longer-term strategic research programmes

  • Understand how SARS-CoV-2 might enter and propagate through the brain and how the immune response to SARS-CoV-2 infection contributes to mental health and neurological symptoms

  • Investigate the long-term relationship between SARS-CoV-2 infection and post-infective fatigue or depressive syndromes

  • Validate clinical biomarkers of SARS-CoV-2 brain infection using MRI and other methods

  • Develop interventions to interrupt or prevent the adverse biological effects of SARS-CoV-2 on brain function and mental health, including repurposed drugs

Neurological symptoms of COVID-19 infection are common, diverse, and often severe. In a retrospective study of 214 patients in Wuhan, China 36% had CNS symptoms or disorders and the subgroup of 88 patients with severe respiratory disease had significantly increased frequency of CNS problems (45%).

97

  • Mao L
  • Wang M
  • Chen S
  • et al.

Neurological manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China.

The problems reported include dizziness, headache, loss of smell (anosmia), loss of taste (ageusia), muscle pain and weakness, impaired consciousness, and cerebrovascular complications. Similar reports have begun to emerge from Italy.

98

  • Talan J

COVID-19: Neurologists in Italy to colleagues in US: look for poorly-defined neurologic conditions in patients with the coronavirus.

Some of these acute neurological presentations could reflect systemic aspects of infection, such as disseminated intravascular coagulation causing strokes or intense inflammation and hypoxia causing delirium.

SARS-CoV-2 infection of the brain could be a contributor to the core medical syndrome of respiratory distress and failure in patients with COVID-19.

99

  • Li YC
  • Bai WZ
  • Hashikawa T

The neuroinvasive potential of SARS-CoV2 may be at least partially responsible for the respiratory failure of COVID-19 patients.

Viral infection of the lung alveoli is the immediate cause of severe acute respiratory syndrome; but viral infection of key brainstem nuclei could disrupt the normal rhythms and homoeostatic control of respiration. This idea needs to be tested rapidly

99

  • Li YC
  • Bai WZ
  • Hashikawa T

The neuroinvasive potential of SARS-CoV2 may be at least partially responsible for the respiratory failure of COVID-19 patients.

because if brainstem infection does contribute to the severity of SARS and the need for treatment in an intensive care unit, it could be directly relevant to the immediate COVID-19 crisis in the NHS and other health-care systems.

In the longer term, it is possible that SARS-CoV-2 will have persistent direct neurotoxic effects and immune-mediated neurotoxic effects on the brain. The Spanish flu epidemic of 1918–19 was linked to a spike in incidence of post-encephalitic Parkinsonism.

100

  • McCall S
  • Vilensky JA
  • Gilman S
  • Taubenberger JK

The relationship between encephalitis lethargica and influenza: a critical analysis.

Currently, it is not known if SARS-CoV-2 infection could cause mental health or neurodegenerative disorders immediately or years after the acute respiratory phase of COVID-19 has passed, but action is needed now to build the research capacity to test these potentially important biological causes of COVID-19-related mental illness.

Immediate actions include the development of a neuropsychological database of COVID-19 cases to bring together standardised, longitudinally repeated data at scale both from the clinic for those needing hospital treatment and by online assessments for patients in isolation at home. Following the progression of clinical symptoms over time will be key to understanding and predicting the effects of infection on the CNS.

Facilities for SARS-CoV-2-infected tissue handling need to be expanded to examine human brain tissue post mortem, which is crucial to understanding the neurotropic and neurotoxic properties of the virus. Facilities equipped to safely handle human (or animal) brain tissue infected with SARS-CoV-2 are currently very few in number. We recommend building pathology and molecular neuroscience networks to enable brain and other tissue to be collected at autopsy and examined for viral infection and damage. This will require protocols for tissue collection and examination in appropriate laboratory facilities to protect researchers and other staff at all times.

The longer-term research priorities are to understand the mechanisms by which SARS-CoV-2 might enter the brain. There are two conceivable pathways: neuronal or vascular.

101

  • Desforges M
  • Le Coupanec A
  • Dubeau P
  • et al.

Human coronaviruses and other respiratory viruses: underestimated opportunistic pathogens of the central nervous system?.

The neuronal pathway, used by other coronaviruses,

102

  • Dubé M
  • Le Coupanec A
  • Wong AHM
  • Rini JM
  • Desforges M
  • Talbot PJ

Axonal transport enables neuron-to-neuron propagation of human coronavirus OC43.

103

  • Andries K
  • Pensaert MB

Immunofluorescence studies on the pathogenesis of hemagglutinating encephalomyelitis virus infection in pigs after oronasal inoculation.

is to invade a specialist sensory receptor in peripheral tissue, travel by the axonal transport systems to the brainstem, and propagate between neurons by trans-synaptic mechanisms. It is not known whether SARS-CoV-2 can follow the same path to infect the human brain or whether it invades nerve cells by hijacking angiotensin converting enzyme 2 (ACE2),

104

  • Wrapp D
  • Wang N
  • Corbett KS
  • et al.

Cryo-EM structure of the 2019-nCoV spike in the prefusion conformation.

105

  • Zhang H
  • Penninger JM
  • Li Y
  • Zhong N
  • Slutsky AS

Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target.

106

  • Netland J
  • Meyerholz DK
  • Moore S
  • Cassell M
  • Perlman S

Severe acute respiratory syndrome coronavirus infection causes neuronal death in the absence of encephalitis in mice transgenic for human ACE2.

despite neurons expressing low amounts of the protein, as described in a preprint

107

  • Brann DH
  • Tsukahara T
  • Weinreb C
  • Logan DW
  • Datta SR

Non-neural expression of SARS-CoV-2 entry genes in the olfactory epithelium suggests mechanisms underlying anosmia in COVID-19 patients.

and two other published studies.

108

  • Baig AM
  • Khaleeq A
  • Ali U
  • Syeda H

Evidence of the COVID-19 virus targeting the CNS: tissue distribution, host–virus interaction, and proposed neurotropic mechanisms.

109

  • Hamming I
  • Timens W
  • Bulthuis MLC
  • Lely AT
  • Navis G
  • van Goor H

Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis.

Alternatively, SARS-CoV-2 might invade the brain from the blood, if circulating particles of the virus were transported across the blood–brain barrier by binding to ACE2 receptors expressed by endothelial cells,

109

  • Hamming I
  • Timens W
  • Bulthuis MLC
  • Lely AT
  • Navis G
  • van Goor H

Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis.

or if infected leucocytes could carry the virus with them as they migrate into the tissues as part of the immune response to infection.

110

  • Desforges M
  • Miletti TC
  • Gagnon M
  • Talbot PJ

Activation of human monocytes after infection by human coronavirus 229E.

Better understanding of how the intense systemic immune response to SARS-CoV-2 infection affects mental health and neurological symptoms,

97

  • Mao L
  • Wang M
  • Chen S
  • et al.

Neurological manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China.

111

  • Chen G
  • Wu D
  • Guo W
  • et al.

Clinical and immunologic features in severe and moderate coronavirus disease 2019.

112

  • Dantzer R
  • O’Connor JC
  • Freund GG
  • Johnson RW
  • Kelley KW

From inflammation to sickness and depression: when the immune system subjugates the brain.

and of the mechanisms of immune clearance of SARS-CoV-2, is also needed.

113

  • Arabi YM
  • Harthi A
  • Hussein J
  • et al.

Severe neurologic syndrome associated with Middle East respiratory syndrome corona virus (MERS-CoV).

114

  • Bender SJ
  • Weiss SR

Pathogenesis of murine coronavirus in the central nervous system.

Post-infectious fatigue and depressive syndromes have been associated with other epidemics, and it seems possible that the same will be true of the COVID-19 pandemic. Longitudinal studies, especially if commenced before or soon after the start of the current pandemic, will be crucial in establishing the often complex biological pathways between infection and mental health outcomes.

115

  • Wessely S

History of postviral fatigue syndrome.

116

  • White PD
  • Thomas JM
  • Amess J
  • et al.

Incidence, risk and prognosis of acute and chronic fatigue syndromes and psychiatric disorders after glandular fever.

117

  • Wessely S
  • Chalder T
  • Hirsch S
  • Pawlikowska T
  • Wallace P
  • Wright DJM

Postinfectious fatigue: prospective cohort study in primary care.

Candidate biomarkers need to be evaluated to measure the effects of SARS-CoV-2 infection on the human brain and brainstem in living patients, including structural and functional MRI, diffusion-weighted MRI, quantitative cerebral blood flow imaging, and magnetic resonance spectroscopy. The 7 Tesla MRI technique has sufficient spatial resolution to measure functional connectivity between subcortical structures that constitute networks for respiratory control and distress.

118

  • Faull OK
  • Jenkinson M
  • Clare S
  • Pattinson KTS

Functional subdivision of the human periaqueductal grey in respiratory control using 7 tesla fMRI.

Other methods could include sampling cerebrospinal fluid or use of PET to measure brain inflammation; patient self-reporting or behavioural testing of smell, taste, and other cranial or vagal sensory functions; electrophysiological methods to measure brainstem function; and computerised tests of cognitive and emotional processing.

Informed by greater understanding of the effects of viral infection on the nervous system and by more accurate biomarkers of brain function in patients with COVID-19, interventions need to be developed to interrupt or prevent the adverse biological effects of SARS-CoV-2 on brain function and mental health. Potential drug targets include putative mechanisms for neuronal invasion, interneuronal propagation, and immune clearance of SARS-CoV-2. Biological and clinical validation of these or other targets would enable experimental medicine studies or early clinical trials of repurposed drugs. For example, the ACE2 inhibitors already licensed for treatment of hypertension, and a licensed drug for reflux oesophagitis, camostat mesylate, that blocks the serine protease TMPRSS2

119

  • Hoffmann M
  • Kleine-Weber H
  • Schroeder S
  • et al.

SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor.

(which operates with ACE2 to facilitate viral entry into cells) have already been advocated as repurposable drugs. There are many other potential candidates for drug repurposing described in a preprint,

120

  • Nabirotchkin S
  • Peluffo AE
  • Bouaziz J
  • Cohen D

Focusing on the unfolded protein response and autophagy related pathways to reposition common approved drugs against COVID-19.

which could be a faster route to effective treatment for CNS infection than development of entirely new drugs or vaccines. Partnerships between researchers in academia and industry will be vital.

Infrastructure and opportunities

Many of the immediate priorities are for surveillance of general and specific populations for effects of SARS-CoV-2 infection on health, ranging from health behaviours, psychological symptoms, neuropsychiatric disorders, and mortality, including, but not limited to, suicide. The other immediate priority is to assemble cohorts to determine longer-term outcomes and provide a resource for nesting intervention studies, and a resource of interventions to monitor their effectiveness. We recommend three main routes. For each of these routes, there is a need to coordinate existing research infrastructure through shared protocols, research measures, and data assets, and to uphold the highest standards of scientific and ethical review. We urge the mental health science community to combine agility in initiating new or adapting existing research with collective scrutiny and collaboration.

First, administrative data assets principally derived from existing electronic health records, with systems in place to interrogate these for research purposes, provide a means of identifying health effects at scale. Health Data Research UK is coordinating national efforts. Examples include the Clinical Practice Research Database

121

  • Herrett E
  • Gallagher AM
  • Bhaskaran K
  • et al.

Data resource profile: clinical practice research datalink (CPRD).

and similar primary care databases; the Clinical Record Interactive Search

122

  • Stewart R
  • Soremekun M
  • Perera G
  • et al.

The South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register: development and descriptive data.

and other related systems for the interrogation of mental health records; and CogStack

123

  • Jackson R
  • Kartoglu I
  • Stringer C
  • et al.

CogStack – experiences of deploying integrated information retrieval and extraction services in a large National Health Service Foundation Trust hospital.

for general hospital settings, which provides near real-time information from health records (eg, to provide feedback on neurological consequences of severe COVID-19). These systems should be linked between mental health services, acute medical services, and community health services to identify patterns and trends both in clinical populations and in individuals with confirmed or suspected COVID-19.

Second, surveillance through recruitment platforms and existing cohorts has the benefit of embedding research on COVID-19 into studies where participants’ mental or cognitive health has previously been ascertained. Existing cohorts or data platforms that can be rapidly deployed for COVID-19 research are likely to be particularly valuable. Examples include the National Institute for Health Research National Bioresource, a platform that already includes clinical and genetic data on participants, and could be deployed for rapid characterisation of mental health and neurological symptoms. UK Biobank has successfully done a web-based mental health survey of 160 000 individuals, and the ongoing neuroimaging studies of 100 000 individuals with some repeat imaging, provide an ideal opportunity to image the effect of SARS-CoV-2 infection on the brain and the brainstem via a before-and-after imaging comparison.

Third, novel population-based studies on mental health and COVID-19 should be established, using appropriate epidemiologically robust survey methodology for both the whole population and specific groups of particular interest (eg, children and young people, front-line staff in health and social care, and people who have survived severe COVID-19). Priority should be given to assembling representive populations using explicit sampling frames. Finally, many other disciplines will be establishing similar studies and it is vital that the ascertainment of mental health should be embedded wherever possible.

Whether using established or new cohorts, priority should be given to methods that can ascertain COVID-19 status, symptoms, and behaviours in as close to real-time as possible, providing a dynamic picture of change in illness status, social circumstances, and behaviours. Questions regarding COVID-19 and mental health symptoms and social stressors can readily be disseminated through smartphones. Passive data from smartphones can also give high temporal resolution to behaviours related to the pandemic. Cohorts should gain permissions for the linkage of records, including serological status, when mass testing becomes available, and consent for recruitment into nested substudies, including randomised trials of interventions.

Patient and public involvement in research is a critical underpinning component to research. Given that the entire population has lived experience of the COVID-19 pandemic, researchers will need to be particularly mindful of consulting and collaborating with patient and public groups that reflect the diverse groups being studied when developing protocols, conducting research, and interpreting results (panel 4).

Panel 4

Principles of good research practice in COVID-19 research

Study design

Researchers must continue to describe the patient group or population and the research question under study. A priori research questions are crucial. Sample size, sources of bias, participant characteristics (including sex, age, and ethnicity), and study design need to be carefully considered and must be appropriate to the research questions.

Ethics

Research on human participants should maintain high standards of ethical practice, including seeking research ethics committee approval.

124

  • Gostin LO
  • Bayer R
  • Fairchild AL

Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats.

Committees now have fast-track procedures to expedite study start up. Ethical considerations for doing coronavirus disease 2019 (COVID-19)-related research have been published.

125

  • Townsend E
  • Nielsen E
  • Allister A
  • Cassidy SA

Key ethical questions for research during the COVID-19 pandemic.

126

Nuffield Council on Bioethics
Rapid policy briefing: ethical considerations in responding to the COVID-19 pandemic.

Vulnerable groups

Researchers should recognise the capacity of the pandemic to exacerbate health inequalities within populations, particularly affecting people with established mental health issues (including severe mental illnesses) and physical disability. Those with precarious or no employment or housing, or other forms of social inequality, such as digital poverty,

41

  • Greer B
  • Robotham D
  • Simblett S
  • Curtis H
  • Griffiths H
  • Wykes T

Digital exclusion among mental health service users: qualitative investigation.

should also be considered.

Involvement of patients, people with lived experience, and the public

Researchers should continue to engage and involve patients, people with lived experience, the public, and service providers in their work by mutually setting research questions, testing the acceptability of protocols and questionnaires, and interpreting results. Researchers should ensure that they discuss their research findings with participants.

Harmonised data and measures

There is an obvious need for researchers to use and share full study protocols and measures, where possible. This will facilitate comparisons between data and projects. The urgency of the research effort should be a strong driver for the principles of open science, reproducibility, and data sharing. The ready availability of analysis code and data is essential to verifying findings. Broad adoption of the registered reports publication model,

127

  • Chambers C

What’s next for registered reports?.

including rapid peer review of study protocols before data collection, will help to minimise waste and ensure conclusions are empirically sound.

Interdisciplinary working

The challenge of the COVID-19 pandemic requires imaginative collaborations between disciplines, including, but not limited to, psychology, psychiatry, neuroscience, virology, intensive care medicine, and respiratory medicine. Previous experience with epidemics has shown the “essential role that the humanities and social sciences play in information, reduction of fear and stigma, prevention, screening, treatment adherence, and control policies”.

128

  • Raguin G
  • Girard PM

Toward a global health approach: lessons from the HIV and Ebola epidemics.

Collaboration and coordination

Where possible, research protocols should be deployed at scale harnessing existing research infrastructures, including the Clinical Research Networks, Biomedical Research Centres, Mental Health Translational Research Collaboration, MQ Data Science group, charities, service user groups, and professional bodies. To avoid waste and protect against participant fatigue, it is essential that there is national coordination across research groups. International collaboration and a global perspective would also be beneficial.

Call for action

Multidisciplinary mental health science research must be central to the international response to the COVID-19 pandemic, given the potential effects on individual and population mental health, and its potential effect on the brain function of some of those affected by the disease. There are important immediate insights to be gained, which could provide evidence-based guidance on responding to this pandemic and on how to promote mental health and wellbeing, and safeguard the brain, should future waves of infection emerge (panel 5).

Panel 5

Rapid learnings to apply to future infection waves or pandemics

The outputs of immediate research could help to inform responses to future infection waves or pandemics by identifying:

  • Mechanisms (eg, coping strategies and preventive interventions) to support vulnerable groups under pandemic conditions, such as front-line health and social care staff, those with pre-existing mental health issues, young people (aged ≤18 years), and older adults (aged ≥65 years)

  • Interventions that can be delivered under pandemic conditions to reduce mental health issues and boost wellbeing, including those that can be repurposed

  • Solutions to the effect of repeated media consumption about coronavirus disease 2019 (COVID-19) on the mental wellbeing of the population, to help individuals stay informed by authoritative sources while also preventing over-exposure and mitigating the effect of viewing traumatic content

  • Methods for promoting more successful adherence to behavioural advice about COVID-19 while enabling mental wellbeing and minimising distress

The research priorities across the social, psychological, and neuroscientific aspects of this pandemic should be coordinated at a national and international level. We urge UK research funding agencies to work with researchers, people with lived experience, and others to establish a high-level coordination group to ensure that the mental health science research priorities are addressed swiftly, and that a firm evidence base is established for long-term studies. We need rigorous, peer-reviewed, ethically approved research codeveloped with people with lived experience that can be translated into effective interventions, rather than the current uncoordinated approach with a plethora of underpowered studies and surveys.

The immediate priority is the collection of high-quality data on the mental health and psychological effects of the COVID-19 pandemic across the whole population and in specific vulnerable groups, and on brain function, cognition, and mental health for patients with COVID-19 at all clinical stages of infection and illness. These datasets must be brought together under a national data portal for rapid access and use.

There is an urgent need for the discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of this pandemic. This includes bespoke psychological interventions to boost wellbeing and minimise mental health risks across society, including in vulnerable groups, and experimental medicine studies to validate clinical biomarkers and repurpose new treatments for the potentially neurotoxic effects of the virus. There is an urgent need for research to address the effect of repeated pandemic-related media consumption and to optimise health messaging around COVID-19. Rising to this challenge will require integration across disciplines and sectors, including industry and health and social care.

New funding will be required to meet these priorities, and it can be efficiently leveraged by the UK’s world-leading neuroscience and mental health research infrastructure. The UK must connect with international funders and researchers to support a global response to the mental health and neurological challenges of this pandemic. In these challenging times, mental health science should be harnessed to serve society and benefit both mental and physical health in the long term.

Contributors

EB, EAH, MH, RCO’C, VHP, IT, and SW contributed to the literature review, conceptualisation, design and interpretation of surveys, and writing and editing of the manuscript as part of the core advisory group. CC contributed to and coordinated the writing and editing of the manuscript. KC analysed the qualitative data gathered via the stakeholder survey. LA, CB, HC, RCS, IE, TF, AJ, IM, SM, AKP, RS, CMW, and LY contributed to the drafting and formulation of the manuscript as part of the expert advisory group. TK, KK, and AS contributed to the drafting and formulation of the manuscript as part of the expert advisory group and by including lived-experience expertise. All authors approved the final version for submission.

Declaration of interests

CB reports grants and personal fees from Acadia and Lundbeck; personal fees from Roche, Otsuka, Biogen, Eli Lilly, Novo Nordisk, AARP, and Exciva; and grants from Synexus, outside the submitted work. EAH reports serving on the board of trustees of the charity MQ: Transforming Mental Health and as chair of the research committee, but receives no remuneration for these roles. EAH receives royalties from books and occasional fees for workshops and invited addresses; receives occasional consultancy fees from the Swedish agency for health technology assessment and assessment of social services; and reports grants from The OAK Foundation, the Lupina Foundation, and the Swedish Research Council. RCO’C is a member of the National Institute of Health and Care Excellence’s guideline development group for the management of self-harm; is co-chair of the Academic Advisory Group to the Scottish Government’s National Suicide Prevention Leadership Group; receives royalties from books, and occasional fees for workshops and invited addresses; and reports grants from Medical Research Foundation, the Mindstep Foundation, Chief Scientist Office, Medical Research Council, NHS Health Scotland, Scottish Government, and National Institute for Health Research (NIHR). KK has received meeting attendance payments from the Department of Health and Social Care, NHS England and NHS Improvement, and the Royal College of Psychiatry (RCPsych) over the last year for service user representative work, and payment for a training session she facilitated for RCPsych; and received a pass and accommodation for the RCPsych annual conference in 2019. AKP reports financial support from UK taxpayers, the UK’s Economic and Social Research Council, the British Academy, the Diana Award, the John Fell Fund, the Leverhulme Trust, Barnardo’s UK, and the Huo Family Foundation in the past five years. As part of science communication and policy outreach activities; and served in an unpaid advisory capacity to the Organization for Economic Co-operation and Development, Facebook, Google, and the ParentZone. IT is a Trustee of MQ: Transforming Mental Health and is on the Council for the Medical Research Council of the UK. MH reports grants from Innovative Medicines Intiative, outside the submitted work. MH and SW are funded by the NIHR Biomedical Research Centre at the Maudsley and a NIHR Senior Investigator Award. NIHR were not involved in any aspect of the publication and had no role in the decision to submit. RCS received funding from the US National Science Foundation, grant SES-2026337. CC reported that Academy of Medical Sciences staff, including herself, and activity costs for this work were partly supported by a core grant the Academy of Medical Sciences receives annually from the Government Department for Business, Energy & Industrial Strategy for policy, communications and public engagement; and reports that her husband is an employee of Otsuka Pharmaceutical Europe and is a trustee of The McPin Foundation. KC was funded by MQ: Transforming Mental Health to carry out the qualitative data analysis of the stakeholder survey. LA is the Mental Health Leadership Fellow for the Economic and Social Research Council. EB is a NIHR Senior Investigator. This Position Paper represents independent research part-funded by the NIHR Biomedical Research Centre at Cambridge University Hospital NHS Trust and the University of Cambridge and South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. RS reports that all research at Great Ormond Street Hospital NHS Foundation Trust and UCL Great Ormond Street Institute of Child Health is made possible by the NIHR Great Ormond Street Hospital Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. LY is an NIHR Senior Investigator and her research programme is partly supported by NIHR Applied Research Collaboration-West, NIHR Health Protection Research Unit for Behavioural Science and Evaluation, and the NIHR Southampton Biomedical Research Centre. The funding for TK’s salary came solely from The McPin Foundation. All other authors declare no competing interests.

Funding source

The stakeholder survey was funded by MQ: Transforming Mental Health. Activity costs for this work, including the Ipsos MORI survey, were partly supported by a core grant the Academy of Medical Sciences receives annually from the Government Department for Business, Energy & Industrial Strategy for policy, communications and public engagement. The views expressed are the views of the authors alone and do not necessarily represent the views of their organisations or funding sources.

Acknowledgments

We are grateful to all staff at the Academy of Medical Sciences and MQ: Transforming Mental Health for their work in coordinating and supporting this project’s secretariat and communications. Special thanks to Rachel Quinn, Nick Hillier, Helen Munn, Neil Balmer, Angeliki Yiangou, Fern Brookes, Holly Rogers, Claire Bithell, Naomi Clarke, Melanie Etherton, Tom Livermore, Dylan Williams, and Daisy Armitage. We also extend our sincere thanks to Katie White, Carolin Oetzmann, Valeria de Angel, and Sumithra Velupillai at King’s College London, and Norman Freshney from Norman Freshney Consulting, for their tremendous efforts in data analysis, and Beau Gamble at Uppsala University and Seonaid Cleare at University of Glasgow for their support with referencing. We are also grateful to the team at Ipsos MORI for their work on the online omnibus. Special thanks also to everyone who participated in the MQ: Transforming Mental Health and Ipsos MORI surveys for sharing their views and personal experiences during challenging times—we are hugely grateful to them for their openness and honesty about mental health and wellbeing. We are grateful to Peter Jones from the University of Cambridge and a member of the MQ: Transforming Mental Health Board of Trustees for comments on an earlier draft.

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Published: April 15, 2020

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DOI: https://doi.org/10.1016/S2215-0366(20)30168-1

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